JEFFREY BRAITHWAITE: How to improve the health system, part 2: learn from things going right as well as things going wrong

Sep 30, 2019

At the Australian Institute of Health Innovation at Macquarie University we have around 80 projects going on at any point in time. There are more than 180 people – doctoral and masters students, professional staff, researchers, visiting academics and associates – and dozens of partners, nationally and internationally. We are working on providing the evidence that supports practical and implementable change in the health system, delivering real benefits to people.

I like to say that, unlike many other types of medical and health research, our lab doesn’t have test tubes and microscopes. Our lab is the health system itself, and much of our research examines how well it does, and how it can work better.

One way we have been optimising our understanding of clinical work is to collaborate with providers of all kinds, and also embed health systems researchers in clinical environments. We can begin to help shape change by understanding more deeply what improvements work best, and under what circumstances, and for whom. Our researchers include implementation science specialists who work alongside hospital teams, in general practice and residential aged care to facilitate better take-up of interventions such as new electronic medical records, equipment or rostering protocols, or new tests. It’s an evidence-based approach to change and improvement.

Another way is to use newer, tailored research designs that have the potential to deliver faster feedback and thus more timely improvement. In a recent example our research teams have been studying how new medication management systems are put in, and testing whether and to what extent they deliver the gains intended by those implementing them – reduced medication errors, fewer adverse drug events, and reduced lengths of patient stays, for instance. That way, hospitals can know much faster what works and what doesn’t.

We also look at questions such as what are the barriers to a software upgrade being workable on the wards? What facilitates a new IT system being adopted quickly? How does new diagnostic technology get used in practice, rather than in the manufacturer’s manual? How can we exploit the artificial intelligence revolution and capture the benefits for patients? From there, our researchers in concert with clinical staff and the system’s managers and policymakers can identify suitable adaptations and more readily smooth the way for leading-edge technology and knowledge to positively affect diagnosis, treatment, and care.

We’ve also been learning what works well in hospitals and departments. Finding those with better safety records and positive cultures is a real benefit — we have been searching for the best models by which to extrapolate that kind of information and spread the gains to other hospitals and departments.

The same can apply for any innovation. If we can learn from a typical kidney dialysis program, heart transplant team, or rapid response system that make things go right for patients through their everyday clinical efforts, we can in principle replicate this anywhere. We are often asking, what is it about high performance that could be adopted by others? Our work on Safety-II and resilient health care has extensively explored this with expert colleagues in over a dozen countries in five published books since 2013.

It is no easy feat to improve health systems. It’s akin to rebuilding an A380 while in the air, because unlike airlines, healthcare can’t stop while we fix things or learn from successes – it must keep on providing care.

All of these studies require significant investment in capacity-building the next generation of researchers and improvement leaders, to look for the good examples, the success stories. Especially in rural and remote regions where resources are scarce.

Time and again the headline numbers tell us that one in ten patients admitted to hospital in Australia experience some form of adverse event. It is right to be reminded through anecdotes from friends and stories in the news, of that one person whose harm becomes a tragedy, like the saddest of most recent cases when Alex Braes died of sepsis because his condition was missed three times over a few days. We should remember the death or disability that can be caused by a person not being able to access treatment in time, or an incorrect diagnosis being given, or a mistake being made.

But we would do well to remember, too, the other nine in ten patients that suffer no harm, and the vast majority of times that Australians get great care.

Lessening things that go wrong and increasing more of what goes right, if we can accelerate both, will make care safer and of higher quality.

There’s always a tendency in healthcare – and in society in general – to only remember the head-shaking cases that go wrong (the ‘never events’ they are called – such as someone operating on the wrong body part, or leaving the scalpel inside the patient and closing them up).

But in all the care that occurs in Australia – the 100 million GP appointments, the eight million emergency department visits, the 11 million inpatient admissions – most things go well. Our research institute is directing a lot of energy to understanding this concept. That means having a balanced view of healthcare and learning from everyday clinical work that produces good care for the many.

Every clinician on the front lines has a story of the patient that was saved from deteriorating by the vigilant ward team. The family that was supported through thick and thin by the GP who understood their needs. The older person who someone sat with as they told of their hopes and fears. The complex operation which two surgeons collaborated over, delivering a much better outcome than a sole surgeon could have managed, no matter how skilled. Getting things right is the best reward for clinicians and is a massive driver for improvement across the system. There’s at least as much to learn from success, as failure.

Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Macquarie University, and President Elect of the International Society for Quality in Health Care.

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