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NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says

BMJ 2013; 346 doi: (Published 06 February 2013) Cite this as: BMJ 2013;346:f847

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Re: NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says

What would Deming, Juran and Crosby have to say about “a zero tolerance” for patient harm?

When reading the BMJ paper by Dyer (2013) (1) on the Francis report (2), I think we have to conclude to go back to basics. Not only the basics, as suggested in the report, to have more attention for care and dignity, but also back to the basics of quality management. Based on Robert Francis’ 290 suggestions to improve care, I think he could be a fan of Philip Crosby. If we combine Crosby’s knowledge and add some of the principles by Edwards Deming (3) and Joseph Juran (4), the two best known fathers of quality management, we could integrate the past and future of healthcare quality. I am sure that Don Berwick agrees (5).

Philip Crosby (1926–2001) was a businessman and one of the less known quality guru’s from last century. He stated that “quality is free but it is not a gift”. It is not only free, it is the most profitable product line we have. Crosby initiated therefore the “zero defects” principle as part of his absolutes of quality management6. The zero defect philosophy is four-fold:

(1) Quality is defined as conformity to predefined targets or specifications,
(2) Preventing defects is better than investing in quality inspection and redesign,
(3) Zero defects is the only quality standard we must accept, and
(4) The impact of quality is measured in a financial way or, in other words, we need to calculate the Price of Non-Conformance to predefined specifications.

It could be helpful that we translate these four Crosby principles to what should happen in healthcare and maybe Deming & Juran can help us to make it happen in daily practice:

(1) Quality is conformity to specifications: Although scientific associations and institutes have developed these specifications in Evidence Based Guidelines and tools like Map of Medicine, we know there is a lack of compliance to these guidelines. The specifications in patient processes are the evidence based key interventions and the process & outcome indicators. Variation between organizations in these specifications can lead to safety issues7-9. Deming would state that, if we want to get out of the crisis, we need to define these specifications with respect to the system, the actual variation within the system, the theories of knowledge and the psychology of the involved team members3. But let us try defining the real key interventions and outcomes as we already experienced that it is not always easy to focus on the vital few and not trying to control the useful many (4). Recently, a strategy was published to develop the evidence based content of patient processes in eight steps10. This could be one way to define the specifications for all high volume, high risk and high cost patient processes.

(2) Preventing defects is better than inspection and redesign: The focus should be on quality planning or quality design (4). Before patients are admitted to hospitals or cared for in primary care, the multidisciplinary teams should have decided on how to take care of these patients within their system (3;11). Juran suggests that if we design a product line (these are the patient processes in healthcare) we should know who are our clients, what do they expect and how can we translate their needs into our operations, only than we can talk about control and further improvement. So, should we take care pathway methodologies back from the shelf as they are used worldwide to design, standardize and follow-up patient focused care processes (12;13)? Crosby, Juran and Deming would agree that a better planning and design would lead to higher compliance to predefined specifications. The (re)design projects, like care pathways, will be complex interventions or multicomponent interventions as Berwick calls them5. Frameworks on complex intervention like the one developed by the Medical Research Council will need to be used more frequently in healthcare to help us in understanding why some interventions to design care work and others do not (14).

(3) Zero defects is the only quality standard we must accept: Zero defects, no harm, no infections, no needless deaths, no waste … or as Don Berwick calls it “the no needless list” should be the only appropriate target on system, hospital, ward and individual patient level. Robert Francis asks for a zero tolerance for harm and we all should support him. Crosby would certainly agree, but Deming & Juran would argue that this is an impossible goal as processes are part of systems and different types of variation can occur because of the systems in which they work. Crosby made an interesting translation of his philosophy for healthcare: who would accept a nurse with 99.9% reliability? Every manager would but … would you also accept that nurse to take care of you or your loved ones … or do you expect 100% reliability when you are involved yourself …? 100% mistake-proof care will not always be possible but we will need to distinguish between adverse events made because of attention & memory failures, mistakes and violations. James Reason states that “We cannot change the human condition but we can change the conditions under which humans work (15)”, that will be the challenge for all involved in healthcare, both clinicians, managers and patients.

(4) The impact of quality is measured in a financial way and we need to know the price of non-conformance: Not only Crosby but also Juran translated all operations into the language of managers: “money”. If we (further) introduce this into healthcare we need to go back to the basics of quality costs and divide them into prevention costs, appraisal & maintenance costs and failure costs (1). If we do not fully understand the differences and only try to save money by saving in prevention costs (by decreasing staffing levels or saving in quality improvement initiatives) we will not understand that on the (mid) long term our total cost will dramatically increase because of an increase in failure costs. Didn’t the Francis report made very clear that this is what happened in Mid Staffordshire? Let’s not forget that failure costs are not only immediately measurable in a financial way, let us not forget the cost of un-loyalty of patients, although this could be less in an NHS system than in private systems, but let us also think about the effects of cost saving on our workforce in ways of compassion fatigue or burnout. The effect on quality & patient safety was made very clear in Mid Staffordshire.

The original four-fold zero defects philosophy by Crosby is now translated into 290 suggestions. So would Deming, Juran and Crosby agree on everything in the Francis report? No, they would certainly not agree on everything, but they would be happy that their philosophies introduced in management years ago are more than ever the ones we need to think about. Let us go back to basics and use their absolutes of quality and not fall into the pitfall of asking consultancy companies to invent all kinds of new methods and tools.

Involving our own healthcare workforce to help us improving the systems will be crucial. It will ask for additional preventive costs but it will increase the professional attitude and pride of our workforce which will decrease failure costs by improving quality and safety and decreasing burnout, and in this way “Quality will be free”. It will certainly be a challenge! Maureen Bisognano, president of the Institute for Healthcare Improvement, asked all 5500 delegates at the previous National Forum on Quality Improvement in Healthcare: “When you come upon a wall, throw your hat over it. Than go get your hat” or as Paul Batalden quoted “In healthcare everyone has two jobs: to do your work and to improve it”16. That is our challenge, not only in the NHS but everywhere!

Reference List

(1) Dyer C. NHS must adopt a culture of "zero tolerance" for patient harm, Francis report says. BMJ 2013; 346(f847).
(2) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. February 2013. www midstaffspublicinquiry com/report
(3) Deming WE. Out of the crisis. Melbourne Syndicate of the University of Cambridge; 1982.
(4) Juran JM, Blanton Godfrey A. Juran's Quality Handbook. Fifth ed. New York: Mc Graw-Hill; 1999.
(5) Berwick DM. The science of improvement. JAMA 2008; 299(10):1182-1184.
(6) Crosby PB. Quality is Free. New York: Mc Graw-Hill; 1980.
(7) Segal O, Bellemans J, Van GE, Deneckere S, Panella M, Sermeus W et al. Important variations in the content of care pathway documents for total knee arthroplasty may lead to quality and patient safety problems. J Eval Clin Pract 2011.
(8) Vanhaecht K, Van GE, Segal O, Panella M, Sermeus W, Bellemans J et al. Is variation in the content of care pathways leading to quality and patient safety problems? Hip Int 2011; 21(6):770-771.
(9) Sarrechia M, Van GE, Hermans L, Deneckere S, Sermeus W, Panella M et al. Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety? J Adv Nurs 2012.
(10) Lodewijckx C, Decramer M, Sermeus W, Panella M, Deneckere S, Vanhaecht K. Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation. Trials 2012; 13(1):229.
(11) Vanhaecht K, Panella M, Van Zelm RT, Sermeus W. An overview on the concept and history of care pathways as complex interventions. International Journal of Care Pathways 2010; 14:117-123.
(12) Pearson SD, Goulart-Fisher D, Lee TH. Critical pathways as a strategy for improving care: problems and potential. Ann Intern Med 1995; 123(12):941-948.
(13) Vanhaecht K, Ovretveit J, Elliott MJ, Sermeus W, Ellershaw JE, Panella M. Have We Drawn the Wrong Conclusions About the Value of Care Pathways? Is a Cochrane Review Appropriate? Eval Health Prof 2011; DOI: 10.1177/0163278711408293.
(14) Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008; 337:a1655.
(15) Reason J. Human error: models and management. BMJ 2000; 320(7237):768-770.

(16) Batalden PB, Davidoff F. What is "quality improvement" and how can it transform healthcare? Qual Saf Health Care 2007; 16(1):2-3.

Competing interests: No competing interests

09 February 2013
Kris Vanhaecht
Senior Research Fellow
Massimiliano Panella, Walter Sermeus
Department of Public Health, KU Leuven, University of Leuven
Kapucijnenvoer 35, B-3000 Leuven, Belgium