I was at a very good conference a couple of weeks ago (the ACHSM Asia-Pacific Health Leadership Congress) and – as you do – mulling over the ideas being discussed during the sessions and over the lunch buffet. Lots of smart and thoughtful people discussing many of the same issues and problems we’ve been talking about since, well, forever.
During a lull in proceedings, I read a recent essay from Mary Dixon Woods (see: BMJ 2019;367:l5514) in which she made a number of interesting points (as always!). One issue she raised was that the way problems of quality and safety are identified, defined and selected for attention – including by whom and through which power structures – has implications for how (or indeed if) the problems are addressed. She cited several powerful examples, but my thoughts turned to more prosaic cases.
For example, what happens when the only healthcare-related issues we’re prepared to address through quality improvement initiatives are those where some harm has already occurred? In all my years working in the health and higher education sectors, I’ve lost track of the number of times I’ve been told there’s no funding or resources available to “fix something that ain’t broke”. Unfortunately, using this filter to identify or select issues that need to be addressed ensures that quality improvement is framed as a reactive or remedial activity. It also all but guarantees that harm occurs within the system.
Likewise, what happens when we disregard issues unless they have been identified by staff of particular professions or seniority levels? I expect most of us can remember times in our careers when we’ve thought “No one listens to me, I’m just a…”. Not only does this filter ensure many issues that impact on daily work practices go unresolved, but it also serves to devalue the knowledge and experiences of many of those who actually do the work.
As I listened to the conversations at the conference, I wondered how much of our inability to address the long-standing issues of quality and safety comes back to this point? Our desire for simple, one-size-fits all solutions drives us – sometimes unconsciously and sometimes consciously – to filter out information from a wide range of sources that might “complicate” the analysis. And so we try a series of narrowly focussed solutions, one after another, that never seem to entirely solve our problems.
Perhaps as a starting point, we might consider widening our sources of information about what works and what doesn’t and avoid pre-judging the relative value of insights that come from the various sources. While we’re at it, we could also rethink the criteria used to determine whether an issue needs to be addressed, recognising that waiting for things to break before we pay them any attention is antithetical to the concept of quality improvement.