Imagine that you have just been appointed chief executive of a large hospital. At your first board meeting you are asked to develop a plan to generically strengthen the care quality/safety of the hospital. The board insist that the intervention (or intervention package) selected should satisfy the following criteria:
- As stated, it should be a generic change, not disease specific.
- It must cover the whole hospital or a substantial hospital department.
- It must be affordable – ideally cash-releasing.
- It must be ‘scalable’ – that is to say it must be something other departments/hospitals could adopt in your country and further afield.
- It must be evidence-based – that is to say it must be an evidence-based service delivery (blunt-end) mechanism to promote evidence-based clinical/safety practices (sharp-end).
- It must be tractable, so that the board can see whether or not it is effective.
Where should one start? One sensible way would be to scour the literature. We would recommend:
- The recent Agency for Healthcare Research and Quality (AHRQ) review of Safety Practices   that are either “encouraged” or “strongly encouraged”. These cover 22 interventions (see Table 2 of Shekelle et al. ).
- The fabled Effective Practice and Organisation of Care (EPOC) Cochrane database.  This covers 103 interventions, grouped into 17 categories (see online).
The CLAHRC WM Director recently perused the above literature, rejecting interventions that did not comply with the criteria (Figure1). Table 1 presents a short-list of surviving items for the CEO to consider.
Table 1. Short list of tractable interventions for generic hospital strengthening
|Discharge planning||An individualised process to decide what a patient needs for a successful transfer from hospital to community. Sometimes called ‘handover’.||CLAHRC International is conducting such a study in India, funded by MRC UK. This is a topic confronting the hospital / community interface and therefore worthy of consideration.|
|Audit and feedback||A summary of health workers’ performance over a period of time, aimed at providing information that allows them to assess and adjust their performance.||It is effective, though effect size is small. Really needs to be part of a co-ordinated set of actions.|
|Communities of practice||Groups of people from a given specialty who interact and thus deepen their knowledge and expertise.||Operates at a supra-hospital level, else it would be an example of audit and feedback.|
|Continuous quality improvement (CQI)||An iterative, process-based, data-driven approach to improving the quality of a product/service.||Typically based on specialists from many hospitals. Similar for audit and feedback, but at team rather than individual level.|
|Academic detailing||Personal visits and education of health workers by trained professionals, in order to improve practice.||Arguably expensive and not scalable unless as part of something more systemic.|
|Tailored interventions||Interventions selected based on an assessment of barriers to change.||Natural partner to CQI.|
|Pre-operative checklists, e.g. WHO check-list||Checklist of items to be completed prior to surgery||But needs to be combined with some action to enhance belief in and use of the checklist.|
|Hand hygiene||Ensuring hands are regularly and thoroughly cleaned at key points in time to reduce the transmission of pathogens.||Many simple interventions based on ‘nudge’ theory. CLAHRC WM recently won a grant from the Health Foundation to pursue this.|
|Do-not-use list of abbreviations||Abbreviations that should not be used due to high risk of miscommunication between prescribers and pharmacists, such as Q.D. for daily||Arguably something best promoted at national level.|
|Barrier precautions to reduce infection||Use of gowns, gloves, disposable examining equipment, etc. to reduce incidence of antibiotic resistant pathogens||Arguably not generic.|
|Medicine reconciliation||Ensuring patients’ medication regimens are reconciled during transitions in care.||Hopefully already in use. Certainly a part of discharge planning.|
|Use of surgical outcome measures||Using measurements and report cards to provide risk-adjusted assessments of outcomes that are fed back to hospitals or departments.||Very controversial because risk-adjustment problems. Bed-fellow of CQI.|
|Rapid response systems||A system designed to identify and respond to patients with early signs of clinical deterioration on non-intensive care units.||Needs to ensure that recognition of deterioration and response are both improved.|
What should be recommended? A theme in service delivery research, and indeed behaviour change in general, is that they are often most powerful when they combine many individual components. This makes sense because there are typically a range of barriers to the optimal behaviour. So one could suggest a compound intervention in which all departments were incentivised to practice CQI, with an emphasis on identifying barriers to change, while encouraging a community of practice? To empower departments, ask them to select an evidence-based clinical practice and provide incentives in the form of management assistance, prizes and honourable mention in the CLAHRC WM News Blog. Alternatively, or in addition, tackle discharge planning since it can reduce the duration of stay and reduce adverse events post-discharge.
Figure 1. PRISMA-type diagram to show interventions the Chief Executive might want to describe from the long-list of 123 potential interventions to improve hospital safety/effectiveness. The list is hierarchical, each item can only be excluded once.
— Richard Lilford, CLAHRC WM Director
- Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013; 158(5 pt 2): 365-8.
- Agency for Healthcare Research and Quality. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Report/Technology Assessment Number 211. Rockville, MD: AHRQ, 2013.
- Effective Practice and Organisation of Care (EPOC). EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2015.
- Effective Practice and Organisation of Care (EPOC). EPOC Taxonomy; 2015.
- Lilford R. A Theory of Everything! Towards an Unifying Framework for Psychological and Organisational Change Models. CLAHRC WM News Blog. 28 August 2015.