Quality of hospital care varies more within countries than between them

Effective, safe and patient-centred care is needed across the board. Jorgejesus4, CC BY-SA

Patient safety and quality of care are priorities in health, as is learning from our mistakes when things go wrong. But little is known about what hospitals are doing to make sure the services they deliver are consistent. And in research we recently published, we found that a concerning number were failing to reach key quality requirements.

For example, just one in three wards in the UK have removed potassium chloride concentrate (a solution known to be fatal if given inappropriately) from their general stocks, even though this was recommended by the UK National Patient Safety Agency back in 2002. Only 56% of clinical areas within hospitals have arrangements in place to treat heart attacks within the recommended timeframe and only half of wards met the standard to be able to identify patients by a wristband.

These figures are far below the compliance rates that are usually expected for crucial basic safety and variations still persist across the UK when it comes to quality of services.

Most of the gaps identified in our study could be remedied with minimum investment and simple strategies. But despite the scandal of Mid-Staffordshire (though thankfully very rare) showing that we need to learn from mistakes and improve care as a priority, little is actually known about what hospitals are doing on the ground beyond the talk.

Across Europe

Our research was the culmination of over three years of work on the DUQuE Project (Deepening our understanding of quality improvement in Europe) and funded by the European Commission. We looked at data collected from nearly 200 hospitals across eight countries including the UK, Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. This included surveys of over 9,800 professionals and 6,500 patients, and reviews of more than 9,000 patient charts, making it the largest collaborative project ever to investigate quality management systems in European hospitals.

Our research published in 12 papers in the International Journal of Quality in Health Care revealed that quality of care varies even more within countries than between them.

The NHS promotes patients seeking care in other EU countries but there are good and bad hospitals in each country – so when it comes to discussions about care across borders it’s not a simple case of saying one country is better than another. It means that patients going abroad should carefully check a particular hospital for its quality and safety, though such information isn’t always easily available.

Patients want to be involved

The definition of care quality is that “care is effective, safe, and patient-centred” – this is enshrined in the NHS constitution. But while systems that manage quality do a good job at ensuring effectiveness and safety, we found that they have no effect on patients’ perceived experience of care.

This is a real concern. More and more patients want to be involved in their care and be to be informed of treatment choices and possible side effects. Hospitals in Europe are starting to involve patients in quality committees, in discussing patient surveys and developing care pathways, but current levels are still too low. And from what we found, hospitals that involve patients in quality work are no more patient-centred than hospitals that don’t.

The importance of patient-centred care was highlighted in the inquiry into the Mid-Staffordshire Foundation NHS Trust, but our findings show this is still a neglected area. The inquiry specifically emphasised the importance of patient representation and prioritising patients’ needs. But if one accepts the NHS’s definition of quality, then who is in charge of making sure it is patient-centred?

Not about individual doctors

Patients often think that it is their doctors’ clinical skills which have the biggest impact on how good their care is. While that might be true in individual cases, looking at hospital outcomes, it is really the capacity of hospital departments to deliver care which is in line with the best clinical evidence that has the strongest effect on care overall. For example, no individual professional or unit can deal with problems such as hospital infections or failure to rescue after high-risk surgery. These require hospital-wide quality management systems to establish priorities, procedures and monitoring.

Unfortunately, these high-level systems have in the past too often been bureaucratic and, rather than supporting the work in clinical departments, become an end in themselves. Now our data clearly shows that high-level quality management without clinical involvement has little impact on the quality of care. Fortunately, this is now being recognised in the NHS, but perhaps all would be better served if more attention was paid to the efforts of improving quality, instead of the few instances where systems fail and have devastating effects on patients.

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