Professor Mary Dixon-Woods looks at improving the quality and safety of care in hospitals, and suggests that we need to take a three-pronged approach: ensuring we are collecting the right data and interpreting it intelligently, looking at the systems we work in and finally how culture and behaviour impact on quality of care. To watch this presentation with accompanying audio/narration, go to: http://www.health.org.uk/multimedia/slideshow/what-we-know-about-how-to-improve-quality-and-safety-in-hospitals/

1. What we know about how to improve
quality and safety in hospitals – and what
we need to learn
Mary Dixon-Woods
Professor of Medical Sociology and
Wellcome Trust Senior Investigator
SAPPHIRE Group, School of Medicine
University of Leicester
January 2013
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2. Goal of regulating healthcare
• To ensure safe, good quality care that is
respectful to patients
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3. Hood’s cybernetic model
Set
standards
Modify Gather
behaviour information
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4. How often do we injure patients?
• Worldwide, incidence of
adverse events is 9.2%
• Around 43.5% are
preventable
• 7.4% are lethal
4

5. Progress has been slow, and solutions
are not easy
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6. Poor reliability of systems
• Reliability of 81% to 87%
• Availability of equipment in theatres ranges from 63% to 88%
• In outpatient clinics, 15% of patients lack some type of
relevant clinical information

7. Challenges in operationalising
standards
• Standard: if you get on plane, you should
arrive alive and in one piece
• But some people will die in hospital anyway,
and some adverse events cannot be prevented
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8. • Incidence of preventable death much lower than
previously estimated
• Only 5% deemed preventable
• Most problems related to quality of clinical monitoring
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9. Judging quality and safety
• Three major rankings of US hospitals
• MGH gets A from Leapfrog, ranked top by US News and
Word report, but gets 45 out of 100 from Consumer
Reports
• Bottom six in the CR ranking all got A from Leapfrog
• http://blogs.sph.harvard.edu/ashish-jha/hospital-rankings-get-
serious/
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10. Only a handful of consistently high performing hospitals,
and may be a chance finding
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11. 11

12. The story of one UK hospital
• Healthcare Commission rated this hospital as
one of four “most improved” hospitals in
2006/7
• Dr Foster’s Good Hospital Guide (2009) ranked
it in best 10 for safety
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13. The story of one UK hospital
The Care Quality
Commission said it
was “appalling”
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14. The story of one UK hospital
“It soon became clear that the real position of
the hospital in the national league of
awfulness did not matter. What did matter
was that many patients had received poor
care and, for some, their treatment was
appalling.”
• Dr Paul Woodmansey
http://www.hospitaldr.co.uk/blogs/tag/mid-staffordshire
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15. Improving patient safety and quality
Intelligence
Culture and
Systems
behaviour
15

16. Intelligence: Why measure?
• Need measures to:
– Signal priority
– Create mission
– Assess improvement and deterioration
– Provide feedback so staff know how they’re doing
– Identify areas for intervention
– Improve transparency and accountability to
patients
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17. Intelligence
• If you’re not measuring, you’re not managing
• If you’re measuring stupidly, you’re not
managing
• If you’re only measuring, you’re not managing
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18. “Data for improvement”
• Insufficient data points
• Lack of sufficient baseline periods
• Changing samples and sampling strategies
• Inadequate annotations of changes
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19. Measuring well is really tough
• Units were not counting either denominators or
numerators consistently
• Wide variability in underlying clinical practices and
laboratory support
• Unsafe to assume infection rates were comparable
19

20. Measuring too much
• In the US, National Quality Forum measures went from
200 in 2005 to over 700 in 2011
• US CMS has introduced 65 new measures in last year
alone
• At MGH, measuring consumes 1% of net patient
service revenue
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21. Improving intelligence
• Measure, but do it really intelligently
• Don’t rely only on measurement as the source
of intelligence
• Use multiple sources of information as
starting points for understanding, problem-
sensing and reward
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22. Staff and patients are among the very
best sources of intelligence
• Data on staff morale, wellbeing and teamwork
• Evidence from staff about what concerns
them
• Whether patients would recommend the
service to others
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23. Lessons on intelligence
• Actively search for harm, not for comfort
• Integrate data for care and data for audit
where possible
• Balance between external measures and
internal
• Interpret and use the data wisely
• Use multiple forms of intelligence
• Focus on action
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24. Improving systems: Human factors
thinking in the work environment
1. Avoid reliance on memory
2. Make things visible
3. Review and simplify processes
4. Standardize common processes and procedures
5. Routinely use checklists
6. Decrease the reliance on vigilance
From the WHO
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25. Healthcare systems
• Piecemeal systems – nobody has ever designed
them
• How they function in practice is often poorly
understood
• Ad hoc improvisations and adaptations are the
norm
• Limited understanding of what it takes to achieve
peak performance
• The blunt end often has very poor grasp of the
operational detail at the sharp end
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26. 1085 incidents in UK 2005-2010
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27. 27

28. Improving systems
• Requires specific skills and expertise
• Often working across several areas
• Needs to work with – not on - staff
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29. 29

30. Standardise processes and improve
teamwork
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31. Errors dropped from 39% of patients
to 11.5%
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32. 32

33. Lessons on systems
• Really know how well you’re doing – focus on
discovery and make an absolute commitment to
honesty
• Use a systematic, structured way to improve and
learn as you go
• Feedback on progress and find merit where you
can
• Change the systems and the behaviour and
culture change too
• NO QUICK FIX
33

34. Eroding of collegial principle is
dangerous
• Because we cannot design perfect rules
• Cannot measure everything we need to know
about
• Risk crowding out intrinsic motivation
• If you neglect the emotional, cultural
dimensions of what you are doing you will fail
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35. 35

36. Mobilise intrinsic motivation
• Front line teams need to know how well they
are doing
• They know where the problems are
• They can deliver the contextual adaptation
necessary for change
• They want to do well
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37. 37

38. Success of Michigan project
• Evidence based intervention in 103 ICUs in
Michigan; included checklist for CVC insertion
and management
• Sustained reduction of CVC-BSI rate:
Baseline: mean 7.7 CVC-BSIs per 1000 catheter days
18 months: mean 1.4 CVC-BSIs per 1000 catheter days
38

39. http://www.newyorker.
com/reporting/2007/1
2/10/071210fa_fact_ga
wande
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40. • Best understood as a culture change
intervention that made patient safety a
priority
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41. Align the incentives
• Incentives need to be properly aligned to the
goals of regulation
• Too often the incentives conflict, compete, or
fail to cohere, or generate unintended
consequences
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42. Financial penalties
• Evidence that they work is weak
• Tend to amplify blame avoidance behaviours
• Take resource out of already stressed systems
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43. 43

44. Lessons on culture and behaviour
• Forms are tempting: resist that temptation
• Make safe, high quality care easier, not harder
to do
• Respect and value people
• Know when it’s a systems problem, know
when it’s a people problem, and know when
one is feeding the other
44

45. Improving patient safety and quality
Intelligence
Culture and
Systems
behaviour
45

46. Conclusions
• Huge challenges lie ahead
• Commit to learning
• Incentivise honesty
• Keep the focus locked on patient benefit, not
blame engineering
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47. www.health.org.uk
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