How strange the change, from major to minor, with apologies to Ella Fitzgerald

How strange the change, from major to minor, with apologies to Ella Fitzgerald

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 29, Issue 2.

In medicine we follow the evidence base. Or do we? Our intentions are good but they may not always transfer into effective actions, using the right drug, or the correct intervention or the right protocol for the disease in question. Enough has been written over the decades on the overuse, the underuse and the misuse of medical treatments to fill many journals and many books on the topic.

While our dedication to finding and following the correct treatments can be challenged at times, greater challenge can be presented in getting us to think of the right theory and practice in improvement science. Quality per se, can be seen as a rather woolly topic, lacking evidence or substance and therefore worthy of systematic conscious and unconscious avoidance of the evidence on the topic by healthcare professionals. A recent comment by Don Berwick suggesting his surprise at how few organisations have studied Edwards Deming suggests that we are not the best in the class at the scientific approach to improvement science.

This issue may address the deficit in our knowledge in this important area. We present a number of papers dealing predominantly with the theoretical and practical applications in improvement science. Starting with the desire and motivation for innovation (and by extension, improvement) Bilal Afsar outlines the factors that influence the fit between the medical personnel, the nursing staff and the patients, providing some clear signposts for organisations that are committed to making the best environment for improvements to occur. Prasanta Dey et al. tackle the perennial problem of overcrowding in hospital emergency departments by looking at the issue from the patients’ perspective and using that information to analyse the staff approach to the issue, using factor analysis as a tool for improvement.

Van Fleet et al. look retrospectively at the values and behaviours exhibited by practioners, revealing the importance of integrity and ethical thought processes in the equation. They stress this issue as a key to building patient confidence and, by extension, the reader can see where this item can be so crucial to interpersonal interactions within organisations. In Sweden, Kajonius et al. look at the behaviours of staff in municipality nursing homes and isolate five key areas that affect the staff-patient (or staff client relationship). What van Fleet calls integrity can been seen within a different light in this paper as affect; staff with a warmer disposition get on better with patients. While this comes as no surprise, it is sometimes necessary to see this written clearly, with the evidence backup for us to give it the respect it, as a factor deserves. When combined with task-focus and person-focus, any organisation that can support these coefficients of care will win more often than not.

Once the organisation has determined that it is going to use an evidence-based approach, it clearly must start at the top, focusing on its strategic direction. Peltokorpi et al. identify five strategic directions (almost in the line of James Collins and Jerry Porras’ big hairy audacious goals) that healthcare institutions might use as a road map to help them illuminate their strategic direction. In their article, they differentiate the goals’ applicability to the individual natures of the institutions, whether it be elective or emergency workload, or illness or wellness goals. Once goals and strategic direction has been decided, the tools of the trade must be embraced by the organisation, at all levels. Deblois has reviewed the copious literature on lean and six sigma, highlighting (or even refreshing) our knowledge of this complex but important topic. The manuscript is a useful digest of the topic.

Mesabbah et al. use Ireland as a teaching example of healthcare strategy at a national level. Reviewing the publications and strategic documents since the inception of a nationalised healthcare service, they identify the successes and failings that can affect any organisation on a national scale. Sometimes, an article like this can act as a mirror to those working within the system, reflecting the good and the not-so-good of large scale change processes. Hopefully, the manuscript may serve as a teaching tool for other countries in the same situation.

And to finish, getting down the finest detail, Kusuda et al. from Japan have designed and trialled a means of quality controlling surgical instruments in their trays using radio-frequency identification technology. They detail the challenges of making radio receivers robust enough for the job yet small enough not to interfere with surgical dexterity.

From macro-to micro, systems need thoughtful design and careful implementation. I hope there is more than enough to stimulate your thought processes in this issue.

Ian Callanan