The Francis Report1 has had a great influence on British public life – from the Cabinet, through the boardroom and down to the shop floor. The report will be widely quoted for many years to come. The report is 1,782 pages long and contains no fewer than 290 recommendations. But how much can one really learn from such an in-depth analysis of just one site? Contrast the Francis Report with a recent systematic overview of the evidence on quality improvement from the Agency for Healthcare, Research and Quality (AHRQ) in Washington, recently summarised in Annals of Internal Medicine2. This AHRQ study is based on a systematic and intellectually grounded analysis of the entire high quality, world literature. It builds on a similar review conducted on behalf of AHRQ by the Stanford Evidence-based Practice Center over a decade ago. And a very interesting and active decade this has been with an exponential increase in research in the areas of quality and safety of healthcare.
Service delivery interventions to improve quality and safety can be divided, from a methodological point of view, into two classes3. Interventions applied close to the patient, with a specific objective in mind, are ‘targeted interventions.’ Interventions applied more upstream of the patient, with multiple objectives in mind are called ‘generic interventions.’ Generic interventions have much broader or diffuse effects on quality. An example of a targeted intervention is the use of ultrasound to guide the placement of intravenous cannulae. Examples of generic interventions include improving the nurse-to-patient ratio or changing the human resources policy.
Targeted interventions are much easier to study – for example they are much more amenable to evaluation through randomised trials. The AHRQ report shows that a number of targeted interventions are effective, including use of peroperative checklists, outlawing use of hazardous abbreviations, medication reconciliation and various types of guideline such as those concerned with ventilator-associated pneumonia, prolonged use of urinary catheters and thromboembolism prophylaxis.
Generic interventions with diffuse effects, are more difficult to study than targeted interventions. Nevertheless, a compelling case for or against generic interventions can often be built systematically by triangulating various sorts of evidence between and within studies.3 It is in this way, for example, that the authors of the overview conclude that improving the nurse-patient ratio leads to better outcomes (including hospital mortality). The report also produces reasonably convincing evidence in favour of rapid response teams, which can be called out from the intensive care unit to attend patients who are deteriorating on the wards. There is very strong evidence for simulation training, especially for complicated technical procedures, but the case for specific team training (as opposed to training in teams) was somewhat less convincing. There is evidence that surgical ‘score cards’ – that is to say a system where surgeons collect detailed data on their cases – leads to improved care when this is owned by the surgical societies and where individual hospitals are put in charge of improvement efforts. This result would seem to vindicate my recent post on how the outcomes of surgical procedures should influence practice. One ‘old chestnut’ is a question of top down cultural change. The evidence that top down cultural change can be produced through ‘heroic’ leadership is extremely unconvincing. A dispersed model of leadership, combined with bottom up specific improvement practices, seems to be the way to go. The report does not treat safety interventions as a black box, but seeks to understand what makes an intervention work or fail. For instance, rapid response teams are dependent on both good monitoring of patients’ conditions on the ward (the afferent arm) and a rapid, efficient response (the efferent arm). Many guidelines, such as checklists, will merely elicit ritualistic displays of compliance unless practitioners have first been convinced of their rationale.
The above are just a small sample of the extensive evidence in the overview. It is a rich source of high quality evidence, based, wherever possible, on comparative studies. It should be essential reading for clinicians and health service managers.
1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Available from http://www.midstaffspublicinquiry.com/report. Accessed 14 March 2013.
2. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, Hempel S, McDonald KM, Ovretveit J, Rubenstein LV, Adams AS, Angood PB, Bates DW, Bickman L, Carayon P, Donaldson L, Duan N, Farley DO, Greenhalgh T, Haughom J, Lake ET, Lilford R, Lohr KN, Meyer GS, Miller MR, Neuhauser DV, Ryan G, Saint S, Shojania KG, Shortell SM, Stevens DP, Walshe K.. Advancing the Science of Patient Safety. Ann Intern Med.2011;154(10):693-696
3. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.