Is quality of care improving in the UK?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c6646 (Published 03 February 2011) Cite this as: BMJ 2011;342:c6646
All rapid responses
Pronovost et al rightly highlight the importance of a number of
elements necessary to improve patient safety in UK hospitals. Training and
support to doctors are identified as two of these critical factors.
Postgraduate Deaneries have a vital role to play in contributing to this
Deaneries are responsible for the foundation and specialist training
of all UK doctors and therefore have a vital role in overseeing any
Serious Untoward Incidents (SUI's) involving their trainees which pose a
risk to patients.
Currently, great variation exists between deaneries in their approach
to monitoring, reporting, and supporting trainees involved in such
incidents; any comparable data available at present is likely to reflect
reporting practices rather than anything deeper. This in turn makes it
difficult to pinpoint where extra training and support should be targeted.
As the author stipulates, human error is indeed a contributing factor
to many serious incidents. However it remains important to highlight the
responsibility of individual Trusts, particularly those involved in
training of doctors, to ensure that causative factors in incidents are
established and systems and processes strengthened to mitigate against
In Yorkshire and the Humber, work is being undertaken by Public
Health Specialty Registrars in partnership with the Deanery, to improve
reporting and analytical processes providing detailed evidence relating
to doctors in training and Serious Untoward Incidents. The Yorkshire and
Humber experience will be presented at the National Association of
Clinical Tutors (NACT) spring meeting in May 2011.
As with any changes to systems or processes, these will take time to
begin to deliver the high quality intelligence necessary, and as Pronovost
points out, such changes involve working closely with local Trusts, the
Quality Observatory and others. Improvements in communication remain vital
if a culture of transparency, learning, and accountability is to be
We hope that the role, contribution and potential of a regional level
body, currently provided by Deaneries in conjunction with Strategic Health
Authorities , in contributing to the patient safety agenda in the UK is
not devolved by the imminent re-structuring of the NHS. It is equally
imperative that the contribution of public health professionals is
highlighted and continues, alongside the other professionals mentioned by
Pronovost. This will help ensure patient safety remains high on the agenda
in terms of regulation, training, and support of doctors within health
care teams as the NHS changes over the coming years.
Competing interests: No competing interests
The editorial (Pronovost, Berenholtz et al. 2011) and the linked
evaluations (Benning, Dixon-Woods et al. 2011; Benning, Ghaleb et al.
2011) of the Safer Patient Initiative (SPI) make many good points about
the successes and failures the patient safety and quality improvement
movement in the UK.
One additional, and crucial, point is that these initiatives were not
targeted at the staff who are most involved in safety work and who are
best placed to drive quality improvement - the junior doctors. 80% of
ward based activity is de facto lead by trainees (Tooke 2008). The SPI
Learning Sets mostly called on trusts to supply teams of; managers,
consultants and senior nurses. This is one of the main reasons why there
was so little penetration to ward level (Benning, Ghaleb et al. 2011).
Very few training junior doctors are aware of the various national safety
projects even at the SPI sites. If we really want to improve safety we
will have to direct our efforts to this group first. This is a key issue
in all NHS 'improvement' initiatives. The people that can make a
difference are not being adequately equipped nor informed.
This situation may be beginning to improve. In the South West there
are now 150 Foundation Year one doctors running quality improvement
projects and in London the Beyond Audit Programme is changing the way
junior doctors think about influencing the standard of care they give to
Surgical Registrar, Severn Deanery
Clinical Advisor, The Health Foundation
Paediatric Registrar, London Deanery
Clinical Leadership Fellow, London Deanery
Respiratory Registrar, London Deanery
Clinical Leadership Fellow, London Deanery
Benning, A., M. Dixon-Woods, et al. (2011). "Multiple component
patient safety intervention in English hospitals: controlled evaluation of
second phase." BMJ 342: d199.
Benning, A., M. Ghaleb, et al. (2011). "Large scale organisational
intervention to improve patient safety in four UK hospitals: mixed method
evaluation." BMJ 342: d195.
Pronovost, P. J., S. M. Berenholtz, et al. (2011). "Is quality of
care improving in the UK?" BMJ 342: c6646.
Tooke, P. S. J. (2008). Aspiring To Excellence, Independent Inquiry
Into Modernising Medical Careers, MMC Inquiry.
Competing interests: No competing interests
Hospital Safety and Complexity
In spite of almost Herculean efforts to improve hospital safety,
results seem at best to be underwhelming.1-4 Why should this be so? In
2001 Plsek and Greenhalgh pointed out that we deal with complex systems.5
It therefore seems reasonable to wonder whether a failure to employ the
Sciences of Complex Systems and Networks6-8 may have something to do with
this. Perhaps as we improve what we do it is matched by complexity and the
outcome is less than fully rewarding.
Transmission of multiple antibiotic resistant organisms (MROs) in
hospitals continues to be a major problem and Vancomycin-resistant
Entercoccus is in many places the current number one villain. It is
reasonable to wonder whether, until we understand more fully the
underlying network structure of transmission,6 we will really be able to
make progressive inroads into MROs.
It has been shown that waiting lists9 have a power law
distribution.10 It seems not unlikely that other events in hospitals such
as length of stay and medication errors may have power law distributions.
This may be important for analyzing and understanding these data. Uncommon
low probability high impact events are likely to occur more commonly in
our hospitals than conventional statistical approaches based on Gaussian
Although investigation of major adverse events often reveals a trail
of pre-existing malfunction, it is a characteristic of complex systems
that low probability high impact events may occur seemingly without prior
cause and therefore to be unpredictable. If an adverse event is
unpredictable, the only defense must be generic. We must make our systems
more sustainable and resilient.12 Resilience involves such things as
modularity, diversity and, above all, some redundancy. Hospitals have
often been reformed to make them more "efficient" and "productive". Highly
efficient complex systems are known to be vulnerable to failure. Nature
makes its complex systems more resilient by building in some redundancy.11
We desperately need to know the correct balance of efficiency and
redundancy. For example, if we run hospitals at near 100% capacity they
are probably going to spend a not inconsiderable part of their time fixing
problems that are related to their efficiency. There appears to be good
evidence that bed occupancy rates between 80% and 85% work better.
Pronovost and his colleagues1 have noted the importance of "bottom-
up" approaches. This is readily understandable in the work of Ostrom13 on
cooperative behaviour, and in complex system emergence and self-
1. Pronovost P, Berenholtz S and Morlock L "Is quality of care
improving in the UK?" BMJ 2011;342:c6646.
2. Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, et al "Multiple
component patient safety intervention in English hospitals: controlled
evaluation of second phase" BMJ 2011;342:d199.
3. Benning A, Ghaleb M, Suokas A, Dixon-Woods M, et al "Large scale
organizational intervention to improve patient safety in four UK
hospitals: mixed method evaluation" BMJ 2011;342:d195.
4. Landrigan C, Parry G, Bones C, Hackbarth A, et al "Temporal trends
in rates of patient harm resulting from medical care" NEJM 2010;363:2124-
5. Plsek P and Greenhalgh T "The challenge of complexity in health
care" British Medical Journal 2001;323:625-8.
6. Watts D "Six Degrees" London, Vintage Books 2004, especially
7. Mitchell M "Complexity" New York, Oxford University Press 2009.
8. Cioffi-Revilla C "Computational social science" WIREs
Computational Statistics 2010;2:259-71.
9. Papadopoulos M, Hadjitheodossiou M, Chrysostomou C Hardwidge C and
Bell A "Is the national health service at the edge of chaos?" Journal of
the Royal Society of Medicine 2001;94:613-6.
10. Brown C and Liebovitch L "Fractal Analysis" Thousand Oaks
California, Sage Publications, 2010.
11. Taleb N "The Black Swan" 2nd ed. Camberwell, Penguin Books 2010.
12. Orrell D "Economyths" London, Icon Books 2010, especially chapter
13. Ostrom E "A general framework for analyzing sustainability of
socio-economical systems" SCIENCE 2009;325:419-422.
Competing interests: No competing interests
We are the CEOs, Medical Directors and other senior Directors involved in
all the 4 UK SPI1 pilots sites. Your editorial makes a number of useful
observations about SPI and quality improvement approaches in general,
based on the evaluations carried out by Lilford et al. While we accept
some of the shortcomings of the SPI approach we feel that neither the
evaluations themselves, nor the editorial article commissioned from Dr
Pronovost and colleagues , reflect the whole picture of the SPI
The evaluation did not attempt to measure the outcome of all of the
interventions implemented during the Initiative and we believe that it has
drawn some conclusions from its case note review which may not be entirely
valid. In particular the authors have suggested that the failure to
demonstrate improvement in a number of elements of care of patients with
community acquire pneumonia indicates that the interventions have not been
collectively successful despite the fact that at least one of those
elements was not a part of the SPI programme.
They rightly point out that no firm conclusions can be drawn from the self
-reported outcome data, and we had hoped that the evaluation would have
compared more of the outcomes between SPI and control sites than it was
able to do. In fact all the SPI sites showed dramatic improvement in some
self-reported outcomes, such as central-line associated bacteraemias,
ventilator acquired pneumonias and cardiac arrest rates, with secondary
improvement in lengths of stay on wards and in ITU, so it is a pity that
these have not been compared to similar data from control sites.
"The initiative was largely top down, with limited input from local
We disagree. The individual workstreams were all lead by clinicians .Their
teams were most actively engaged in the improvement work .Of course, not
every clinician in organisations employing thousands of staff could be
actively engaged or even enthusiastic in that first 18 months but a
consensus of agreement about the validity of the interventions was sought.
In fact two of the originally-proposed interventions were dropped on the
grounds that our clinicians were not convinced of their evidence-base.
What SPI1 achieved that many other initiatives fail to do was to engage
the Board, and ourselves as key organisational leaders, and it is
surprising that our efforts to put patient safety at the top of our
Board's agenda is being criticized.
"The interventions and measures were not sufficiently pilot tested" -
As the article points out, the interventions selected were based largely
on those which had been implemented in many US Hospital during the "Save
100000 Lives Campaign". We had to "Anglicise" some of the approaches and
we soon realised we had very few measurements of patient safety indicators
in place so it took over 12 months to establish these. The attention that
the IHI approach forced us to give to measuring the reliability of process
and outcome was invaluable and has formed the basis of the safety
dashboards that we now employ.
"It asked hospitals to implement 43 interventions, when most
hospitals would find it difficult to implement three. "- While this may
be true, the scale of the 43 improvement initiatives meant that most
departments were touched by the approach, which had its own benefits in
The fact is, all 4 SPI1 sites achieved the goals set by the Health
Foundation and IHI - that was to reduce adverse events by 50% (as measured
by the global trigger tool). In all 4 sites there are many examples of
stunning reductions in harm to patients and the near-elimination of some
"complications", has produced a change in mindset for staff who had
historically come to accept these as inevitable.
In addition all 4 SPI1 sites went on to become the influence behind their
own country's national patient safety campaigns over recent years. Those
involved in this initiative have learned that real transformation does not
take place over 18 months, more like 10 years. But we have also found that
an intensive focus on leadership, goals and measurement across the entire
hospital can produce some real improvements in outcomes and, as the
evaluation did show, begin to change the culture of the organisation. The
high profile work undertaken by SPI had a significant impact on managerial
and clinical culture in the UK , and together with some well publicised
events at Mid-staffordshire, promoted a sea change in prioritising quality
and safety in the NHS.
Credit must go to the Health Foundation , and to IHI , for the foresight
and commitment to trying something new, something other than Governance ,
Assurance and Compliance. Something more ambitious, more exciting and
engaging, something more proactive and moving. Something that helps with
the difficult task of implementation. Something transformational.
Signed by all 4 SPI1 Pilot sites :-
Conwy & Denbighshire NHS Trust (now Betsi Calwaladr University Local
Health Board - Gren Kershaw (former CEO) and David Gozzard (former Medical
Down Lisburn Trust ( now included in South Eastern HSC Trust) Noeleen
Devaney (former Medical Director)
Luton & Dunstable Hospital - Stephen Ramsden (former CEO) and John
Pickles (Medical Director)
NHS Tayside - Gerry Marr (CEO), Pat O'Conner (Deputy CEO) and Diane
Campbell (Patient safety Development Manager)
Competing interests: all are Directors or former Directors of SPI1 sites
The reports of the apparent lack of success of investments in patient
safety in hospitals by the NPSA and the Health Foundation (BMJ, February
6th, 2011) are remarkable for their absence of economic evaluation. Given
the focus on "cost effectiveness" of NICE and public R&D programmes, the
lack of consideration of value for money in these studies is reminiscent
of old fashioned "effectiveness myopia"! With budget cuts and structural
"redisorganistion", the pertinent study question remains whether (and
what) funding of patient safety merits resource shifts from other aspects
of patient care?
Competing interests: Until 2010 Chair, York Hospitals NHS Foundation Trust
That safety and quality is rising in the NHS [1, 2] is cause for
optimism but not complacency. Harm to patients remains stubbornly high
with most recent estimates set between 3 and 25% in acute care and about
9% in primary care . Furthermore, reliability of routine clinical
processes would not meet standards set in other safety critical industries
(for example, a recent study showed a failure rate of between 13 and 19%
in four key clinical systems ).
In building on its learning from the Safer Patients Initiative, the
Health Foundation remains at the vanguard of patient safety.
* In 2008, we launched an innovative programme bringing together
leading academics and practitioners from across 4 health systems to co-
design new solutions to current challenges in patient safety. This work
has informed the design of Safer Clinical Systems - our new UK-wide
initiative to apply proactive approaches to detecting risks in clinical
systems of care and mitigate these through implementing appropriate
strategies from systems thinking and human factors.
* In 2010, we hosted a colloquium to explore the emerging discipline
of improvement science with leading thinkers including those from
evaluation, biostatistics, RCTs, ethnography, social science and patient
safety alongside practitioners. They identified the common challenges to
those working to improve quality and the knowledge we need to build in
order to address them. We have now established an international network
led by Paul Batalden, Professor of Paediatrics, Community and Family
Medicine at the Dartmouth Institute for Health Policy and Clinical
Practice and Professor of Quality Improvement and Leadership at Jonkoping
University in Sweden, to further develop the science of improvement and
provide multi-disciplinary support to our newly launched post-doctoral
fellowship in improvement science to develop original, applied research
dedicated to improving healthcare in the UK.
* Later this year our annual innovation scheme (Shine) will support
healthcare organisations to develop pragmatic solutions to some of the
commonly identified barriers to improving quality such as a lack of
improvement capacity and capability in the workforce, poor measurement,
and insufficient clinical engagement.
Too many lives - of staff and patients - continue to be blighted by
the consequences of avoidable harm. In the face of unprecedented cost
pressures and system reform, leaders at every level need to continue to
make patient safety a priority.
Dr Jo Bibby,
Director of Improvement Programmes,
The Health Foundation
1. Benning A, Dixon-Woods M, Ghaleb M, Suokas A, Dawson J, Barber N,
et al. Large scale organisational intervention to improve patient safety
in four UK hospitals: mixed method evaluation. BMJ2011;342:d195.
Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, et al.
Multiple component patient safety intervention in English hospitals:
controlled evaluation of second phase. BMJ2011;342:d199.
3. The Health Foundation (forthcoming, 2011). Research scan: Levels of
4. The Health Foundation (2010) Evidence in brief: How safe are clinical
Competing interests: The Health Foundation commissioned and funded the Safer Patients Initiative.