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Can the ‘third man’ of healthcare improvement emerge from the shadows?

‘For all the talk about quality healthcare, systems performance has frozen in time. Only 50-60% of care has been delivered in line with level 1 evidence or consensus based guidelines for at least a decade and a half; around a third of medicine is waste, with no measurable effects or justification for the considerable expenditure; and the rate of adverse events across healthcare has remained at about one in 10 patients for 25 years.’

These are the word of Jeffrey Braithwaite from the Australian Institute for Health Improvement. The BMJ has this week launched a new series of articles about healthcare improvement  funded by The Health Foundation. In the first issue of the series Jeffrey Braithwaite talks about the fundamentals of how we think about improving healthcare with an associated podcast ‘Thinking about healthcare as an ecosystem not a machine’.

Jeffrey Braithwaite is a leading health service researcher. Beyond his work on the performance of health care organisations Jeffrey has been involved in research on patient safety and Medical Emergency Teams, the area in which most of my expertise sits.

His analysis for this paper is that a) healthcare systems are really really complex and that b) improvement needs to be driven through a change in organisational culture from the bottom up. Complexity means that it is often impossible to predict how individuals or the whole system will respond. The assumption that we can work out from first principles and robust science how improvement is best created and implemented is almost certainly wrong. Cause and effect will be different in different systems and at different times in the same system and nearly never linear. Healthcare is a system of complex adaptive systems.

Braithwaite highlights how dictates from policy makers, managers or external ‘advisors’ rarely achieve impact unless they are aligned with clinicians views and culture. Powerful words and sobering truth!

While I believe that he is right in his analysis I was surprised to see that the focus of  the piece seems to assume that there are mainly two partners: the health care professionals vs bureaucrats and managers. Patients feature, but as passive objects not subjects who are able to drive improvement. Given the many permutations of relations between clinicians and managers and policy makers and the lack of a breakthrough in over 20 years it would seem that this is a good time to reconsider: The lost third ‘man’ or ‘women’ in this conversation needs to emerge from the shadows of improvement science. THIS insitute’s Jenni Burt promotes just this in her blog ‘Out of the Towers and into the Trenches’: Citizen science by staff and patients as the answer to more coherent concepts in improvement science. In the same vein our group safer@home is launching an study later this year to allow patients a stronger say in ‘what matters’ in acute care. Flashmobs are being used in social activism but can also function as a platform to allow patients’ voice to be heard. Our Dutch colleagues have only recently used the method to evaluate the quality of sleep in hospital. What this space!

When in most industries quality is rewarded by customer satisfaction and loyalty in healthcare choice is limited, especially in emergency care. The absence of insights into the sewers of performance of hospitals and clinicians means that patients can’t actively drive the improvement. Those who have the most skin in the game have hence the least opportunity to contribute to improvement. Surely this needs to be at the heart of ‘new’ ways to improve quality.

If we don’t want the ferris wheel of healthcare improvement to turn endlessly we need to find ways to get ‘the third man’ of healthcare improvement out of shadows!

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