Recent eLetters
Displaying 11-20 letters out of 44 published
-
IMRaD as a model for quality improvement reports
Submit responseDear Editor,
In the Scandinavian countries we have a lot of discussions related to how to publish quality improvement work, and process oriented writing courses are ongoing. Therefore, this article comes on time. I really agree with the authors that a quality improvement report has to follow the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger improvement evidence" and Table 2 are really helpful and understandable, and will help me as a teacher and adviser of these courses. Thanks!!
-
Crucial data
Submit responseDear Editor,
The no-child-left-behind program grades schools on the basis of test- scores on their pupils. Waters, Lefevre, and Budetti have arguably developed a far more valid and relevant measure of school-performance by assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop data on which medical schools produce graduates who experience little litigation, more litigation and most litigation, but omit publication of those specific data, according to named medical schools. Such publication would doubtless be incendiary, among medical schools in the third tier and maybe even in the second but wouldn't the authors best serve the public interest by releasing such data, the better to inform prospective medical students, in advance, of the risks to which they may expose themselves and their future patients, if any, by accepting admission to certain medical schools? Shouldn't there be a National Medical School Data Bank, available to prospective medical students to enable them to choose medical schools rationally?
If not, what justification is there for the National Practitioner Data Bank, which keeps track of the dirt on physicians? A physician, if "bad", may hurt a few patients. A medical school, if "bad", may produce hundreds of "bad doctors" who may hurt thousands of patients.
-
What to do with outliers?
Submit responseDear Editor,
The paper by Spiegelhalter is a valuable contribution to the literature on presenting and displaying performance related outcome measures.[1] It provides further methodological guidance on identifying service providers whose performance falls outside control limits using funnel plot methodology. When reporting on performance it is important to have procedures in place which should be followed when outliers are identified. These issues have been considered by the Paediatric Intensive Care Audit Network (PICANet) who use the funnel plot methodology for reporting risk-adjusted mortality from all paediatric intensive care units (PICU) in England and Wales. Prior to producing these funnel plots for the latest National Report, we issued a policy statement drawn up in consultation with both our Clinical Advisory and Steering Groups.[2] In summary, the PICANet policy (published in full at http://www.picanet.org.uk) recognises that a PICU whose risk-adjusted mortality lies outside of the control limits will be identified as having returned data that is markedly different to the other PICUs. It is important to note that a PICU lying outside the control limits is not sufficient evidence to suggest that it has either markedly higher or lower mortality than other PICUs, merely that the data they have returned is different to that of other PICUs. To resolve why this data is different, PICANet will work with the units to provide a satisfactory explanation, following the plan below
i) Review the data to investigate whether there are data driven reasons for a PICU lying outside of the control limits (it is known that risk-adjustment tools can be unreliable when a PICU has a particularly high proportion of patients at either end of the bounds of the tool.)
ii) Review the quality of data supplied by the PICU. The quality of the data is the PICUs’ responsibility. PICANet will provide feedback from PICU data validation visits and central validation procedures. PICUs will be expected to check the quality of individual data items.
iii) Plot the data quality indicators over time to identify whether the anomaly can be traced to a certain data collection period.
iv) Plot the mortality ratio over time to identify whether the anomaly can be traced to a certain data collection period.
v) Plot the observed mortality over time to identify whether the anomaly can be traced to a certain data collection period.
vi) Plot the expected mortality over time to identify whether the anomaly can be traced to a certain data collection period.
vii) Investigate the primary diagnoses for admissions to the PICU. If the PICU has a very different diagnostic casemix when compared with other PICUs this may suggest further refinements to the risk-adjustment method are required.
viii) Produce a brief summary report of the above for the lead clinician and Chief Executive at the PICU concerned together with an invitation to meet in person to review the data with the PICANet team.
We believe having such a policy in place, clearly outlining our interpretation and proposed actions before publication of such funnel plots is vital to the chances of such information being accepted by staff at the participating units and thus more likely to result in positive actions being taken.
Yours sincerely,
Dr Gareth Parry, co-director of PICANet and reader in Health Services Research, University of Sheffield.
Dr Elizabeth Draper, co-director of PICANet and senior research fellow. Department of Epidemiology and Public Health, University of Leicester
Prof. Patricia McKinney, co-director of PICANet and professor of paediatric epidemiology. Paediatric Epidemiology Group, University of Leeds
References
1. Spiegelhalter DJ. Handling over-dispersion of performance indicators. Qual Saf Health Care 2005; 14: 347-351.
2. Paediatric Intensive Care Audit Network. National Report 2003–2004. Universities of Leeds, Leicester and Sheffield, May 2005 (ISBN 0 85316 254 9).
-
Unlicensed Assistive Personnel
Submit responseDear Editor
The issue of using UAPs to perform various medical duties has been debated in the US as well. [Shostek K. Unlicensed Assistive Personnel: Risk Management Considerations. J Healthc Risk Management 1998 Winter;18(1)] The 'role drift' described by M. McKenna is the result of a shortage of professional and licensed caregivers like nurses and technologists with college degrees. The performance of a task (such as phlebotomy) and the understanding of the complexities of anatomy, physiology, and human response to disease are not inseparable with appropriate training and adequate oversight. In light of the need to focus more on patient safety and less on "turf", teamwork in healthcare may be the best approach.
-
'Sceptics or realists' - Authors' response
Submit responseDear Editor
We note Dr Checkland’s comments on our paper on scepticism with interest.[1] In response, we do not believe that the paper argues that it is not legitimate for staff to be sceptical; indeed, we acknowledge the fact that scepticism can be useful in highlighting gaps and flaws in improvement initiatives. Nevertheless, the study – based on interviews that centred on listening to the opinions of others – did identify the negative impact that scepticism and resistance are having on the pace of change in the NHS.
With regard to the use of terms such as modernisation and improvement, we think that this is a semantic argument that ignores the underlying spirit and intent of planned reform. It is surely legitimate to make certain assumptions about meaning in this context. Changes designed to make health care better for patients deserve to be described as improvements until subsequent research evidence demonstrates otherwise. The drive to involve frontline staff in leading service improvement encompasses the notion that change that proves not to be beneficial in practice can be reversed. If we implement only that which has been scientifically proven to be effective, the pace of change will be very slow.
Reference
1. Checkland KH. Sceptics or realists [electonic response to Gollop et al. Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors’ and managers’ views] qshc.com 2004http://qhc.bmjjournals.com/cgi/eletters/13/2/108#80
-
Sceptics or realists
Submit responseDear Editor
The article by Gollop et al.[1] raises an interesting question: does labelling a programme of change an "improvement" programme mean that such a programme will automatically deliver improvements?
I am disturbed by the implication that simply because something is "a key component of the government's strategy to modernise the NHS and make it more accessible to patients" it is therefore not legitimate for staff to be sceptical. In fact, the inclusion of such a sentence in the article provokes me to yet greater scepticism: what exactly does "modernise" mean in this context, and when did it become synonymous with "improve?" This Orwellian use of language and the presumption that it is not legitimate for intelligent observers to be sceptical about unproven innovation are two of the reasons that many of us are so disillusioned with life in the NHS. Having worked in the NHS for nearly twenty years, I have experienced many waves of change: some have brought improvements, some have been disastrous; some I have embraced and some I have resisted. I reserve the right to remain sceptical and questioning, and I hope that the Modernisation Agency will, as it matures as an institution, lose some of its evangelical fervour and learn to listen to the opinions of others. Changing its name might be a start!
References
1. R Gollop, E Whitby, D Buchanan, and D Ketley. Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views, QSHC 2004; 13:108-114.
-
Organizational trust: the responsibility of the leadership
Submit responseDear Editor
Firth-Cozens article explores the effect of trust and the ways in which it can be developed in health care organizations to enhance patient safety.[1] Leadership attributes of ability, benevolence and integrity most certainly contribute to the establishment of trust in a leader however, these attributes alone are not enough to overcome the barriers to open disclosure of errors.
Organizational trust must first be earned by its leaders through demonstrated commitment to a ‘no blame’ policy with respect to adverse event investigations. The author acknowledges ‘the importance of considering the multi-causal and sociotechnical nature of most accidents’[1] however, I believe this aspect of the article requires more explicit discussion as it is fundamental to the development of organizational trust.
Quick judgments and routine assignment of blame obscure a more complex truth, a series of events and departures from safe practice, each influenced by the working environment and the wider organizational context.[2] If analysis of adverse events focused less on individual error and more on organizational or system factors, an environment of trust may begin to prosper and strategies to enhance patient safety would become visible. No amount of leadership ability, benevolence or integrity will lead to organizational trust if fear of blame exists. A consistent and transparent process for a root cause analysis of adverse events is essential for health care leaders to demonstrate in order to achieve any degree of organizational trust and subsequent open disclosure.
As Firth-Cozens states in a previous publication, ‘the main driver of higher organizational trust is going to have to come from the actions and attitudes of leaders and managers at every level’.[3] Actions undoubtedly speak louder than words when it comes to investigation and assignment of blame in the analysis of adverse events. A culture change is required and it must begin with the leadership of each health care organization. Leaders who consistently demonstrate and acknowledge the role of system failures as the root cause of adverse events, will have greater success in establishing the trust that health care organizations so desperately require. Maybe then we will begin to impact on the quality and safety of the health care which we deliver.
References
1. Firth-Cozens J. Organisational trust: the keystone to patient safety. Qual Saf Health Care 2004;13:56-61
2. Vincent C, Taylor-Adams S, Jane Chapman E, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyze clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol 2000;320:777-781
3. Firth-Cozens J. Learning from error. In: Harrison J, Innes R, Van Zwanenberg T, eds. Regaining trust in health care. Albingdon: Radcliffe Medical Press, 2003.
-
A whole healthcare record
Submit responseDear Editor
At the Linnaeus Collaboration meeting in Canberra, Australia last week (sponsored by the Australian Primary Health Care Research Institute and the US Agency for Healthcare Research and Quality), primary care researchers from Australia, Canada, England, Germany, New Zealand, and the United States met to consider further research aimed at improving patient safety in primary health care. We discussed the issues raised in the editorial by RM Wilson because we also think that improvements in medical record-keeping are crucial to improving patient safety. From our discussion, the following was clear:
1. Paper medical records are not a viable phenomenon for the 21st century and beyond. This is a particularly challenging notion for the countries in North America and Australia, where there has not yet been a wholesale clinical and political commitment to electronic medical records.
2.. The medical record of the 21st century may well be patient held and maintained. As researchers we found this idea worrying because medical records are a rich and valuable research resource - we worry that they may become so well disintegrated that they may no longer be available for research.
But to answer Wilson's questions: 1. We agreed that the key functions of the medical record are to keep a record of all encounters between patients and the formal health system. This record may then be used: (1) to maintain patient safety by ensuring that health information about a patient exists and is accessible to those who need it - at any time and in any place, (2) to identify early signs of catastrophic events (e.g. bioterrorism) through sentinel monitoring, (3) to measure costs and benefits of healthcare in the real-world setting, and therefore (4) in light of the above, to be a continuous healthcare quality improvement tool.
2. What constitutes a "minimum" dataset for a patient record has already been considered (e.g. [1]). To best fulfil all its functions, medical records should hold full information about each healthcare encounter, including setting and encounter method (face-to-face, phone, email, video, etc), dates, both patient and provider views of reason for encounters, and details of care provided (including information about medications, investigations, referrals, immunisations, and other preventive measures). There is disagreement between countries on the extent of patient information that is necessary in a patient's medical record. For instance, in New Zealand the government is concerned that patients' ethnicity and residence location (for calculating deprivation and measuring inequalities) are recorded - neither piece of information having particular significance for gps' clinical decisions. No other country represented at the meeting had to provide these particular items, but in the US and Germany health insurance information is absolutely required. There will obviously be international variation in "key" elements.
3. How do we implement such requirements? Marshall and Smith write persuasively in this issue of financial incentives [2]. While we agree that financial incentives are necessary for systemwide adoption of medical records standards, we also think political will, a rationale that is credible to healthcare providers, and cultural change in practice are crucial.
References
1. Tilyard MW, Munro N, Walker SA, Dovey SM. Creating a general practice national minimum data set: present possibility or future plan? NZ Med J 1998; 111: 317-20.
2. Marshall M, Smith P. Rewarding results: using financial incentives to improve quality. Qual Saf Health Care 2003; 12(6): 397-8.
-
Initiatives for promoting the quality of guidelines: The Electronic G-I-N Guideline Library
Submit responseDear Editor
We fully agree with Hasenfeld and Shekelle that many published guidelines fall short of the internationally consented quality criteria for their production and use, although the principles for the development of sound evidence–based guidelines are well established. In response several national and international initiatives have been working on programmes for the promotion of quality in guideline development.[1-3] In order to promote sustainable international partnerships in the field of guideline development, use and research activities, a network of non-for- profit organisations dealing with development, implementation and evaluation of EBGs was founded in November 2002, called Guidelines International Network (G-I-N). To date 46 institutions from 24 European, American, Asian and Oceanian countries including WHO have become members of the network.
In November 2003, G-I-N's released the first international Electronic Guideline Library (http://www.g-i-n.net) giving access to nearly 1400 guidelines and related resources with special focus on the methodological quality of clinical practice guidelines. This initiative is meant as a contribution to the improvement of guidelines' quality and to dissemination of best available practice guidelines worldwide.
References
1) Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J, for the AGREE Collaboration. Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs. Int J Qual Health Care 2003; 15: 31-45.
2) Council of Europe. Developing a methodology for drawing up guidelines on best medical practice. Recommendation Rec(2001)13 and explanatory memorandum. Strasbourg, Council of Europe Publishing 2002.
3) The AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23
-
What is a 'safety culture'?
Submit responseDear Editor
We welcome Singer and colleague’s contribution to developing the concept of a safety culture.[1] Policy-makers, managers and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that when these initiatives are evaluated the results will probably show a marginal impact on patient safety, and one that is likely to be poorly sustained. In order to maximise their impact we need to understand the shared attitudes, beliefs, values and assumptions that underlie how people perceive and act upon safety issues within their organisations. This is what is commonly called the ‘safety culture’ of an organisation.
The problem with the approach adopted in this paper is that it fails to get to the heart of the hospital’s culture. What they have done is to use a blunt survey instrument to assess the opinions of individual members of staff to a series of statements about safety. The responses represent the most superficial evaluation of the ‘climate’ of the organisations in which they work. These opinions are likely to be influenced by a wide range of factors that have little to do with the organisation’s culture. Furthermore, the relationship between these opinions and the shared values that underlie them is largely unknown.
If we really want to understand the safety culture of an organisation we need to use more sophisticated approaches.[2] These should draw on a wide range of methods – participant observation, in-depth and semi- structured interviews and focus groups, alongside attitudinal surveys and the use of new and established culture-measurement tools.[3] Developmental or action research approaches might provide additional insights into the complexity of the organisations. The aim should be not only to understand and assess the concept of safety culture but also to examine ways of improving it and integrating it with the broader field of organisational culture. This presents a significant challenge to health service researchers. Singer and colleagues have made a start but there is a long way to go before we know how, or indeed whether it is possible, to change the safety culture of our hospitals and primary care centres.
References
(1) Singer S et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Quality and Safety in Health Care, 2003. 12: p. 112-118.
(2) Mannion R, Davies H, Marshall M. Cultures for performance in healthcare: evidence on the relationships between organisational culture and organisational performance in the NHS. Centre for Health Economics: York, 2003.
(3) Scott J et al. The quantitative measurement of organisational culture in health care: A review of the available instruments. Health Services Researcher, in press.
Register for free content
The full back archive is now available for all BMJ Journals. Institutional subscribers may access the entire archive as part of their subscription. Personal subscribers will also have access to all content when logged in. Non-subscribers who register have free access to all articles published before 2006 right back to volume 1 issue 1. Register here to access the free archive of all BMJ Journals.
Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.
