Piotr Ozieranski, Victoria Robins, Joel Minion, Janet Willars, John Wright, Simon Weaver, Graham P Martin and Mary Dixon Woods
Research on patient safety campaigns has mostly concentrated on large-scale multi-organisation efforts, yet locally led improvement is increasingly promoted. The purpose of this…
Abstract
Purpose
Research on patient safety campaigns has mostly concentrated on large-scale multi-organisation efforts, yet locally led improvement is increasingly promoted. The purpose of this paper is to characterise the design and implementation of an internal patient safety campaign at a large acute National Health Service hospital trust with a view to understanding how to optimise such campaigns.
Design/methodology/approach
The authors conducted a qualitative study of a campaign that sought to achieve 12 patient safety goals. The authors interviewed 19 managers and 45 frontline staff, supplemented by 56 hours of non-participant observation. Data analysis was based on the constant comparative method.
Findings
The campaign was motivated by senior managers’ commitment to patient safety improvement, a series of serious untoward incidents, and a history of campaign-style initiatives at the trust. While the campaign succeeded in generating enthusiasm and focus among managers and some frontline staff, it encountered three challenges. First, though many staff at the sharp end were aware of the campaign, their knowledge, and acceptance of its content, rationale, and relevance for distinct clinical areas were variable. Second, the mechanisms of change, albeit effective in creating focus, may have been too limited. Third, many saw the tempo of the campaign as too rapid. Overall, the campaign enjoyed some success in raising the profile of patient safety. However, its ability to promote change was mixed, and progress was difficult to evidence because of lack of reliable measurement.
Originality/value
The study shows that single-organisation campaigns may help in raising the profile of patient safety. The authors offer important lessons for the successful running of such campaigns.
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Justin Waring, Mary Dixon‐Woods and Karen Yeung
This paper aims to outline and comment on the changes to medical regulation in the UK that provide the background to a special issue of the Journal of Health Organization and…
Abstract
Purpose
This paper aims to outline and comment on the changes to medical regulation in the UK that provide the background to a special issue of the Journal of Health Organization and Management on regulating doctors.
Design/methodology/approach
This paper takes the form of a review.
Findings
Although the UK medical profession enjoyed a remarkably stable regulatory structure for most of the first 150 years of its existence, it has undergone a striking transformation in the last decade. Its regulatory form has mutated from one of state‐sanctioned collegial self‐regulation to one of state‐directed bureaucratic regulation. The erosion of medical self‐regulation can be attributed to: the pressures of market liberalisation and new public management reforms; changing ideologies and public attitudes towards expertise and risk; and high profile public failures involving doctors. The “new” UK medical regulation converts the General Medical Council into a modern regulator charged with implementing policy, and alters the mechanisms for controlling and directing the conduct and performance of doctors. It establishes a new set of relationships between the medical profession and the state (including its agencies), the public, and patients.
Originality/value
This paper adds to the literature by identifying the main features of the reforms affecting the medical profession and offering an analysis of why they have taken place.
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Quality improvement is imperative for healthcare organisations. Despite the importance of the topic, many efforts have been wasted on failed improvement programs. Various studies…
Abstract
Purpose
Quality improvement is imperative for healthcare organisations. Despite the importance of the topic, many efforts have been wasted on failed improvement programs. Various studies have tried to identify the failure factors in improvement programs, but the divergences in the results hamper this research field’s evolution. This study reviews scientific activity from 2000 to 2019 on failure factors in Healthcare Quality Improvement Programs (HCQIP) to help academics and managers understand the field’s evolution better. This research intends to answer four questions on failure factors in HCQIP: Who are the most active authors in this field?; Which journals have been used as diffusion channels?; What are the themes addressed the most in this field?; and What are the themes considered to be emerging?
Design/methodology/approach
The authors conducted a bibliometric-based literature review on a sample of 5,137 articles, and 104 studies were included in this review, covering a longitudinal analysis in two periods (P1: 2000–2010 and P2: 2011–2019). Performance analysis, citation, co-citation, co-words analysis and network mapping identified the authors in this scientific field, the journals, the number of articles, along with the current and emerging themes that reveal the latent structure of the factors associated with failures in HCQIP.
Findings
The number of articles in P2 (83 studies) is almost four times higher than in P1 (21 studies). The results reveal a dynamic field attracting more authors since 2013, expanding from 5 to 42 journals that publish on the topic. Furthermore, research has evolved from comprehensive manufacturing programs to more theory-based and contextualised health care. In this sense, the recent literature (P2) suggests that failure factors related to quality improvement programs can be minimised if these initiatives align with the human centrality paradigm.
Practical implications
Analysing the evolution of failure factors in HCQIP helps redesign research and management for better quality health outcomes. Knowledge of the scientific community trajectory over nearly 20 years enables better planning from the patient's perspective and contributes to reducing failures in quality programs.
Originality/value
This study contributes to developing the field of failure factors in HCQIP by providing researchers and managers with an evolutionary, systematic and pioneering view of the theme.
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Emma‐Louise Aveling, Graham Martin, Natalie Armstrong, Jay Banerjee and Mary Dixon‐Woods
Approaches to quality improvement in healthcare based on clinical communities are founded in practitioner networks, peer influence and professional values. However, evidence for…
Abstract
Purpose
Approaches to quality improvement in healthcare based on clinical communities are founded in practitioner networks, peer influence and professional values. However, evidence for the value of this approach, and how to make it effective, is spread across multiple disciplines. The purpose of this paper is to review and synthesise relevant literature to provide practical lessons on how to use community‐based approaches to improve quality.
Design/methodology/approach
Diverse literatures were identified, analysed and synthesised in a manner that accounted for the heterogeneity of methods, models and contexts they covered.
Findings
A number of overlapping but distinct community‐based approaches can be identified in the literature, each suitable for different problems. The evidence for the effectiveness of these is mixed, but there is some agreement on the challenges that those adopting such approaches need to address, and how these can be surmounted.
Practical implications
Key lessons include: the need for co‐ordination and leadership alongside the lateral influence of peers; advantages of starting with a clear programme theory of change; the need for training and resources; dealing with conflict and marginalisation; fostering a sense of community; appropriate use of data in prompting behavioural change; the need for balance between “hard” and “soft” strategies; and the role of context.
Originality/value
The paper brings together diverse literatures with important implications for community‐based approaches to quality improvement, drawing on these to offer practical lessons for those engaged in improving healthcare quality in practice.
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Mark Exworthy, Glenn Smith, Jonathan Gabe and Ian Rees Jones
In recent years, the clinical performance of named cardiac surgeons in England has been disclosed. This paper aims to explore the nature and impact of disclosure of clinical…
Abstract
Purpose
In recent years, the clinical performance of named cardiac surgeons in England has been disclosed. This paper aims to explore the nature and impact of disclosure of clinical performance.
Design/methodology/approach
The paper draws on literature from across the social sciences to assess the impact of disclosure, as a form of transparency, in improving clinical performance. Specifically, it employs the “programme theory” of disclosure.
Findings
The “programme theory” of disclosure involves identification, naming, public sanction and recipient response. Named individual (consultant) surgeons have been identified through disclosure but this masks the contribution of the clinical team, including junior surgeons. Mortality is the prime performance measure but given low mortality rates, there are problems interpreting this measure. The naming of surgeons has been achieved through disclosure on web sites, developed between the health‐care regulator and the surgical profession itself. However, participation remains voluntary. The intention of disclosure is that interested parties (especially patients) will shun poorly performing surgeons. However, these parties' willingness and ability to exercise this sanction appears limited. Surgeons' responses are emergent but about a quarter of surgeons are not participating currently. Fears that surgeons would avoid high‐risk patients seem to have been unrealised. While disclosure may have a small effect on individual reputations, the surgical profession as a whole has embraced disclosure.
Originality/value
While the aim of disclosure has been to create a transparent medical system and to improve clinical performance, disclosure may have the opposite effect, concealing some performance issues and possibly strengthening professional autonomy. Disclosure therefore represents greater transparency in health‐care but it is uncertain whether it will improve performance in the ways that the policy intends.
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Gerry McGivern and Michael Fischer
The purpose of this paper is to explore general practitioners' (GPs') and psychiatrists' views and experiences of transparent forms of medical regulation in practice, as well as…
Abstract
Purpose
The purpose of this paper is to explore general practitioners' (GPs') and psychiatrists' views and experiences of transparent forms of medical regulation in practice, as well as those of medical regulators and those representing patients and professionals.
Design/methodology/approach
The research included interviews with GPs, psychiatrists and others involved in medical regulation, representing patients and professionals. A qualitative narrative analysis of the interviews was then conducted.
Findings
Narratives suggest rising levels of complaints, legalisation and blame within the National Health Service (NHS). Three key themes emerge. First, doctors feel “guilty until proven innocent” within increasingly legalised regulatory systems and are consequently practising more defensively. Second, regulation is described as providing “spectacular transparency”, driven by political responses to high profile scandals rather than its effects in practice, which can be seen as a social defence. Finally, it is suggested that a “blame business” is driving this form of transparency, in which self‐interested regulators, the media, lawyers, and even some patient organisations are fuelling transparency in a wider culture of blame.
Research limitations/implications
A relatively small number of people were interviewed, so further research testing the findings would be useful.
Practical implications
Transparency has some perverse effects on doctors' practice.
Social implications
Rising levels of blame has perverse consequences for patient care, as doctors are practicing more defensively as a result, as well as significant financial implications for NHS funding.
Originality/value
Transparent forms of regulation are assumed to be beneficial and yet little research has examined its effects in practice. In this paper we highlight a number of perverse effects of transparency in practice.
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Sue Kilminster, Miriam Zukas, Naomi Quinton and Trudie Roberts
The aims of this paper are to understand the links between work transitions and doctors' performance and to identify the implications for policy, regulation, practice and research.
Abstract
Purpose
The aims of this paper are to understand the links between work transitions and doctors' performance and to identify the implications for policy, regulation, practice and research.
Design/methodology/approach
The paper explains transitions in terms of the inseparability of learning, practice and performance and introduces the concept of the transition as a critically intensive learning period to draw attention to this phenomenon. It also identifies implications for practice, research and regulation
Findings
Drawing on empirical data in relation to prescribing and case management, the paper will show that, in contrast to current assumptions of, understanding about and practice in doctors' transitions, doctors can never be fully prepared in advance for aspects of their work.
Originality/value
Transitions are explained in terms of the inseparability of learning, practice and performance and we introduce the concept of the transition as a critically intensive learning period to draw attention to this phenomenon. Also identified are implications for practice, research and regulation.
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This paper aims to clarify the potential to use data on doctors and fitness to practise (FTP) cases held by the UK General Medical Council (GMC) for wider regulatory purposes…
Abstract
Purpose
This paper aims to clarify the potential to use data on doctors and fitness to practise (FTP) cases held by the UK General Medical Council (GMC) for wider regulatory purposes, such as identifying risk factors. The paper aims to concentrate on how data are shaped by the GMC's functions and organisational concerns, and by the configuration and use of their electronic database.
Design/methodology/approach
The GMC provided samples of their data, access to documentation surrounding the configuration and use of the database, and meetings with staff able to provide background on the database, GMC procedures, and the GMC as an organisation.
Findings
The FTP database is designed to process cases within complex legal rules, and to provide for accountability. The database and its use are adapted to these purposes. Attempts to use it for other purposes are likely to find it difficult to use, the scope and quality of data uneven and some codes unsuitable. The register data are very narrow in scope. While combining register and FTP data to identify risk factors is by itself of limited value, the database can contribute to closer study of risks to patient safety from poorly performing doctors.
Research limitations/implications
The research was exploratory. It provides initial insights and the basis for further research.
Practical implications
The data have potential policy use for the GMC, but it is essential to understand the limitations.
Originality/value
The paper examines previously unanalysed influences on the GMC's data. It also develops new angles on questions in the regulation literature about organisational risks and the creation of risk data.
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Peter J. Pronovost, Sally J. Weaver, Sean M. Berenholtz, Lisa H. Lubomski, Lisa L. Maragakis, Jill A. Marsteller, Julius Cuong Pham, Melinda D. Sawyer, David A. Thompson, Kristina Weeks and Michael A. Rosen
The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms.
Abstract
Purpose
The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms.
Design/methodology/approach
An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA.
Findings
The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions.
Practical implications
This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms.
Originality/value
Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.
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Health systems worldwide are hampered by disconnects between governance, management, and operations, which negatively impact on their ability to deliver efficient, effective, and…
Abstract
Purpose
Health systems worldwide are hampered by disconnects between governance, management, and operations, which negatively impact on their ability to deliver efficient, effective, and safe healthcare services. This paper shows how insights from the Viable System Model (VSM) can help us to conceptualise health system disconnects impacting specialist clinical services and develop solutions to address organisational fragmentation.
Design/methodology/approach
A case study of a specialist clinical service was undertaken, where the VSM was used to guide semi-structured interviews and workshops with clinicians and managers and analysis of findings.
Findings
The VSM provides a coherent way to conceptualise the disconnects and identify their structural underpinnings. Three novel organisational pathologies emerged from the study.
Research limitations/implications
This New Zealand-based study was undertaken during the COVID-19 pandemic and a period of major health system reform, introducing uncertainty into service provision that may have impacted stakeholders’ views.
Practical implications
The three novel pathologies affect how health systems define their services, their understanding of the management function, and the importance of coordination. The resulting clarity of functioning could improve service quality, staff and patient satisfaction, and the effectiveness and efficiency of healthcare service delivery.
Originality/value
This study contributes to the VSM literature on organisational pathologies by providing three novel pathologies for a perspective that may be useful beyond healthcare and invites consideration of health system disconnects as a coherent field of study.