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MILLIONS of dollars are spent annually implementing quality management strategies in Australian public hospitals — ranging from hospital accreditation to teamwork training to quality improvement initiatives. Many of the individual programs are based on some forms of evidence (although often not RCT, level 1 evidence). Evaluation of their effectiveness is typically restricted to single hospitals, wards or teams, with little consideration of the system-wide effects of multiple interventions.
What impact do these policies and procedures in combination have on the care patients receive in hospital? The fact is, we have very little understanding of this.
Over 5 years, we worked intensively with 32 public hospitals and 119 departments nationwide to answer this question. We went inside the black box of quality improvement to uncover how things were working, in-depth.
The Deepening our Understanding of Quality in Australia (DUQuA) study is an Australia-wide research project funded by the National Health and Medical Research Council that focuses on the standards, consistency and outcomes of care in Australian public hospitals. It involved 2387 participants, including clinicians (doctors, nurses, and allied health professionals), hospital managers, 2401 medical record reviews and 151 external assessments of the quality of care; 14 031 patients were involved.
DUQuA provides a national profile of acute care, and efforts to improve the quality of that care – a detailed snapshot of performance plus a unique Australian perspective, adding to the international body of knowledge established by earlier European work, the Deepening our Understanding of Quality Improvement in Europe (DUQuE) study. This research, half a decade ago, sought to understand the relationship between quality management systems and patient outcomes in 188 hospitals across seven European countries.
As a guiding principle, DUQuA sought to answer two main questions: what is the relationship between strategies to manage quality of care at the organisation and department levels within the hospital, and do these strategies make a significant difference to the quality of patient care?
Can hospitals be made safer for patients?
Our work in DUQuA is tied very closely to our longstanding interest in making care safer for patients. It is generally accepted that one in 10 patients will experience some form of harm while in the health system. Unfortunately, and despite countless attempts to reduce harm over many years, this figure has remained persistent in Australia and overseas.
With DUQuA, we recognised the need to dive deeper. We wanted to understand how quality and safety measures are implemented both on the wards and by hospital management. How do these strategies work in practice, and do they demonstrably improve care for patients?
To execute the study, we focused on three major health conditions that typically result in a person presenting to hospital: acute myocardial infarction, stroke, and hip fracture. We followed patients with these conditions on their journey from admission to the ward, and on to discharge.
Are organisational level quality management strategies effective?
While DUQuA is the largest and most ambitious study on quality management to date in Australian public hospitals, and one of the largest conducted internationally, we found no compelling evidence that quality management strategies driven at the organisational level result in better quality healthcare. These hospital-wide strategies include directives and policies emanating from governance boards, CEOs and executives, and performance monitoring initiatives, such as mandating systems for incident reporting and auditing. We found that while a hospital may have these structures in place, it is the degree to which they are enacted on the frontline that is most likely to influence patient care.
Put simply, DUQuA not only assessed whether a hospital had a policy to reduce hospital-acquired infections, it also examined the extent of practical application such as whether hand hygiene gel was available on the wards, standards were being met, and patient safety posters were omnipresent. Likewise, protocols may be written around medication reconciliation, but DUQuA also looked on the ward at how medication safety was handled, including observation of patients and their experiences of safety-related activities during their time in hospital.
Our results suggest that frontline interventions might be more effective in improving care than hospital level strategies. In the emergency department, for example, we were able to establish that while implementing evidence-based safety strategies resulted in slightly longer waiting and treatment times for patients, the care delivered was more in line with best practice, clinically and procedurally.
How can hospitals make gains in patient safety?
Nobody doubts that providing care to patients in hospital takes place within an extremely complex system with an array of stakeholders with differing levels of responsibility. This includes clinical teams and individuals, governing bodies, administrators, funders and consumers – all operating at distinctive yet interconnected levels within the system. Any attempt at change and improvement at a hospital therefore needs to be a concerted effort by multiple parties. Almost all meaningful change needs to be multi-pronged, and should be adapted to the circumstances, with progress measured over time. To attempt to change one thing in isolation—say a clinical technique or a nursing routine or an allied health practice—without factoring in adjustments required elsewhere, by others in the system, is quite simply to invite failure.
Importantly, with DUQuA, we have developed tools to measure quality management systems in hospitals, both at the organisational level and also at the department level, for the conditions for heart attack, stroke, and hip fracture. The organisational level tools align with accreditation measures and may therefore be useful for hospitals in creating more effective change. They can be adapted for other conditions, too.
We have also developed tools to assess clinician leadership and safety culture across care pathways. And we have purpose designed or modified existing tools including those to enable patients to report on safety-related aspects of their care. Add this all up, and there’s something for everyone who wants to be in the improvement business and make a difference.
The way ahead
The results of DUQuA will inform the future direction of quality and safety interventions in Australia and internationally. We remain optimistic that as our ways to measure the quality of patient care mature, we will also make headway in tackling the thorny problem of improving quality of patient care in our hospitals and health systems.
In line with our Institute’s commitment to ensuring research is translated into real actionable terms for the health system, each hospital in the study received a confidential benchmarking report comparing their performance against others in the study. Feedback from the hospitals receiving their reports already provides evidence that hospitals will use the information to not only understand their current performance, but also to measure the effectiveness of ongoing and future quality and safety initiatives. As much as it is satisfying for us as researchers to publish articles from our studies in high-quality international journals, this may be the best of all markers of success.
Overarching, summary results from DUQuA are available on our website. The full collection of articles appears in the International Journal for Quality in Health Care.
Dr Robyn Clay-Williams is a senior research fellow with the Australian Institute of Health Innovation at Macquarie University, and leads a research stream in the field of human factors and resilient health care in the Centre for Healthcare Resilience and Implementation Science.
Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science, and Professor of Health Systems Research at Macquarie University. Professor Braithwaite is President-Elect of the International Society for Quality in Health Care.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Hi Jeffrey – congratulations on your research. Depressing isn’t it? We’ve known the key ingredients to high performing organisations that deliver high-quality care for several years now. The question is – what aren’t we applying them? The layers in this answer are many, of course – but there are some that appear to me to be more constraining than others.
In my experience – and research – we have a combination of policy makers and CEOs who ‘don’t know squared’, combined with a lack of will and skill. Many people don’t know what they don’t know about what it takes to create consistently high quality care and how to engage people in that, and lack the will to find out. What’s the real incentive to strive for consistently high quality care, after all? Even where organisations have the will, we often lack the implementation, change and improvement knowledge and skills required to make it business as usual.
So we continue with ‘quality’ being a series of misaligned transactions and projects and compliance and feel-good programs full of buzzwords that kill staff interest and motivation. The question I’m asked most often is how to engage staff in ‘quality’ – often by those who are doing the most to drive them away. Unfortunately, ‘quality’ in this context is often code for ‘how can I get staff to do a lot of boring stuff they can’t see the point of?’ As long as this is ‘quality’, rather than what staff create with consumers at point of care, nothing will shift. Consistently high quality care is still seen by many CEOs as a nice to have, rather than a must have, (with many in aged care openly saying it’s impossible, so why bother?) despite all the person-centred rhetroric – in a way that well-managed finances would never be. This is a big boulder in the road to progress.
It can be done – of course! And where it is done well, the results are exciting. As you know, Sandy Leggat and I did a smaller study over three years that concurs with your findings. Ours compared health services that took a strategic approach to creating a consistently high quality experience at point of care – that was clearly and simply defined by consumers and staff throughout the organisation – with those taking a more traditional and ubiquitous compliance-based approach. In the strategic model, the whole organisation aligns around supporting staff to create that experience – consistently. Although three years wasn’t enough to see wholesale changes across all measures, the strategic health services did demonstrate significant improvements in some measures, as well as more positive staff attitudes that shifted from seeing the Q system being unhelpful to helpful over the three years (including doctors.)
We also seem to struggle with the concept that people create high-quality care – or not. We consistently put the program before the people. Too often, the new shiny thing comes along, CEO says ‘yes’ and the quality person’s job is to shoe-horn staff into it. Starting with the people – staff and consumers – getting clear on what’s important to them (which is surprisingly consistent between the two groups) and making the compliance and projects and programs work to support this now seems to me to be common sense (after many years of doing it the other way around!) But it appears it will still be a long time before it’s common practice. I hope your research moves us in that direction.
It’s good to see an independent assessment of hospital Quality systems. I’m in agreement with most of the comments above, but it doesn’t have to be this way.
Firstly, most hospital Clinical Governance examines past events and responds reactively. Not surprisingly this often results in re-inventing a wheel that has been around for a long time.
Secondly, the process almost always results in recommendations which increase the complexity and paperwork burden on busy clinicians. To an engineer, simplicity is elegance: less moving parts make for less potential failure points.
Thirdly most of these activities occur at a local level and are based on local opinion, rather than international best-practice evidence.
The solution therefore is for Clinical Governance to focus on process improvement by simplifying the processes without compromising the ultimate goal of better patient outcomes. And this must be done in a forward-looking fashion, taking into account all the available evidence. We must move out of our hospital silos, welcome outside scrutiny and collaborate with experts in the field.
I commend the authors for their article, the content having been a talking point for the medical profession and other clinicians for some time.
The finding that front line staff make the most important contributions to patient care and safety should not be a surprise to us but this research now provides the evidence.
Unfortunately, when derogatory phrases such as “medical administrative rogues” and “Death knell for medical administration and administrators!. Hooray” are used it is obvious that some readers have neither understood the article nor its implcations. It is also disconcerting that colleaguess make such unhelpful comments under the veil of anonymity.
In my view, it is a stark reminder of just how far some in our profession need to advance in relation to properly and accurately measuring patient outcomes. Such comments demonstrate that many colleagues are unwilling to accept there is a problem or that we should attempt to improve care and safety in the whole health sytem – not just in Australia but globally.
How can we tolerate adverse events in 1 in 10 patients admitted to hospital… some of whom will be even those reading this article?
The real question is how do we improve on this based on high quality information?
First ensure natural justice for doctors. We can talk about systems and processes later. In a climate where medical administrative rogues can threaten to ‘stand down’ doctors after executing ‘setups’, talking about these is hilarious. There is ‘no quality in quality’ is less of a problem.
Far too much ‘quality management’ is a masquerade, because it is focussed on processes, not outcomes. This has led to ever increasing spirals of over-engineered processes (think ever expanding tick box documents), which add cost, add complexity (making error more likely), and distract frontline staff from concentrating on the patient and the patient health outcome. Unfortunately it has become the norm. We need to go back to the basic and original tenet of quality management: measure outcomes and use that to guide change (and stop measuring the processes). Measuring outcomes includes measuring errors, but you have to disregard random errors and concentrate on system errors. This requires expertise. Unfortunately too many random error events lead to changed processes (more tick boxes and another few pages to a policy, etc), but not real improvement. It was a shame this article did not discuss the problem of relying on process measurement & management as a proxy for outcome measurement & management. To me, it is the root cause of the waste of time and effort that most ‘quality management’ has become.
SURPRISE SURPRISE! Docs on the front line knew this anyway. The whole purpose of the never-ending paper trails seems to be to allow someone, somewhere, in Head Office justifying their own incomes and empires by getting others to tick boxes. Sadly, i’ll be retired before there is any significant change…..
Death knell for medical administration and administrators! Hooray
The answer, a resounding no, should come as no surprise. But what is worrying is the toll these ‘quality business’ take on the Medical Doctors. Systems such as the Incident management sytem or ‘Riskmans’ are used as weapons instead of their intended purpose. There is a linear rise in bullying, harassment and discrimination with the introduction of these systems. I strongly condemn the indemnity industry and regulatory bodies from benefitting out of harassing the medical profession using such tools under the pretext of quality. I am sure people interested in the future of this country will not support such systems lest we risk a social rot. IT is not information technology but Information Theivery. And such systems form the backbone of these frivolous endeavours. The money spent on IT can be better spent on improving Specialist access, buying vital life saving equipment and supporting Junior Medical officers.