Peter I Lachman, Ellie Day, Lynette M Linkson, Jane Runnacles
Quality improvement and the clinician
The concept of quality in healthcare and the understanding of its relevance and role have evolved over the past twenty years. Our aim as paediatricians is to improve the quality of care and outcomes for children. Our challenge is to work with children and families to understand the issues they face, to jointly define the potential solutions and then develop improvement programmes to implement them. We now understand that advances in medical science achieved in the last century are insufficient to guarantee good clinical outcomes. The UK reviews following the paediatric cardiac surgery clinical crisis at Bristol and high profile child protection cases confirm that we need more than our knowledge about clinical medicine and guidelines to achieve good clinical outcomes. These seminal events led first to the development of clinical governance and clinical audit, and subsequently raised the profile of the patient safety agenda and the concept of quality improvement.
Quality improvement in healthcare is ‘the combined and unceasing efforts of everyone, i.e. healthcare professionals, patients and their families, researchers, commissioners, planners and educators, to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)’. This implies that we all are responsible for the quality of care we deliver and that quality improvement should be part of our job as clinicians and other healthcare providers.
The purpose of quality improvement in paediatrics and child health is to ensure that children receive the care needed and wanted the first time, every time. This requires safe, effective, care that is reliably and consistently delivered and the consideration of its value. The latter is defined from the viewpoint of the child and their family, i.e. what do they value in terms of the care that is delivered, both in terms of value for money but more importantly the value in achieving the child’s desired outcome? There is a definite gap between what we know to be best practice from research and the care that is delivered to children. Quality improvement provides the framework to close this gap.
Major quality issues facing the health services in general
The Institute of Medicine identified six dimensions to quality care:
• Patient or person centeredness: ensures that patient values guide all clinical decisions.
• Patient safety: intends to avoid harm from the care that is intended to help.
• Effectiveness: the provision of evidence-based care based on the need of the patient.
• Timely care: aims at ensuring access when and where care is needed.
The above principles can be translated into practical standards, which form a useful framework for an approach to quality improvement:
• Partnering with patients to develop services and how services are delivered.
• Preventing and controlling healthcare-associated infections.
• Ensuring medication safety from prescribing to dispensing to administration and reconciliation.
• Patient identification and procedure matching at all times.
• Reliable clinical handover at all interactions.
• Blood and blood products safety.
• Preventing and managing pressure injuries.
• Recognizing and responding to clinical deterioration in acute settings.
• Preventing falls and harm from falls.
• Ensuring that the access to and the flow of patients through the system is timely and efficient.
Quality problems facing children
Most of the above are adult focused but also apply to children. However, in paediatric and child health practice, children are subject to multiple and complex additional issues either in hospital or in the community. Any paediatric improvement programme either at national or local level needs to take account of and address these specific challenges.
Variations in service provision
As in adult care, variation in service provision is a key problem. An analysis of the way health services for children are organized has revealed that there are wide disparities in service provision across Europe (Wolfe et al 2013). A more consistent approach to the way we design and integrate services and how we address the totality of children’s needs would result in the development of equivalent outcomes. On a system or policy level (known as the macro level), it has been recommended that in order to improve outcomes, one needs to look at the whole healthcare system and consider reconfiguration of the different elements of care in health as well as in social care and education. It is estimated that approximately 1500 preventable deaths occur in paediatric departments in the UK each year, while many more children live with preventable disabilities, chronic pain and unequal access to the services they need. Across the UK, variation in how care is delivered in different areas has a major impact on local outcomes.
There are three key components to variation in service provision: variation in how services are designed, variation in the choice of care interventions, and variation in the delivery of effective care.
1. Variation in how services are designed
The design of services and what can be provided is a major factor in the standard of care that children receive, and on their resultant outcomes. Variation is to be expected in all that we do and in all processes we undertake. This may be in the way we set up the systems and processes of care, or in the way we treat individual children. An example of systems variation is the difference in the way emergencies are managed within the working day, overnight and over weekends or bank holidays. The processes are clearly different; there is variation in the clinical expertise available and in the outcomes that are achieved. Another example is in emergency care provided when a major accident increases the number and rate of arrival of patients above the normal predicted range. This in turn can lead to problems in access and equity of delivery. Some areas may have long waiting times and others are seen promptly, depending on how the service is designed. Where a child lives determines the quality of the care they will receive. The Royal College of Paediatrics and Child Health (RCPCH) has highlighted this problem as one of the challenges that the NHS must address. Reports on disease-specific outcomes, e.g. on epilepsy, have demonstrated the impact variation can have on clinical outcomes.
2. Variation in choice of care interventions
In the past, the evidence base in paediatrics was not as robust as it is today. Many aspects of what we do now is well evidenced and the development of guidelines has provided a basis for what works and what does not. Parents will often defer to the opinion of the clinician, believing that it is based on the best evidence available. In cases where robust evidence does not yet exist, there needs to be local consensus on how to manage certain conditions in order to minimize variation.
3. Variation in the delivery of effective care
Where there is a clear evidence base and a gold standard of care for a specific disease or patient group, every child with that condition should receive the same care. Variation from standardized protocols, not dictated by the clinical needs of the child, may be unwarranted and harmful. Variation is to be expected in all clinical activity and is an inevitable consequence of differences between systems, i.e. different hospitals, different clinicians, different patients, etc. Unwarranted variation in care is that which is not explained by the clinical need or the choice of the parent and child. Unwarranted variation in care is widespread and occurs when clinicians:
• Overuse treatments or procedures that do not help patients get better
• Underuse interventions that can work
Variation in clinical care derives from decisions that clinicians make regarding diagnosis and treatment interventions and is the responsibility of clinicians. Resource and service design are less likely to be under the clinician’s control. Trainees are aware of the different preferences of their consultants in the treatment of children where they work. Guidelines are often not followed and variation can be confusing for both staff and families and ultimately has a detrimental impact on outcomes. Despite short-term clinical placements, trainees are well placed to undertake small tests of change and lead team-based improvement projects. Trainees have an opportunity to highlight and then address local variation through the use of improvement methodology.
To understand variation further, one also needs an understanding of the individuals who work in healthcare, i.e. their beliefs and attitudes, which form the culture of their work environment. Doctors are taught to be professionally autonomous and this influences their ability to work in teams. Changes in working patterns due to policies such as the European Working Time Directive require new ways to work together. These require a shift in culture and a change in previously held beliefs. Particular attention needs to be placed on the interaction of different professional groups within multidisciplinary teams; and across primary, secondary and social care boundaries. An understanding of the culture of the different professions, different clinical teams and the organization as a whole is essential to achieve improvement. Improvement and data collection needs to be seen primarily as a means to improve care rather than to judge how well individuals are doing or score performance.
Higher risk of harm
Patient safety is defined as freedom from healthcare-associated, preventable harm. Patient safety in children is different from adults, as they are vulnerable, dependent on adults and may lack a voice. Children rely on adults, and adult-trained clinicians frequently provide their healthcare in adult-oriented facilities.
Children vary in size, posing problems in interventions such as medication, e.g. weight-dependent drug dosing increases the risk of medication errors. Children are also more vulnerable from the failure of health professionals to recognize abnormal vital signs, such as heart rate, which vary with age.
A patient safety incident is any healthcare-related event that was unintended, unexpected and undesired and which could have caused or did cause harm to patients. Serious patient safety incidents are usually caused by multiple systems failures, rarely simply by frontline staff error. Errors may occur many times without any consequence; however, they only need to align once to cause a serious harm event. Patient safety projects need to consider a wider perspective and address the process of care rather than the individual care provider.
Risk management is the process by which one identifies factors that prevent the provision of safe, efficient and effective care. Traditional ways of detecting adverse events in paediatrics have relied on voluntary reporting. Approximately 10–20% of errors are reported, and of those many do not cause harm. The measurement of harm is complex and requires a number of perspectives. Harm is best defined as ‘anything that one would not like to happen to oneself, one’s own child or a member of one’s family’. Using a broad definition that is personal at the same time helps one understand how pervasive harm can be. The key is that in patient safety one wants to reduce harm to the minimum possible.
For children, the key challenges for safety are:
• The healthcare system is not child-focused, e.g. seeing children in an adult hospital.
• The environment may not be child-centred or designed around the needs of the child.
• The equipment may not be appropriate for all the children of different ages and needs.
• The tasks may not be appropriate for the level of training or experience of the clinicians.
Specific problems include:
• Failure to recognize clinical deterioration resulting in collapse and death.
• Infections of different types, especially peripheral and central line infections.
An increasing number of patient safety tools are emerging to reduce medication harm (such as drug calculator apps and zero tolerance prescribing) and healthcare-associated infections (including care bundles to reduce central line infections), and to improve both the identification and management of the deteriorating child (Paediatric Early Warning Score (PEWS)) and communication between healthcare professionals (Situation, Background, Assessment, Recommendation (SBAR)).
Clinical care bundles are collections of processes required to effectively and safely deliver care for patients undergoing particular treatments with inherent risks. A bundle is a grouping of several scientifically grounded elements
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