Why is improvement so hard?

1. Why is improvement so hard? HQIP Annual Conference 2010 Martin Marshall Clinical Director and Director of R&D

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

5. 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

6. On average, 45% of patients fail to receive recommended care McGlynn et al., NEJM, 2003

7. 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

8. The overall 5 year survival for all malignancies is 20% higher in Sweden than in the UK Source: EUROCARE-4, 2007

9. Nearly 60% of patients are not told about the potential side-effects of their prescribed medications Source: Commonwealth Fund, 2005

10. How are other sectors doing? Safety 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 Quality 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

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

12. Governmental Regulation Performance management Legislation Ways of improving patient care Professional Education and training Clinical audit Peer review/ collaboration Guidelines Economic Incentives/sanctions Patient choice Competition Commissioning ‘Industrial’/ organisational Org. development TQM/CQI, BPR, PDSA, Lean, 6 sigma

13. Factors relating to the intervention Why is improvement so hard? Factors relating to the environment Factors relating to the people involved

14. Factors relating to the intervention Why is improvement so hard? • 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 • 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 Factors relating to the environment Factors relating to the people involved

15. Factors relating to the intervention • 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 • 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 Why is improvement so hard? Factors relating to the people involved Factors relating to the environment

16. Factors relating to the intervention • 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? Factors relating to the environment Factors relating to the people involved

17. Why is improvement so hard? Isn’t it remarkable that we are doing as well as we are?!!

18. So, why is improvement so difficult? • We don’t know as much about large scale and sustained improvement as we should • ACTION: We need to build the evidence base underpinning improvement in the health sector • What we do know, we rarely put into practice • ACTION: 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 improvement • ACTION: We need to adopt more sophisticated approaches to influencing and motivating people • We have naïve expectations of what we can achieve • ACTION: A generous dose of realism and tenacity is required

20. Thanks for listening martin.marshall@health.org.uk www.health.org.uk