Who is responsible for providing quality and safe care?

Mª Luisa de la Puente

Chris Ham and Don Berwick argued that the teams of professionals who care for patients are mainly responsible for providing quality care and safety, placing managers and regulators second.

The health managers’ role is to manage the means of communication, training, resources and the time critical requirements to enable the functioning and constant improvement of the care and safety requirements. They cannot achieve this it if they are not focused on what is happening in the front line and making this their main priority.

While managers have the responsibility to add value to clinical teams surrounding them with the resources necessary for continuous efficiency and safety improvement, the clinical leaders must connect with the managers and the professionals and focus on  detecting the organisational factors that may leave room for improvement and work in the reordering them and in innovation to carry these out. According to this view, the new definition of professionalism assumes that those professionals who work in the first line, with the support of others, must accept the responsibility to identify and remove the obstacles that may get in the way of a high quality of care. Similar recommendations have been proposed by others like Bohmer since 2010, but the authors insist on this fact, given the practical difficulty to carry them out. 

Regulators ought to focus more and better on the modernization of resources, technology and information systems and on the training of the professionals of the future as well as in requiring the educators to orientate their goals towards continuous quality improvement and subsequently monitoring the changes made towards this goal.

After in-depth studies on hospitals like Western Sussex Hospital NHS and Virginia Mason Medical Center, specialists in safety, security and the involvement of its professionals as well as centres, patients, professionals, leaders and managers of the institutions of the National Health Service (NHS) came to the same conclusion.

The finding made them wonder what happens today in the "normal” care offered by the NHS, things like unnecessary delays, unfulfilled promises, fragmentation of the care between the professionals of the different institutions and the same institution, inefficiency of the functions, disorganized pathways. While all this is happening managers and regulators talk about the excellence of management and innovative front-line projects.

Why this apparent paradox?

The main issue that is discovered is that the leaders of the organizations are not paying enough attention to the front line. The gap between managers and clinical teams is too great. They live in the world of finance, strategies and outside opportunities. The others live in the world of present and future care. The consequence is frustration by both front line and management. The good organizations have dealt with this difference because sensitivity to operational needs is one of the great factors in the success of an organization.

The task of improving the daily work of the front line, where there is an exchange between the professional and the patient is always necessary, but especially where resources are scarce. Under pressure, everyone - professionals, managers and leaders - in an attempt to survive on a daily basis, sacrifice innovation towards improvement. Paradoxically, just when it’s more important to improve processes, standardization, innovation, patient safety and the promotion of workers' morale it’s when reality jeopardises them.  

How to avoid this vicious circle?

Bob Klaber, a paediatrician at Imperial College, part of the NHS Healthcare, in one of the interviews said that we think that quality is predominantly a technical issue, but that it’s clear that the challenge is the implication: giving support, facilitating and encouraging professionals, patients and patients’ families to identify and make improvements. There are four central elements in which they work to improve quality:

1. Ensure that all professionals support the managers and leaders in their work role and in the continuous improvement of their work.
2. Provide training in the continuous improvement of quality to all professionals and managers.
3. Design improvement projects together with professionals, patients and the population.
4. Rigorously incorporate the methodology of quality improvement within the institution.

Tom Downes, geriatrician and clinical leader of Quality Improvement in the Sheffield Teaching Hospitals established that all professionals were trained in quality improvement methodology and leadership, and received the necessary support to gradually carry out the changes proposed from experience. As a result, they have successfully developed innovative projects related to patient discharge processes and new models of mid-stay care.

The reality in our country is similar in many aspects to that found in other institutions. The great pressure to which healthcare professionals are subject and the demands placed on institutions to maintain their sustainability and leadership and to meet external requirements not always related to local healthcare priorities, make it difficult to work on the path of continuous improvement of quality. We need to pay much more care to the operation of the front line in their day to day activities, support the clinical leadership and train in the search and implementation of the improvements. This is inescapable if we want to advance in the direction of effectiveness and safety which is the ultimate purpose of the work of the professionals and institutions.