Studying large-scale programmes to improve patient safety in whole care systems: Challenges for research
Introduction
In the UK and other countries, large-scale national and multi-institutional patient safety improvement programmes are beginning to emerge, to address the problems of patient safety and reliability in care that have been highlighted by a series of influential reports (eg. Dept. Health, 2000, Kohn et al., 2000). Such safety improvement programmes and campaigns are ambitious in their aims and represent intervention on a scale not seen before in health care. Current national campaigns are being designed on the basis that it is only through organisational-level development that any gains made in patient safety will be sustained and may be replicated throughout the system.
As our understanding of the origins and causes of failures grows, practical knowledge concerning how to rectify the problems and improve systems lags somewhere behind. Until recently, the majority of improvement initiatives may be considered to have been focused at the microsystems level within a health care organisation. There is now growing recognition, that patient safety and the capacity of an organisation to deliver consistent, high-quality and failure-free care is both a systemic issue and one that needs to be addressed at the level of the whole organisation or care system. If we are to understand how large-scale programmes can become effective in meeting these aims, we need research designs that are sensitive to the complexity involved in intervening to change whole systems. In this article, we discuss the challenges for research into large-scale patient safety improvement programmes, drawing upon our experience of developing research into the Safer Patients Initiative, a large-scale improvement programme in the United Kingdom.
Section snippets
Research into organisational-level improvement programmes
Several authors have drawn attention to the limited evidence base for the efficacy of large-scale improvement programmes in health care (eg. Mittman, 2004, Shojania and Grimshaw, 2005). The majority of the available research relates to the popular breakthrough collaborative programme model (Institute for Healthcare Improvement, 2004), which involves teams from multiple institutions working together to focus upon improvement in a specific clinical area (eg. Bate et al., 2002, Kilo, 1998). Rather
The challenges for research design
Large-scale improvement programmes provide a number of challenges for research design, due to the inherent complexity in attempting to achieve effects in large-scale adaptive sociotechnical systems, such as a hospital site or whole health care organisation. In the discussion that follows, we first consider the research challenges that must be overcome to improve our understanding of these programmes, before describing a specific example of applied research in this area, to exemplify the
A practical example: research design for the UK Safer Patients Initiative
In order to illustrate how the research challenges outlined above influence applied research in this area, we turn to a practical example from the authors' current research based upon a large-scale safety improvement programme in the United Kingdom: The Safer Patient's Initiative (2004–2008). This work sought to understand the ‘journey to safety’ in 24 hospital sites, or how whole health care organisations can make significant and sustainable improvements in the quality and safety of care
Research limitations
We have described how one possible research design may meet the challenges of complexity in a large-scale intervention, but as with all methodological decisions under resource constraints, the reality is that in selecting one approach over another, the researcher makes various trade-offs. The relative virtues of qualitative and quantitative approaches and their combination in mixed-methods designs have been discussed elsewhere (Bryman and Teevan, 2001, Pope and Mays, 1995, Pope and Mays, 2000).
Implications and conclusions
We have discussed a number of methodological issues pertinent to the design of research into large-scale improvement programmes and have considered these in the context of a practical example in the UK. The characteristics, inherent complexity and multi-level nature of these programmes as systems for change pose some unique challenges for researchers. This is particularly the case where programme effects span levels within a system; vary dynamically or are cumulative over time; where
References (50)
The paradoxes of almost totally safe transportation systems
Safety Science
(2001)- et al.
Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma
The Lancet
(2004) - et al.
The 100,000 lives campaign: a scientific and policy review
Joint Commission Journal on Quality and Patient Safety
(2006) Quality improvement learning collaboratives
Quality Management in Health Care
(2005)- et al.
Understanding the complexity of redesigning care around the clinical microsystem
Quality and Safety in Health Care
(2006) - et al.
Quality by design: A clinical microsystems approach
(2007) - et al.
Organizing for quality: The improvement journeys of leading hospitals in Europe and the United States
(2008) - et al.
Report on the breakthrough collaborative approach to quality and service improvement within four regions of the NHS: A research based investigation of the orthopaedic services collaborative within the Eastern, South and West, South East and Trent Regions
(2002) - et al.
Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative
Journal of Evaluation in Clinical Practice
(2009) - et al.
Statistical process control as a tool for research and healthcare improvement
Quality and Safety in Health Care
(2003)