Intended for healthcare professionals


Rethinking medical ward quality

BMJ 2016; 355 doi: (Published 18 October 2016) Cite this as: BMJ 2016;355:i5417
  1. Samuel Pannick, clinical research fellow1,
  2. Robert M Wachter, professor of medicine and, interim chairman2,
  3. Charles Vincent, professor of psychology3,
  4. Nick Sevdalis, professor of implementation science and patient safety4
  1. 1NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
  2. 2Department of Medicine, University of California, San Francisco, USA
  3. 3Department of Experimental Psychology, University of Oxford, Oxford, UK
  4. 4Centre for Implementation Science, King’s College London, London, UK
  1. Correspondence to: s.pannick{at}
  • Accepted 4 October 2016

For quality to improve, we need to embrace the complexities of general medical inpatient care, say Samuel Pannick and colleagues

Medical wards deliver the majority of acute inpatient care in health systems worldwide. This care is expensive, costing the NHS around £5bn (€5.5bn; $6.2bn) a year, a quarter of its inpatient expenditure.1 Improving the performance of medical wards is an international priority,2 3 not only because of the scale of care that they deliver. Their core workload—treating complex, increasingly frail patients in a time pressurised setting—represents the broader challenges facing healthcare.4 Yet major gaps remain in our understanding of how wards perform.5 6 7

Safety and quality interventions have been most effective in improving standardised clinical tasks in the operating theatre and intensive care unit, such as the insertion of central venous catheters. The processes of ward care require a more nuanced approach to improvement. Medical patients’ clinical syndromes often fall between traditional diagnostic categories,8 and specific organisational challenges exist for the teams that care for them. We discuss the unique properties of medical wards and the problems they face, before setting out a vision for ward improvement that embraces the complexity of ward care.

The medical ward is a different animal

Important differences exist between medical wards and other clinical settings, from haemodialysis units to operating theatres. Medical ward teams care for a particularly heterogeneous group of patients, with no single best pathway for diagnosis or treatment. Staff are skilled in the management of a diverse range of conditions, from pyelonephritis to gastrointestinal bleeding and terminal cancer. Many patients arrive without a diagnosis; indeed, empirical treatment can be concluded with no definitive diagnosis ever established. This sets medical wards apart from other hospital settings, which typically manage more narrowly defined patient populations with more predictable care trajectories. With such heterogeneity, medical …

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