Domhnall MacAuley: All change on Tuesdays

Paris in the spring clearly caught the imagination of the record 2000+ delegates attending the International Quality Forum. Some fascinating lessons in quality improvement but as often, not the ones you anticipate. The first message was never to make changes on a Tuesday- because in any health care system that is when you will have a full complement of staff and the system working at its best.

Think more about systems change that will still work on a Saturday night when staffing is suboptimal and everyone is under pressure.

And, don’t just look at the system- look at how staff work the system because that is where there is potential for mistakes. As an example Carol Haraden (USA) and René Amalberti (France) described a new pill dispensing system that slowed down hospital medicine rounds. But, staff subverted the system by storing tablets in their pockets and the speed of medicine round was limited only by the number of pockets in the uniform.

Mats Bojestig and Göran Henriks (Sweden) , using examples from their remarkable community project in Jönköping, were keen that we think in projects rather than single changes and that microsystem change must be supported by the macrosystem.

But what if things go wrong? Patient safety was a recurring theme at this conference, and one method of learning from errors is Root Cause Analysis.

Brian Toft (UK), who has investigated some difficult high profile incidents using this method, criticised the media use of the word “blunder” and explained how inadvertent error in health care was often the result of a combination of technical, organisational and social factors. He urged us to be aware of “hindsight bias” that it is easy looking back and, “outcome bias” where errors appear so much worse when we know there has been an adverse outcome.

And there were lighter moments. Who could not be seduced by the deliciously entitled talk that suggested that “If quality is important in chocolate, why not in general practice?” Or enjoyed the honesty of the group who conscientiously measured the impact of their information leaflet and found that it left patients more confused! Any comments? Have your say on the blog