Quality and safety – inseparable partners on the improvement journey

Quality and safety are intimately linked, hand in glove. You can’t really say you’re delivering quality healthcare without also addressing the safety of patients. As Associate Editor for saferhealthcare (the BMJ and National Patient Safety Agency?s joint website for patient safety) I’m always trying to sniff out good ideas, success stories, pilot studies, new approaches and the myriad of other innovations in healthcare that demonstrate improvements to safety. Many of these small scale improvements never make it into the peer reviewed literature or indeed any literature at all. Most often they are shared through informal networks, meetings and events. With this ongoing quest in mind, I joined the BMJ team in Prague for the 11th European Forum on Quality Improvement in Healthcare and volunteered my sketchy credentials in improvement as a blogger for bmj.com.

Joining an event designed for chief executives, leaders, policy makers and high level thinkers with the task of delivering some sensible copy for a specialist medical audience, has caused me slight loss of sleep, however it?s my hope this idiosyncratic review of an intense, interesting and sometimes extraordinary meeting will give you a sense of where the healthcare quality movement is heading, where they think they?re at, and why you should join them ? and register with saferhealthcare – without further delay.

Wednesday ? morning
Getting past take off?
Sometimes you get the impression going to a conference is more trouble than it?s worth. Getting to Prague from Cardiff took me 24 hours and 30 minutes. Yes, that?s right, I left at 9am on Tuesday morning and arrived at 9.30am on Wednesday. Instead of an early afternoon arrival, supper with some of our editorial board who?d also be arriving on Tuesday, I found myself sleeping in a dreary Dutch dorm, an hour?s drive from Schiphol airport after a KLM fiasco with a grounded plane, fog and a bus to Bristol. The knock on effects for me were missing an entire nights sleep (three hours doesn?t count as a night, surely?), sleepwalking through the first day of the meeting, missing the fun and games after the reception and then spending the rest of my time here running to catch up with myself.

I was thoroughly put out by the whole thing. It was an experience that left me angry, dissatisfied, and in some way victimised ? why had it happened to me, why here, why now? Didn?t they know I had a job to do?

The plane had a hydraulic fault somewhere in its system, discovered just seconds before take off ? we were on the runway. The engines were roaring we were all set ? then nothing. Minutes later we were told the plane couldn?t leave and were towed back to the terminal.

A cabin crew girl said to me, ?Well its better they found it now, than half way over the North Sea?. I couldn?t agree more. Here we all were, completely unharmed by the whole experienced, despite inevitable inconvenience.

The safety systems of the plane prevented the error becoming a failure and then a disaster. That?s all great, and yes, there?s got to be lots we can learn from aviation in getting healthcare to the same point of safety consciousness, but it?s not the whole story.

What?s more interesting, is how even though the plane?s safety system was top notch, the quality or the system was pretty much close to zero. And it was the absence of quality that turned me from a reasonable, sympathetic and understanding customer into a blood thirsty harridan ready to kill or at least maim the next person I met in a KLM uniform who gave me an insincere ?sorry?.

After getting off the grounded plane I spent a long day being shunted from queue to queue. At no point in time was an apology given that explained what would happen next or how I would be compensated. Neither was I offered a drink or anything to eat ? my comfort was of no concern. I was told lies ? that I would make my connecting flight. And I was given incorrect information that meant my night?s sleep courtesy of KLM in a disgracefully poor hotel somewhere by the sea and nowhere near the airport, was cut short by a taxi ride at 4am ? arranged by KLM an hour too early ? to catch a flight at 7.10am. I tried contacting the KLM press office to discuss this, but they were all away at a meeting.

There are parallels here for healthcare, most notably what Charles Vincent describes as the aftermath. There?s an aftermath for staff involved in a medical error, but there?s also a lot of work that needs doing with patients who?ve suffered harm as a result of an error in their treatment.

Nobody got hurt by KLM?s shoddy customer care, but perhaps it does help make it clearer why patients who?ve suffered harm often feel angrier about their treatment afterwards than they did about the mistake in the first place. We know that patients who?ve suffered harm and have not received an apology are more likely to sue. We also know that for the most part clinicians are struggling with being open and honest about disclosing untoward events and saying sorry to their patients when things go wrong. It looks like healthcare and aviation are level pegging on this one.

The system failure with the plane was something all of the passengers and crew could accept ? gratefully ? but the shoddy treatment afterwards was absolutely unforgivable.

Safety, it would appear, needs quality, just as much as quality needs safety.

Wednesday ? coffee break
La plus ca change?
It?s taken me ages to locate the ladies loo in the congress centre, don?t ask me why or how, but it just has. And I was surprised to find waiting for me, at my service, the familiar, Eastern European own brand of oddly brown recycled paper loo roll. I?d forgotten all about brown loo roll, but it epitomised life under state communism in many ways ? entirely functional, devoid of beauty, and used to generate additional income ? in this case by more opportunistic toilet attendants who?d exchange a few sheets for spare change on your way in, rather than hope for the customary tip on the way out.

And rediscovering this relic of times past here in the congress centre, one of the last great monuments to modernisation and progress the old communist party was so fond of, it reminded me of the last time I was here, in 1992, just as the realisation that state socialism was finally over was starting to sink in.

At that time there was still a massive statue of Lenin in the park immediately over the river Vlatva from my hotel, but that?s gone now. Gone too are the exhaust beltching fleets of pale blue and green trabants, ladas and skodas that wove perilously in and out of the bell ringing trams. The trabants have been upgraded to Clio?s, Golfs, and A3s, but the trams are still here – although they?re now covered with adverts for Benetton and HSBC bank.?

So in amongst all this apparent change, all this glitz, glamour and widespread and welcome improvement in Prague, the strangely familiar, functional, cheap and ugly brown loo roll has persisted.

Why am I telling you this? Because even in improving healthcare systems and there are still going to be the ?ugly?, that?s to say, high risk practice, procedure or accepted way of doing things, that invisible because it?s always been there. And if it is noticed, it?s often not considered important because it?s always been that way, and if there?s never been a problem or a complaint, why bother changing it?

The task of quality and safety improvement is not only to expose all these ugly practices, but to become so acutely aware of them they can be seen them at a distance. To get beneath the feel-good veneer of ?doing well? and impression ? however valid and worthy of celebration – of making great strides from tracking actual improvements, and hunt down all the potential errors that can be found, expose less than perfect procedures and put right anything not working properly, whether it?s a team structure or an old piece of equipment, and never rest easy.

To literally ? and pardon the pun ? flush them out of the system.

Wednesday afternoon
A deathly silence
?We had ten goals, now we only have one,? says Cathie Furman, Vice President of Virginia Mason Medical Centre.

?To ensure the safety of our patients and eliminate avoidable death and injury.?

Cathie has to force herself to speak, she?s close to tears. The mood in the room is quiet and slightly stunned. Moments before we were riding a wave of enthusiasm with her as she described how Virginia Mason adopted the Toyota Production System to radically transform their systems and she?d shared with us how this manufacturing process has been adopted, the development of a safety alert system in line with the philosophy of zero defects and stopping the line.

How well they?d done, how brilliant they?d been ? how all of this seemed like a truly inspiring story of fresh thinking, innovation, commitment with well deserved success. Which it was ? but ? and it was a big but, two years into zero defects, they experienced a devastating error which killed a patient, a death that was entirely avoidable.

Mary McClinton?s case was well known to me. I?d come across it in my weekly sweep for our news in brief on patient safety when the settlement for the family?s compensation was agreed in the courts. At the time I was shocked and disgusted. Here was a woman who?d been in for a relatively routine procedure and had never left the hospital. Instead of an injection of saline, she?d been given an injection of chlorhexidine ? a cleaning agent ? instead.

Cathie Furness described what happened to Mary in obvious distress. She told us how Mary was a valuable member of the African-American community and how her loss was a great loss to many people, not only her family. Here she was with responsibility for quality and safety improvement, busily improving safety and feeling good about all the progress they?d made. And yet she couldn?t see a disastrous situation waiting to happen because not a single staff member had recognised its potential for harm and raised an alert, until it was too late.

In the operating theatre it was accepted practice not to label the three frequently used solutions at the table: saline, contrast dye and chlorhexidine. The theatre staff knew which was which, not only from experience, but because the chlorhexidine was orange, and while the saline and the contrast dye were both clear and mixing these two carried little risk to the patient. However, the chlorhexidine manufacturer had recently changed the presentation of the product, removing the orange dye and now supplying as a clear solution. So now there were three clear, solutions in unlabelled cups beside the operating table. And as it was accepted practice not to label these cups, no one thought twice, even though a potentially lethal solution was now sitting side by side with two that were sometimes muddled but with no ill effect on the patient (?Oh – nothing showed up, so we must have given saline instead of dye! Let?s try again with the dye.?).

When Mary?s death was investigated, it turned out that the hospital next door to Virginia Mason had experienced an error with the solution two years ago, but they hadn?t disclosed it. Many others had also had misgivings about the change in colour of chlorhexidine and seen the problem coming, they?d ?wondered? about it, but had said nothing.

As Jim Reason says, safety demands a feral vigilance. It?s not something you do, it?s how you think. How you keep looking for risks and threats, then what you say and how you change your behaviour because of them.

That?s why Virginia Mason now has only one goal, not ten ? to keep patients safe.

Thursday – morning
Same path, different journey
At a meeting this big there?s bound to be some overlap in content, and both yesterday and today there was discussion of care pathways. But despite similar subjects those presenting their work couldn?t have been more different or done a better job in highlighting the essential tension in healthcare improvement: is improvement a quantifiable exercise that can be measured and costed, or are we striving for an altogether more subtle attitudinal change in clinical care and the way in which it is managed?

In Paul Bate, Peter Mendel and Glenn Robert?s session we were treated to the ?secrets? of high performing healthcare organisations both in Europe and in the US. In their analysis San Diego hospital was given as an example of how the development of care pathways had been used as a tool for wider, cultural change. Their attention to the development of accurate pathways, responsive to patient need and delivering the safest and highest quality care was part of a cultural change and a demonstration of mindfulness in the delivery of care.

In contrast, today?s breakfast meeting, sponsored by BUPA to highlight their work in developing and implementing care pathways across all their UK hospitals, told a different story.

BUPA is the UK market leading independent healthcare provider. And although it?s a provident association reinvesting any profit back in the business, like any business, variation in service delivery is undesirable ? customer expectations are not always met, the brand integrity can be eroded and revenues lost.

Their description of successfully developing flexible and responsive care pathways was exemplary, but begged the question of whether the imperative to create care pathways that could be reproduced in all of their 26 British hospitals, was motivated more by the desire to standardise a product, control costs and guarantee customer satisfaction, than transform a culture by putting safety and quality improvement at its core as San Diego had done.

It?s a bit like the choice we?ve all had to make this week ? do you stay in the Holiday Inn next door to the congress centre or trust to luck in an independent hotel in the old town? You know at the Holiday Inn the level of service is guaranteed, you know there?ll be hot water at all times of the day and night, that the broadband connection won?t cut out on you when half way through downloading an extra couple of PowerPoints for your presentation tomorrow ? but you also know there will be no surprises, no eccentric waiters, no charm, history or personality. I know which I?d prefer, but my hotel isn?t a life and death choice ? just comfort vs discomfort, expense vs value and convenience vs beauty.

How do we reduce variation yet retain meaningful relationships, responsiveness, flexibility, creativity and innovation ? such telling signs of culture?

Thursday afternoon
The power of suggestion?
?So what?s happening in the UK ? you?ve got the NPSA, the Innovations Agency, the Safer Patients Initiative, and aren?t you reducing the number of health authorities?? ? what?s the strategy for quality improvement here?? The question came from a confused Dutch delegate in response to another improvement presentation from the UK, sponsored by yet another agency ? this time the Healthcare Foundation sponsored Safer Patients Initiative. But the answer to ?what?s the plan then?? is a tough one to answer ? just what are we doing in the UK? What is the driving force for change and where?s the motor to power quality improvement?

The question is one that?s uppermost on Carol Haraden?s mind too. As Vice President of the Institute for Healthcare Improvement, Boston, USA, the key partner for the Safer Patients Initiative in driving forward a programme of work to achieve quantifiable improvement in patient safety in five key areas of clinical practice, she wants to know how come quality improvement isn?t an actual necessity for trusts in the UK?

The NPSA can only suggest changes in practice to improve patient safety, the Healthcare Commission can only indirectly shape practice by choosing which indicators it will measure as regulator. If the Healthcare Commission does have teeth enough to bite, are they busy snapping at the heels of those reluctant to get moving to improve patient safety and deliver a quality health service?

And in our soon to be rationalised health authorities, what chance is there in delivering a planned approach to quality improvement, when quality is an additional and perhaps unwanted responsibility added to servicing a larger patient population at an austere level of financial efficiency.

What hope is there for effecting quality improvement programmes throughout the NHS using the power of suggestion alone?

Questions, questions…but no answers as yet. I guess there are always the sessions tomorrow.

Thursday ? late afternoon
From why to how
Running to catch up with Don Berwick ? quality guru, leading light, charismatic leader of the Institute for Healthcare Improvement. I?d spotted him sampling the pilsner & sausage at the Czech reception last night, but hadn?t the guts to extract him from his huddle with Muir Gray, he most lately of the National Electronic Library for Health in England. To my great surprise, I managed to catch him alone and in relative peace and quiet after an improvement clinic just as we left the congress hall. I had his attention from the doors to the stairs which led to yet more people, more meetings, more colleagues.

?Where?s safety in all this quality improvement, Don, can you have one without the other?? I chirruped, swiftly turning on my voice recorder.

?If an organisation were very responsive to patient needs, very efficient, very reliable but unsafe?, Don paused thoughtfully as if the question had never been asked before, ?um, then I guess, no, I wouldn?t want to be a patient there, so no that wouldn?t mean quality.?

?But on the other hand, if an organisation were super safe, but undignified, wasteful and otherwise unreliable, then I wouldn?t want to go there either. So we need to see quality as a collection of dimensions that include safety and are all important.?

We were fast approaching the head of the stairs, and I felt like we hadn?t even made it to the metaphoric foothills of the quality mountain.

As a founding member of the Quality Forum I was eager for his perspective – what progress? What challenges are ahead of us? What?s next?

?Yes, it?s really encouraging.

?We are making progress. Take the session we?ve just had. Years ago you’d have seen real resistance to the idea of putting patients on an equal footing with healthcare professionals in service design and delivery, but now people are asking, not why, but how do we do this. This is a dramatic shift in tone from only a few years ago, I think.’

And hopes for the future?

Yes, but here we were at the head of the stairs, and he artfully rounded me off with a satisfyingly straight-in-the-eye thank you.

So the interview of my saferhealthcare career to date, lasted less than two minutes ? one minute 46 seconds to be precise ? the time it took from the doors of the congress hall on level three, to cross the marble to the top of the stairs and the networking brouhaha below.

(Shortly after I caught up with Don Berwick, I had chance to chat with Lynne Maher of the NHS Institute for Innovation and Improvement and the mischievous consultant Paul Plsek, renowned for his work on complexity, and discovered that Don?s artful circulation in crowds usually resulted in conversations on average 80 seconds long. So I did quite well.)

Friday ? en route early coffee
Prague?s patient revolution
Prague is no stranger to revolutionary thinking and there was plenty to be found at the quality forum. Just as the Velvet Revolution set Prague apart from its neighbours by taking a brave stand against the oppression of the Communist state and demonstrated the resistance that was never lost, so too might this meeting in Prague mark a revolution ? or at least a determined and brave stand ? in patient involvement in the all aspects of the quality agenda. What would have been almost heretical in the early days of the forum ? that patients can and must be involved in improvement ? was now being discussed openly, frankly, without fear or indeed resistance.

?I wanted to know about progress in European countries in safety issues also I am interested to learn what kind of progress you?ve made in patient participation and patient advocacy programmes because we need this in Japan and I want to benchmark our programmes,? Professor Naruo Uehara of Tokyo University and the Japanese Society for Quality and Safety in Healthcare told me.

I don?t know if Professor Uehara went to Don Berwick?s improvement clinic on Thursday afternoon, but there was a presentation that was perhaps the most telling indicator of a revolution in progress.

South West Sheffield Primary Care Trust in the UK have brought together a panel of patients and trained them in clinical audit. They?ve signed the same confidentiality agreement as paid staff and have the same status as other members of the clinical audit team, although they work on a voluntary basis. They are having such success in their work that clinicians have been heard to ask them ?well, you tell us, what should we do?? in matters of service improvement.

The irony is that demand for their services outstrips supply ? more clinicians want to use these patient representatives than the clinical audit patient panel in Sheffield is able to supply. How strange to have a revolution in which ?the oppressor? is finding it hard to mobilise ?the oppressed?.

Old hands like David Stevens (editor of Quality and Safety in Health Care) didn?t think patients would drag their feet over involvement in healthcare for much longer.? Generation Y, he argued, are true consumers ? they want quality services, at the right price when they want them, and healthcare is no different to anything else. As mass connectivity has put us all on the same level ? there?s no privacy for the medical profession anymore ?our sins are there for all to see, but so too is the information on which many healthcare decisions are made, which is and will continue to change the nature of the patient-health system relationship from here onwards.

Next year expect to hear more from patients, if not, you can be sure there will be bitter complaints from the delegates.

Friday – later in the morning
Not a network, a place
Listening to the delegate from J?nk?ping County Council talk about how resources are available to all involved in delivering a seamless pathway of paediatric care – right from the patient?s local and personal situation, all the way up to tertiary services – you?d be forgiven for thinking they had access to a fabulous library somewhere in the depths of the J?nk?ping countryside.

So welcoming indeed this place of knowledge exchange sounds, you might think they?re getting together in a small house, door left slightly ajar, filled with the smell of freshly brewed coffee and humming with hushed voices interspersed with the occasional laughter of relaxed collaboration turning into friendship.

You can imagine shelves of well thumbed documents, impeccably filed and easily accessed, many terminals to search and access online journals and reports. Here you?d find everything you need to know for realising a continuous pathway of care in your specialism, whether clinician or manager.

This house really does exist, and in it you?ll find doctors, nursing staff, school nurses, consultants, patients and other health professionals. They are indeed using and discussing all the tools and information they need to keep this pathway at the forefront of their practice and inform every step of the patient?s journey.

But it?s an entirely digital workspace found within the intranet of the county council. Accessible to all involved in delivering and accessing healthcare services for each speciality in paediatrics, it?s a point of reference, a meeting place and a focus.

People talk about it as if it were a place where knowledge is exchanged, work is done, and essential maintenance on keeping everything up to date ? not just information but also the systems impacted by changes to guidelines – is carried out.

It?s just a shame you can?t smell the coffee or hear the laughter.

For digital information workers this is our challenge ? to make the online environment as meaningful and inviting as a physical space. To add value by filtering information for the task in hand, bringing essential evidence up from the search engines and placing it immediately in the hands of those who need it. And of course making sure everything is pertinent, timely and accurate.

For the paediatric specialisms in J?nk?ping accessing this workspace, you can be sure it adds to their success ? it represents a larger way of working and thinking, beyond the tribalism found in many healthcare systems, and has helped create unity in care pathways that cut across many systems, specialisms, professions and centres.

Friday – in the fading Forum twilight
System transformation
As an initiate, the Forum was an exhilarating experience. Where else on earth might you find this kind of international collection of experience, innovation and commitment for healthcare?

But the Forum is not an easy place to hang out if you find it difficult to think laterally ? it has many strands, many layers and many philosophical and methodological contributions. It is a meeting point for many people with many agendas at many different levels of influence. But a strange alchemy did occur last week ? amongst all the diversity of knowledge, experience and systems, a quiet realisation grew – of order from chaos, consensus from cacophony.

The Forum in Prague marks arrival at a place of initial mastery ? the technology, tools, ideas, experience and networks are all in ready, proven and increasingly widely available. Next up appears to be the challenge of moving from ?doing to being? ? from small scale local change to regional and national system change, from project to transformation.

I think Maureen Baker CBE ( Royal College of General Practitioners and advisor to National Patient Safety Agency in the UK) summed it up well, when she said we?ve reached a point that requires ?a great leap forward? and not more piecemeal change.

It?s time to change the thinking of quality improvement, and instead conceptualise the next quality challenge as transforming systems, as a whole, at all levels, simultaneously. Systems thinking will turn ?quality improvement? into ?quality thinking? and embed quality into the daily business of healthcare delivery. As one delegate said:

?we can?t change healthcare if we don?t change it all at the same time.?

Thanks to all those who spared time to share their thoughts, especially:
Suzette Woodward, David McCutcheon, Jonathon Gray, Sir John Oldham, Fiona Moss, Duncan Neuhauser, David Stevens, Paul Plsek, Don Berwick, Carol Haraden, Pat O?Connor, Jim Reason, Lynne Maher, Vanessa Wood, Goring Henrik, Gill Hastings, Viv McLoughlin, Bharat Patel, Jane Smith, Gillian Bowtell, Arlene Shenkorov, Frank Mansell, Rick Johnson, Phil Higton and Yvonne Engels.

Competing interest: The BMJ Publishing Group (for whom I work) runs the European Forum along with IHI.

Jenny Kowalczuk, Associate Editor, saferhealthcare www.saferhealthcare.org.uk
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