Why is improvement so hard?Why is improvement so hard?

Martin Marshall

Clinical Director and Director of R&D

HQIP Annual Conference 2010

“You can’t solve a problem by using the thinking that got your there”

Albert Einstein

10 percent of patients admitted to hospital experience iatrogenic harm

More than half of this harm could have been prevented if staff had followed established good practice

Vincent et al., BMJ, 2001

On average, 45% of patients fail to receive recommended care

McGlynn et al., NEJM, 2003

Between 2001 and 2006 there was a 450% increase in death rates in

England from C. Diff.

Source: HPA, Scottish Parliament, NHS Wales, CDSC Northern Ireland, 2007

The overall 5 year survival for all malignancies is 20% higher in Sweden than in the UK

Source: EUROCARE-4, 2007

Nearly 60% of patients are not told about the potential side-effects of their prescribed medications

Source: Commonwealth Fund, 2005

How are other sectors doing?How are other sectors doing?

SafetySafety

QualityQuality

In the aviation business there is one death per 10 million flights

In the health sector there is 1 iatrogenic death per 300 hospital admissions

Motorola tolerates 3.4 defects per million manufacturing processes

In the health sector the ‘defect’ rate is 900,000/million processes for the management of alcohol dependence

How have policy makers, clinicians and managers responded to the quality challenges that we face?

Professional

Education and trainingClinical auditPeer review/ collaborationGuidelines

Governmental

RegulationPerformance management

Legislation

Economic

Incentives/sanctionsPatient choice

CompetitionCommissioning

‘Industrial’/organisational

Org. developmentTQM/CQI, BPR, PDSA, Lean, 6

sigma

Ways of improving patient care

Why is Why is improvement so improvement so

hard?hard?

Factors relating to the intervention

Factors relating to the

environment

Factors relating to the people

involved

Why is improvement so hard?

Factors relating to the intervention

Factors relating to the environment

Factors relating to the people involved

Research examining the overall effectiveness of interventions

• Most can be effective but overall effect size small

•Variable impact depending on context•Often takes long time to achieve change

e.g. QQuiP evidence reviews

Research examining the characteristics of successful interventions

• Active approaches better than passive ones

• Multifaceted interventions more effective than single ones

• Interventions more effective if• relative advantage• compatible• simple• testable• observable/measurable• involving

e.g. Grimshaw, Grol, Greenhalgh

Why is improvement so hard?

Factors relating to the intervention

Factors relating to the

environment

Factors relating to the people involved

The policy environment

• Different policy approaches to achieving change need to be integrated and based on evidence

• The unintended consequences of different levers need to be predicted and managed

The organisational environment

• Change management programmes often fail

• High performing organisations have strong leadership, clear vision, commitment to build capacity, well integrated services, excellent IT, focus on users and on measurement, engaged clinical staff through active explicit processes, strong sense of accountability, aligned incentives, sensitivity to local context/culture

• Characteristics of failing organisations tend to be mirror image of above

e.g. Kotter, Baker, Bate, Davies, Shortell, Fullop

Why is improvement so hard?

Factors relating to the intervention

Factors relating to the environment

Factors relating to the people

involved

Psychological approaches

• Change is more likely to be effective when individual characteristics are taken into account• attitudes to new ideas e.g. innovators,

early adopters, early and late majority, laggards

• stage of journey towards change e.g. pre-contemplation, contemplation, preparation, action, maintenance, completion

e.g. Rogers, Prochaska and Velicer, Grol

Sociological approaches

• Improvement can be seen as social activity rather than technical achievement

• Clinicians may behave more like ‘workers’ than as professionals

• Professional identity explains many behaviours e.g. defining and legitimising risk, heroic behaviours, rituals

• There are often inadequate structures of authority and accountability in clinical teams

e.g. Roberts, McDonald, Dixon Woods, Checkland, Greenhalgh

Why is improvement so hard?Why is improvement so hard?

Isn’t it remarkable that we are Isn’t it remarkable that we are doing as well as we are?!!doing as well as we are?!!

So, why is improvement so difficult?So, why is improvement so difficult?

• We don’t know as much about large scale and sustained improvement as we shouldACTION: We need to build the evidence base underpinning improvement in the health sector

• What we do know, we rarely put into practiceACTION: We need to be more systematic about how we design and implement policy and practical approaches to improvement

• We are giving insufficient attention to the human side of improvementACTION: We need to adopt more sophisticated approaches to influencing and motivating people

• We have naïve expectations of what we can achieveACTION: A generous dose of realism and tenacity is required

Thanks for listeningThanks for listening

martin.marshall@health.org.uk

www.health.org.uk