Minutes of the Liverpool Society of Anaesthetists Meeting
Thursday 23rd January 2014
'Intensive care - Quality improvement or performance management?'
Professor Julian Bion, Queen Elizabeth University Hospital, Birmingham
The meeting was opened by Dr C C Evans, who was standing in for the current President of the Liverpool Medical Institution, Mrs Linda de Cossart. He then handed over to the LSA President, Dr Janice Fazackerley, who introduced the speaker, Professor Julian Bion, Professor of Intensive Care, at the University of Birmingham.
Professor Bion opened his talk by looking at the balance between quality improvement and performance management. He characterised quality improvement as clinically driven by motivated professionals who work together to sustain a perpetual increase in the quality of patient care. This is in contrast to performance management which is usually management driven by either policy or financial targets, short term in nature with penalties if targets are not reached. By whatever means the public must trust in the delivery of ever improving quality, or the Health Service will no longer be able to function. He highlighted an annual survey where the public are asked who they trust. Doctors are regularly at the top of this survey with politicians, who set the agenda and targets for the National Health Service, being regularly at the bottom.
Professor Bion then looked at the origins of the purchaser/provider split. This was introduced in the 1990’s to bring pressure on secondary care to become more efficient and effective, so as to reduce the demands on tax payers whilst maintaining the volume and quality of services supplied to the public. He described the context of the NHS which costs over £100 billion per year or 8.4% of GDP. Funding had been greatly increased in the 2000’s but with it had come further reorganisation and complexity. He showed some of the recent publications to improve quality in a climate of efficiency savings, a flat-line budget with 5% annual inflation. He also demonstrated the fall in hospital beds over the last 25 years, and the ever greater complexity of the intertwining NHS bodies.
Profession Bion spoke about the NHS outcomes framework with its five domains. He thought that these had laudable and simple aims. However, the ways that the domains were measured were extremely complicated. He showed the three classes of organisations that provide care for patients: GP practices, acute or mental health trusts, and thirdly private hospitals. He then contrasted this with the vast array of organisations that provide input into healthcare without giving direct care to patients.
Professer Bion described the variations in quality of care and the relatively high rate of adverse events leading to avoidable patient deaths. He showed a table produced by McGlynn et al (NEJM 2003; 348:2635-2645) that demonstrated that, on average, only 55% of patients receive the care recommended for the particular condition being treated. The best care seemed to be provided for patients with cataracts, breast cancer and cardiovascular disease, with the worst and most variable being hip fracture and sexually transmitted diseases. A paper from Australia (Runciman WB et al. Med J Aust. 2012 Jul 16;197(2):100-5) demonstrated a similar result. A paper in this week’s Lancet by Cheung SC et al demonstrated a 7.6% 30 day risk of death following acute myocardial infarction in Sweden. This contrasted with a figure of 10.5% in the UK. A paper by Rupert Pearse, looking at mortality after surgery in Europe, demonstrated variations in outcome for non-cardiac surgery across countries. This also seemed to be the case in other areas such as the incidence of MRSA. As a consequence, to combat the latter, there had been an outpouring from various bodies, to reduce the incidence of healthcare acquired infections. This had led to the incidence of MRSA bacteraemia actually falling which had been associated with a rise in the use of alcohol hand rub. He also demonstrated the way that financial penalties placed on Trusts, had forced changes in behaviour, reducing infection rates. He commented that this may not be the ideal way of achieving better practice, but it appeared to be effective.
Professor Bion then looked at the report on the Mid-Staffs Hospital public enquiry. He thought that there probably was some very good care in that hospital, but it was poor too often and more often than in most other hospitals. He thought that the consultant body had actually got off quite lightly because professionals should not have disengaged and accepted falling standards in the way that they apparently did. However, it did seem to be human behaviour to have a fatalistic attitude, accepting poor practice, which then became normalised. He thought that there had been a lack of professional leadership and this was highlighted by Stephen Dorrell, MP, the Chair of the House of Commons Health Committee, who commented that the key to high care standards will always be the commitment and professionalism of the clinical staff. The MP also said that everyone working within the National Health Service has a personal and collective accountability for the standards of care provided.
Professor Bion discussed the scale of the challenges and in particular, the many ways a human body can go wrong with the many different medicines and treatments that can be given to combat illness, in a population of 53 million people just in England. He showed the way that venous thrombo-embolism prophylaxis had become an ever greater priority for the National Health Service and the multiple publications that had gone with it. This had led to a doubling to 94.2% in 2013, of patients receiving a VTE risk assessment on admission which may have led to a significant reduction in VTE associated mortality although the data is still unpublished.
Profession Bion then showed the four domains that make up a competent professional: knowledge, skills, behaviours and attitudes and beliefs. These are all important to reliably deliver best practice. But Professor Bion thought that it was the non-technical skills, behaviours and attitudes that were the most important in this respect. He looked at a typical ward round with its initial hand-over, the amount of data that was reviewed and the human factors that play such an important role in this tradition, central to medical practice. He then went onto look at the “Matching Michigan Project” to minimise central venous catheter blood stream infections in intensive care units. The origin of this programme had been in the United States where the introduction of technical and non-technical interventions to prevent catheter infections had led to significant improvements in this area. The findings of this project in the UK, highlighted variations in non-technical interventions, unreliable data collection, variable infection control practices and the wide variety of practices within different intensive care units. These practices are deemed to be normal in each unit and the same as everywhere else which is clearly not the case. However, it did demonstrate the focus that staff have on patient safety and their willingness to adhere in changes in technical intervention. It also demonstrated the importance of senior clinical support to bring change and the way that subtle things like the wearing of hats and masks can fundamentally change behaviour. He thought that many consultants could be completely blind to their own behaviour and its wider consequences. He had actually introduced a form of multi-source feedback into his own unit many years before this became a mandatory part of appraisal and revalidation. He said that he had found it very helpful but individuals must be able to accept negative comments and learn from them.
Professor Bion then looked at the sometimes subtle influence of bias on decision making in health care. He highlighted the fraudulent work of Jaochim Boldt on fluid resuscitation using starches. The European Medicines Agency had approved the use of infusions containing hydroxyethyl starch. However, one of the members of the approval committee was also employed by Fresenius, a manufacturer of one of these products. Similarly, the wife of Dr Boldt was also an employee of Fresenius.
Professor Bion thought audit was another form of reflective learning. He showed an audit from 2012 (Freemantle N et al. J R Soc Med. 2012 Feb;105(2):74-84) which had demonstrated that weekend admission was associated with a higher 30 day mortality than week day admissions. Another paper from Australia in 2012 demonstrated a much higher error rate at weekends as compared to week days. Both of these papers had produced evidence to support the publication in December 2012 by the Academy of Medical Royal Colleges, of their recommendations for the 7 day presence of consultants in hospitals. There were three standards. Firstly, all hospital inpatients should be reviewed by an on-site consultant at least once every 24 hours, 7 days a week. Standard two said that interventions and investigations should be provided 7 days a week whenever results will change the outcome or status of a patient’s care. Thirdly, support services both in hospitals and in primary care should also be available 7 days a week.
Professor Bion went on to speak about the high intensity specialist led acute care (HISLAC) research project (www.hislac.org) which will look and determine any associations between the presence or absence of specialists at weekends and the subsequent outcomes for patients admitted at these times. It will investigate a number of different factors including the quality and timeliness of diagnosis, investigations and treatment, as well as communication between fellow professionals and patients. He then described another project, the EPOCH trial (www.epochtrial.org), which would look at the effectiveness of a quality improvement project to implement a robust and evidence-based integrated care pathway to improve patient outcomes following emergency laparotomy.
Finally, Profession Bion looked at ways of bringing the various bodies together to have a co-ordinated approach to quality improvement. In intensive care this would be known as the critical care forum, and would try to bring the multiple groups together such as the Faculty of Intensive Care Medicine, nursing organisations, audit and research bodies, as well as other NHS bodies.
In summary, Professor Bion thought that quality improvement should be professionally led and patient centred. He thought that we all had a personal responsibility for this and it should be driven by audit, research and critical enquiry. Clinicians should own their own performance data and this should all be supported by our professional organisations. He thought the challenges would be high and they centre around good leadership to cause a change in organisational culture engaging staff and reducing professional tribalism. Without the carrot of incentivising individuals to participate and the stick of there being consequences for individuals that will not engage, then quality improvement led by professionals will be unsustainable and the balance would move towards performance management.
Profession Bion took some questions from the floor, and the vote of thanks was given by Dr John Gannon.
30th January 2014