Intended for healthcare professionals


Is quality of care improving in the UK?

BMJ 2011; 342 doi: (Published 03 February 2011) Cite this as: BMJ 2011;342:c6646

Is Quality of care improving in the UK ?

Dear Sir,

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
clinicians" -
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
culture change.

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

08 February 2011
stephen ramsden et al
independent consultant
several listed
former CEO Luton & Dunstable Hospital