Harveian Oration 2018: Improving quality and safety in healthcare

Clinical Medicine, Journal of the Royal College of Physicians of London

Volumn 19, Issue 1, 2019, Pages 47-56

  Dixon Woods, Mary ^a,b  

^a UNIVERSITY OF CAMBRIDGE   (United Kingdom)

^b HOMERTON COLLEGE   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL AUDIT; EVALUATION STUDY; EVIDENCE BASED MEDICINE; HEALTH CARE PLANNING; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HEALTH ECONOMICS; HEALTH SURVEY; HUMAN; INCIDENT REPORT; MEDICAL PROFESSION; NATIONAL HEALTH SERVICE; PROBLEM SOLVING; PROFESSIONAL STANDARD; PROGRAM EFFECTIVENESS; REVIEW; SAFETY; TOTAL QUALITY MANAGEMENT; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY; UNITED KINGDOM;

HUMANS; PATIENT SAFETY; QUALITY ASSURANCE, HEALTH CARE; QUALITY IMPROVEMENT; STATE MEDICINE; UNITED KINGDOM;

EID: 85060169629     PISSN: 14702118     EISSN: 14734893     Source Type: Journal    
DOI: 10.7861/clinmedicine.19-1-47     Document Type: Review

References (87)

1. Charlesworth AJ, Johnson P (eds). Securing the future: funding health and social care to the 2030s. London: Institute for Fiscal Studies and the Health Foundation, 2018.
2. Holmes A. Infection prevention and control: lessons from acute care in England. Towards a whole health economy approach. London: Health Foundation, 2015.
3. Neuburger J, Currie C, Wakeman R et al. The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Medical Care 2015:53:686-91.
4. Brown JR, Solomon RJ, Sarnak MJ et al. Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention. Circ Cardiovasc Qual Outcomes 2014; 7:693-700.
5. Cloud G, Hoffman A, Rudd A: On behalf of the Intercollegiate Stroke Working Party. National Sentinel Stroke Audit 1998-2011. Clin Med 2013:13:444-8.
6. Montray J, Breau RH, Cnossen S et al. Change in adverse events after enrollment in the national surgical quality improvement program: a systematic review and meta-analysis. PLOS ONE 2016:11:e0146254
7. Blanchfield BB, Demehin AA, Cummings CT et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure. Jt Comm J Qual Patient Saf 2018:44:583-9.
8. Rudd AG, Hoffman A, Paley L et al. 20 years of researching stroke through audit. Clin Rehabil 2018:32:997-1006.
9. Boyle DA, Keep DJ. Clinical audit does not work, is quality improvement any better? Br J Hosp Med 2018:79:508-10.
10. Himmelstein DU, Ariely D, Woolhandler S. Pay-for-performance: toxic to quality? Insights from behavioral economics. Int J Health Serv 2014:44:203-14.
11. Woolhandler S, Ariely D, Himmelstein DU. Why pay for performance may be incompatible with quality improvement. BMJ 2012:345:e5015.
12. Armstrong N, Brewster L, Tarrant C et al. Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. Social Sci & Med 2018; 198:157-64
13. Deming WE The new economics: for industry, government, education. MIT Press, 2000.
14. Berwick DM Continuous improvement as an ideal in health care. N Engl J Med 1989; 320:53-6.
15. Department of H.A promise to learn: a commitment to act. Improving the safety of patients in England. London: Department of Health, 2013.
16. Dixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hosp J 2016; 3:191-4
17. Alexander JA, Hearld LR. What can we learn from quality improvement research? A critical review of research methods. Med Care Res Rev 2009; 66:235-71.
18. Benn J, Burnett S, Parand A et al. Studying large-scale programmes to improve patient safety in whole care systems: challenges for research. Soc Sci Med 2009; 69:1767-76.
19. Holden RJ Lean thinking in emergency departments: a critical review. Ann Emerg Med 2011; 57:265-78.
20. Taylor MJ, McNicholas C, Nicolay C et al. Systematic review of the application of the plando-study-act method to improve quality in healthcare. BMJ Quality Saf 2014; 23:290-8.
21. Martin G, Ozieranski P, Willars J et al. Walkrounds in practice: corrupting or enhancing a quality improvement intervention? A qualitative study. Jt Comm J Qual Patient Saf 2014; 40:303-10.
22. Scott I. What are the most effective strategies for improving quality and safety of health care? Int Med J 2009; 39:389-400.
23. Jones EL, Lees N, Martin G et al. How well is quality improvement described in the perioperative care literature? A systematic review. It Comm I Qual Patient Saf 2016; 42:196-206.
24. Woolf SH The meaning of translational research and why it matters. JAMA 2008; 299:211-13.
25. Grady D, Redberg RF, O'Malley PG. Quality improvement for quality improvement studies. JAMA Int Med 2018; 178:187.
26. Basu S, Meghani A, Siddiqi A. Evaluating the Health Impact of Large-Scale Public Policy Changes: Classical and Novel Approaches. Annual review of public health 2017; 38:351-70.
27. Chen YF, Hemming K, Stevens AJ et al. Secular trends and evaluation of complex interventions: the rising tide phenomenon. BMJ Qua/Saf 2016; 25:303-10.
28. Marshall M, Pronovost P, Dixon-Woods M. Promotion of improvement as a science. Lancet 2013; 381:419-21.
29. Nicolay CR, Purkayastha S, Greenhalgh A et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg 2012; 99:324-35.
30. Berwick DM The science of improvement. JAMA 2008; 299:1182-84.
31. Benning A, Dixon-Woods M, Nwulu U et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ Clin Res Ed 2011; 342:d199.
32. Benning A, Ghaleb M, Suokas A et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ Clin Res Ed 2011; 342:d195.
33. Morgan DJ, Diekema DJ, Sepkowitz K et al. Adverse outcomes associated with Contact Precautions: a review of the literature. Am J Infect Control 2009; 37:85-93.
34. Westbrook JI, Li L, Hooper TD et al. Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. BMJ Qual Saf 2017; 6:734-42.
35. Power M. Organized uncertainty: Designing a world of risk management. Oxford: Oxford University Press, 2008.
36. Leigh A. Randomistas: how radical researchers are changing our world. New Haven: Yale University Press, 2018.
37. Allen D. From polyformacy to formacology. BMJ Qual Saf 2017; 26:695-7.
38. Sterman J, Oliva R, Linderman K et al. System dynamics perspectives and modelling opportunities for research in operations management. J Oper Manag 2015; 39-40:1-5.
39. Bindman AB, Pronovost PJ, Asch DA. Funding innovation in a learning health care system. JAMA 2018; 319:119-20.
40. Wachter RM, Pronovost PJ. The 100,000 lives campaign: a scientific and policy review. Jt Comm J Qual Patient Saf 2006; 32:621-7.
41. Brewster L, Aveling E-L, Martin G et al. What to expect when you're evaluating healthcare improvement: a concordat approach to managing collaboration and uncomfortable realities. BMJ Qual Saf 2015; 24:318-24
42. Ivers N, Jamtvedt G, Flottorp S et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 6:CD000259.
43. Power M, Tyrrell PJ, Rudd AG et al. Did a quality improvement collaborative make stroke care better? A cluster randomized trial. Implementation Sei 2014; 9:40.
44. Martin GP, McKee L, Dixon-Woods M. Beyond metrics? Utilizing 'soft intelligence' for healthcare quality and safety. Social Sci Med 2015; 142:19-26.
45. Martin GP, Aveling E-L, Campbell A et al. Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns. BMJ Qual Saf 2018; 27:710-7.
46. Shekelle PG, Pronovost PJ, Wachter RM et al. Assessing the evidence for context-sensitive effectiveness and safety of patient safety practices: developing criteria. Rockville, MD: Agency for Healthcare Research and Quality, 2010.
47. Mitchell BG, Gardner A, Stone PW et al. Hospital staffing and health care-associated infections: a systematic review of the literature. Jt Comm J Qual Patient Saf 2018; 44:613-22.
48. Aiken LH, Sloane D, Griffiths P et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf 2017; 26:559-68.
49. Draycott T. Practical obstetric multi-professional training - PROMPT. London: The Health Foundation, 2013.
50. Powell A, Rushmer RK, Davies H. A systematic narrative review of quality improvement models in healthcare. Edinburgh: NHS Quality Improvement Scotland, 2009.
51. Vaughn VM, Saint S, Krein SL et al. Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies. BMJ Qual Saf 2018, in press.
52. Rutter H, Savona N, Glonti K et al. The need for a complex systems model of evidence for public health. Lancet 2017; 390:2602-4.
53. Wells M, Williams B, Treweek S et al. Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials 2012; 13:95.
54. Syverson C. What determines productivity? J Econ Lit 2011; 49:326-65.
55. Bloom N, Eifert B, Mahajan A et al. Does management matter? Evidence from India. Quar J Econ 2013; 128:1-51.
56. Kingdon JW, Thurber JA. Agendas, alternatives, and public policies. Boston: Little, Brown, 1984.
57. Schneider JW Social problems theory: the constructionist view. Ann Rev Sociol 1985; 11:209-29.
58. Stone DA Causal stories and the formation of policy agendas. Politcial Sci Quarterly 1989; 104:281-300.
59. Pfohl S. Toward a sociological deconstruction of social problems. Social Problems 1985; 32:228-32.
60. D'Lima D, Archer S, Thibaut BI et al. A systematic review of patient safety in mental health: a protocol based on the inpatient setting. Syst Rev 2016; 5:203.
61. Boozary AS, Shojania KG. Pathology of poverty: the need for quality improvement efforts to address social determinants of health. BMJ Qua/Saf 2018; 27:421-4
62. Cribb A. Improvement science meets improvement scholarship: refraining research for better healthcare. Health Care Anal 2018; 2:109-23.
63. Carter SM, Williams J, Parker L et al. Screening for cervical, prostate, and breast cancer: interpreting the evidence. Am J Prevent Med 2015; 49:274-85.
64. Carter SM Valuing healthcare improvement: implicit norms, explicit normativity, and human agency. Health Care Anal 2018; 26:189-205.
65. Draycott T, Sibanda T, Owen L et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006; 113:177-82.
66. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491-9.
67. Neily J, Mills PD, Young-Xu Y et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010:304:1693-700.
68. Clarkson PJ, Bogle D, Dean J et al. Engineering better care. London: Royal Academy of Engineering, 2017.
69. Dean J. Systems engineering for healthcare improvement 101. Future Hosp J 2017; 4:s19.
70. Sujan MA, Embrey D, Huang H. On the application of human reliability analysis in healthcare: opportunities and challenges. Reliability Eng Syst Saf 2018, in press.
71. Shorrock S. The loneliest profession in healthcare. Humanistic Systems 2018. https://humanisticsystemscom/2018/05/11/the-loneliest-profession-in-healthcare.
72. Batalden P. Getting more health from healthcare: quality improvement must acknowledge patient coproduction. BMJ 2018; 362:k3617.
73. Dlugacz YD, Spath PL. High reliability and patient safety. In: Spath PL (ed). Error reduction in health care: a systems approach to improving patient safety. San Francisco: Jossey-Bass, 2011.
74. Aveling EL, Parker M, Dixon-Woods M. What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociol Health Illness 2015; 38:216-32.
75. Thompson DF Moral responsibility of public officials: The problem of many hands. Am Polit Sci Rev 1980; 74:905-16.
76. Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Qual Saf 2016; 25:485-8.
77. Bowie P, Bradley NA, Rushmer R. Clinical audit and quality improvement - time for a rethink? J Eval Clin Pract 2012; 18:42-8.
78. Evetts J. The sociological analysis of professionalism. Int Sociol 2003; 18:395-415.
79. Yeung K, Dixon-Woods M. Design-based regulation and patient safety: a regulatory studies perspective. Social Sci Med 2010; 71:502-9.
80. Parsons T. The professions and social structure. Social Forces 1939; 17:457-67.
81. Martin G, Armstrong N, Dixon-Woods M et al. Professionalism redundant, reshaped, or reinvigorated? realizing the 'third logic' in contemporary healthcare. J Health Social Behav 2015; 56:378-97.
82. Black J. Constructing and contesting legitimacy and accountability in polycentric regulatory regimes. Regul Governance 2008; 2:137-64.
83. Freidson E. Professionalism, the third logic: on the practice of knowledge. Chicago: University of Chicago Press, 2001.
84. Powell WW Neither market nor hierarchy: Network forms of organisation. Res Org Behaviour 1990; 12:295-336.
85. Granovetter M. Economic action and social structure: the problem of embeddedness. Am J Sociol 1985; 91:481-510.
86. Offer A. Between the gift and the market: The economy of regard. Econ Hist Rev 1997; 50: 450-76.
87. Tarrant C, Leslie M, Bion J et al. A qualitative study of speaking out about patient safety concerns in intensive care units. Social Sci Med 2017; 193(Supplement C):8-15.