{"id":363,"date":"2008-04-25T10:36:47","date_gmt":"2008-04-25T09:36:47","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/2008\/04\/25\/domhnall-macauley-all-change-on-tuesdays\/"},"modified":"2008-04-25T10:36:47","modified_gmt":"2008-04-25T09:36:47","slug":"domhnall-macauley-all-change-on-tuesdays","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2008\/04\/25\/domhnall-macauley-all-change-on-tuesdays\/","title":{"rendered":"Domhnall MacAuley: All change on Tuesdays"},"content":{"rendered":"

Paris in the spring clearly caught the imagination of the record 2000+ delegates attending the International Quality Forum<\/a>.\u00a0Some 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.<\/p>\n

Think more about systems change that will still work on a Saturday night when staffing is suboptimal and everyone is under pressure.<\/p>\n

And, don\u2019t 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 Ren\u00e9 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.<\/p>\n

Mats Bojestig and G\u00f6ran Henriks (Sweden) , using examples from their remarkable community project in J\u00f6nk\u00f6ping, were keen that we think in projects rather than single changes and that microsystem change must be supported by the macrosystem.<\/p>\n

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.<\/p>\n

Brian Toft (UK), who has investigated some difficult high profile incidents using this method, criticised the media use of the word \u201cblunder\u201d 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 \u201chindsight bias\u201d that it is easy looking back and, \u201coutcome bias\u201d where errors appear so much worse when we know there has been an adverse outcome.<\/p>\n

And there were lighter moments. Who could not be seduced by the deliciously entitled talk that suggested that \u201cIf 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<\/p>\n","protected":false},"excerpt":{"rendered":"

Paris in the spring clearly caught the imagination of the record 2000+ delegates attending the International Quality Forum.\u00a0Some fascinating lessons in quality improvement but as often, not the ones you […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-363","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\nDomhnall MacAuley: All change on Tuesdays - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2008\/04\/25\/domhnall-macauley-all-change-on-tuesdays\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Domhnall MacAuley: All change on Tuesdays - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Paris in the spring clearly caught the imagination of the record 2000+ delegates attending the International Quality Forum.\u00a0Some fascinating lessons in quality improvement but as often, not the ones you [...]More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmj\/2008\/04\/25\/domhnall-macauley-all-change-on-tuesdays\/\" \/>\n<meta property=\"og:site_name\" content=\"The BMJ\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bmjdotcom\/\" \/>\n<meta property=\"article:published_time\" content=\"2008-04-25T09:36:47+00:00\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:site\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Domhnall MacAuley: All change on Tuesdays\",\"datePublished\":\"2008-04-25T09:36:47+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/\"},\"wordCount\":370,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#organization\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2008\\\/04\\\/25\\\/domhnall-macauley-all-change-on-tuesdays\\\/\",\"name\":\"Domhnall MacAuley: All change on Tuesdays - 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