The slow progress of clinical safety, a problem of "many hands"

Cristina Roure

In this section we usually discuss overdiagnosis and overtreatment, but today we will talk about the difficulty in achieving safe care environments for patients.

Some will remember the publication in the year 2000 of the report “To err is human. Building a safer Health System” by the Institute of Medicine's Quality Care, which created a big impact in the media due to the alarming figures of deaths caused by medical errors in the USA. (1). Since then, a lot of work has been done in order to improve patient safety, and a lot of progress has been made for the dissemination of the clinical safety culture, and a great deal of effort and resources have been devoted to the implementation of safe practices for reducing the risk of medical errors.

10 priorities for integrating physical and mental health, according to The King's Fund

Andrés Fontalba

The current health care model that classifies patients by system or medical specialty categorises care to for any health problem. The causal attribution to diseases according to the psychic vs. organic dichotomy inhibits seeing the process of the pathologies in their totality and contributes to the problem of patients taking their illness from one service to another, with the risk of overacting in some cases or of non-holistic intervention method of integrated solutions in other complex cases.

Health incentives: don’t shoot the behavioural economists!

Pedro Rey

The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 

Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

Improving the emergency and territory services: defragmenting the system

Xavier Bayona

In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.