Quality, safety and patient experience

In every service , there is a relationship between quality and quantity, The health service does not only have this relationship, but also involve patient's experience and safety. The drive to achieve numbers and targets will drvie quality, patient's experience and safety in the opposite direction. We need a balance. A R Markos

There is an inherent conflict between need for quality care and the need to meet targets, whether time-based or financial. The increasing financial pressures in the NHS can only make it harder to ensure high quality patient care, but we will strive to continue to deliver quality care

I've had far to many doctors speak to me recently to say that they are still worried about speaking out and trying to resist "initiatives and developments" supposedly designed to improve patient care but which they believe will have deleterious effects on patient care. We've seen far too many examples recently of patient safety disasters which have come to light too late. Although the NHS supposedly encourages its staff to raise concerns there is still a culture, and fear, amongst some staff which prevent them from doing this and the NHS, encouraged by the BMA, needs to do more to protect its staff and to show, by example, that it really does want them to raise concerns openly and honestly.

top down quality enforcement is just that. the professions leads and delivers quality care by each one of us being professional in local practice. thus we influence by setting local standards (derived from our training/education/ colleges). we should therefore not tolerate poor practice, and act whenever standards are threatened. that means you and me, here and now, always! john.

Quality: requires a clear definition of the objective required - the key purpose of the hospital/surgery/health system; I suggest: * To deliver what the patient wants & needs, defect free * ...one by one, customized to each individual patient * ...on demand, exactly as requested * With an immediate response to problems or changes * With no waste * In an environment safe for patients, staff & clinicians: physically, emotionally & professionally. This should serve as the focus for all departments, because *all* departments should be focussed on delivering what the patient wants and needs; *how* they do it (medical care, nursing care, sensible finances, recruiting appropriate numbers of trained/trainable staff etc) will vary. The current QIPP agenda is perceived as mainly focussed on money (sorry, "productivity", however that is meant to be defined). However, if we focus on prevention not only for patients but for systems (to stop things going wrong in the first place), we may have a chance to deliver care that is both high quality and not wasteful: integration, rather than competition, will provide the benefits. This will require changes in culture from the DH down: 1. to maintain constancy of purpose toward continuous improvement 2. to drive out fear at all levels, so that everyone works together for the patient & hospital (see Deming'a other points for more details: http://respirologist.blogspot.com/) Driving out fear will obviate the need for whistleblowing: issues will not be hidden, but with openness will be dealt with. I would suggest that the CQC (or replacement) should focus on facilitating quality improvement work and applying industry-standard quality assurance (for example, encouraging & auditing to ISO 9001), perhaps aided by groups such as the Charted Quality Institute or Good Governance Institute. The CQI already provides certification for quality specialists; it would be helpful to have that expertise in the NHS.

Trainess are in a unique position, rotating from service to service, seeing good and bad practice, and encouraged to do audits and engage in reflection frequently. The PMETB (or equivalent) survey include questions on whistle-blowing, and could include questions on patient safety and management issues, and this should be fed back to the services involved (after the trainees have moved to maintain objectivity), and the results should be given great credence.

The Coalition wants more for less, and I'm afraid they can't have it. Quality and quantity are mutually exclusive in most cases and the law of diminishing returns applies as much to medicine as any other area. However, it's quality that we should cling to. Better to do one operation well than three badly. Of course, Clinical Excellence Awards are meant to be all about rewarding quality, and the current administration plainly don't care about them...

I think as doctors we need to speak out when we see things being done in a way which is bad for patients (or bullying of colleagues). And the BMA needs to support individual doctors who do so. I know - I've spoken out several times - and been bashed for it. But I haven't given up.