Monday, 30 January 2012

Hemadri's Four Fundamental Questions for Clinical Quality Improvement

Hemadri's 4 fundamental questions for Clinical Quality Improvement

1) Do you have local clinicians' agreement on clinical healthcare delivery? (Doing the same thing by all professionals in the same manner for the same condition)

2) Are you measuring the right things in the right manner? (Measuring process and outcomes over time)

3) Do you have a human approach to leadership and management? (In other words do your staff love you, do your patients love you? Working with and enjoying ambiguity and limitations)

4) Can you prove meaningfully that you have shared to others and you have learned from others within your organisation? (Proof that every individual does whole system improvement)

To some of you these four questions might sound like cliches. To some of you these might be stating the blindingly obvious. The questions are not 'lay'; they are highly technical questions with strong theories and some practical examples behind them. There are specific and explicit frameworks, methods and techniques to explore these questions and then to make them happen.

There is a general impression that healthcare does all the four well; especially if you work in healthcare you may be tempted to answer 'Yes' to all the four questions. You may even proceed to argue and 'prove' it. There is much evidence that healthcare in general lacks all the above four. The chances are it will be surprising if many areas of healthcare delivery had even one of these. But once these questions can be answered with a real 'Yes' healthcare leaps into a bright better zone.

Success in Healthcare can be found only if the the answers to all the four questions can be a clearly demonstrated 'YES'.

We explore these at the CQI to some extent. I am hoping that over a period of time I should be able to blog about these things in specific detail rather than in broad general terms. Perhaps even write a book.

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Tuesday, 24 January 2012



I believe this is the opposite of absenteeism. This is when people are ill but still turn up to work to reduce productivity. It costs Australia $6billion. 

Hold on, its not a peculiarly Australian problem. We have it too. 20% of NHS staff have reported coming to work even when they are ill. Before you pat yourself on the back on some perceived altruism or hyper-sincerity, please remember that in the insurance business 45% of staff come to work when they are ill .

Its not just the people who are off sick who decrease productivity; people who are at work but who should not be, also reduce productivity. Please share your view on how you deal with this issue in your place of work. I wonder if the recent sickness counselors we have appointed in the NHS will identify persons who should not be there and send them home to rest properly!

Wednesday, 18 January 2012

Mortality 1998 & Now - What can we learn?

Mortality 1998 and now: What can we learn?

I found these 4 pages full of 30 day hospital mortality rates from 1998 – 1999 which you find below the write up (you may have to print it, if you want to look at it as you go along). Those were the days before HSMR (though retrospective calculations should be available). Some powerful details are jumping out.


This look at the data has some limitations in the sense that a snapshot of 1998 – 1999 is being compared to the most recent three years rather than for the whole period 1998 to 2011. So it is not a true performance over time that I advocate. Having said that, I feel that the lessons are still valuable based on the logic that if you are in the same place or in a worse place than in 1998 there has been no improvement either relative or absolute which is in general true (though in a purely technical sense that may not always strictly be the case for some hospitals). Also, I have only looked at some highlighting examples rather than a detailed research type of analysis so there may be other good examples that I have not looked at (possibly some place like Harrogate perhaps).

The current status was ascertained from dr Foster’s website in end of Dec 2011 and early Jan 2012.

Remaining where they were

Page one you will find Scunthorpe in the first section/small-medium hospitals rating at the higher end and it remains in the higher end.

East Yorkshire Hospitals rate is high (page 1). On page two you will find Hull Royal rates are high. They are now the HEY NHS Trust and are high currently.

Medway, Dartford and Gravesham remain at the higher end (currently in the highest 10 mortality)

Basildon and Mid Staffs remain at the higher end (page 1)

University Hospital Birmingham rates are at the higher end then as they are now (page 3)

Interestingly Bolton more or less remain where they were – nearer to the higher end of the spectrum.

Interestingly again, Luton more or less remain where they were - in the middle.

On page three under acute teaching hospitals; you will find that Chelsea & Westminster are low in 1998 as they are now.

Moving to a high mortality

North East Lincs (DPoW) seems to have moved from a low mortality to current high mortality.

There are some hospitals like George Elliot and Morecambe Bay who seem to have moved from somewhere in the middle to current higher rates of mortality.

Moving to a low mortality

In page one and page two you will find Birmingham Heartlands, Solihull and Good Hope (on page one) all of which form the HEFT, having a high mortality in 1998 but now have below 100 HSMR over 3 years and could be sited as a case of consistent improvement over time. They still not a ‘low’ mortality hospital though.

Bradford has moved from the higher end to very low mortality.

On page three you will find Kings and St Georges at the very high end in 1998 but are now very clearly in the lower end over a three year period. Page 4 has Airedale which was towards the higher end at that time, now for a good many years they are a low mortality hospital.


LESSONS (My personal interpretations)

As a generalisation, many hospitals tend to remain where they are. This is not unusual. I think I have already written about how it is human nature and natural physiology to maintain status quo. The difficulty is when a high mortality hospital remains high where status quo is not a good situation to be in.

It is possible to move from low to high mortality.

It is possible to move from high to low mortality (Bradford, Airedale).

The popular examples may not always be the really the improved ones (Bolton and Luton are popular).

Though mortality is a good headline important measure it is well linked up with good performances in other areas of safety and quality.

As an aside,
It seems to me that (once service configuration changes are explained) most of the improvement is related to the change and improving cultures of the organisation who act in a pro-active (rather than reactive way) - I have not provided reasoning and justification for my assertion here.

From a general reading around this I find that hospitals tend to take the CQC more seriously than dr Foster (or other companies analysing and reporting on mortality) – again I have not provided reasoning and justification for my assertion here.

Whom should we learn from?

If we do the learning circuits we will hear Luton. We will also hear often from Bolton especially about the lean systems. Till recently George Eliot was also doing the rounds talking about improvement. I have attended many of these presentations and have found them very useful from an educational and knowledge perspective.

From a political perspective it is relevant to learn from the experiences of University Hospitals Birmingham who ably withstood the bad press that they had in 2011 (whose CE Julia Moore was recently became Dame Julia Moore) and HEFT whose CE Dr Mark Goldman was seen to leave HEFT following bad press at Solihull ( ; but Dr Goldman was reported as having ‘turned around’ hospitals and as being ‘wise’ in the Worcester area . It is probable that the cultures in these two Birmingham trusts are very different even though geographically they are not apart from each other. Political learning is very important as it is about perceptions, how people see them and how to handle them.

From a persistent long term improvement perspective we certainly need to learn more from HEFT, Kings, St Georges, Bradford and Airedale.

I am sure that there are many examples in each category that I have not looked into who are equally improved (or not as the case may be); hence the above is just a sample of what attracted my attention and not a thorough analysis.

This is certainly interesting but you ought to tell me if it provides any more insight.

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