tag:theconversation.com,2011:/fr/topics/quality-of-care-10173/articlesQuality of care – The Conversation2022-08-24T06:44:57Ztag:theconversation.com,2011:article/1887452022-08-24T06:44:57Z2022-08-24T06:44:57ZComplaints, missing persons, assaults – contracting outside workers in aged care increases problems<figure><img src="https://images.theconversation.com/files/480700/original/file-20220824-16-fauxdr.jpg?ixlib=rb-1.1.0&rect=60%2C17%2C5691%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/portrait-disabled-senior-care-home-600w-262066259.jpg">Shutterstock</a></span></figcaption></figure><p>Aged care homes struggling to meet staffing needs are increasingly relying on externally contracted care workers to make up shortfalls. </p>
<p>However, <a href="https://onlinelibrary.wiley.com/doi/10.1111/ajag.13132">our new study</a>, shows homes that rely more heavily on externally contracted care staff provide significantly worse quality of care.</p>
<p>With the government convening a national <a href="https://treasury.gov.au/employment-whitepaper/jobs-summit">jobs and skills summit</a> next week, much attention is focused on addressing current staff shortages across the economy. <a href="https://www.aph.gov.au/Parliamentary_Business/Bills_Legislation/Bills_Search_Results/Result?bId=r6874">Legislation</a> has just been passed to increase the numbers of workers in aged care homes, and our research indicates workers’ employment conditions are critical to ensuring higher quality of care is provided to senior Australians.</p>
<h2>‘Agency’ staff across the sector</h2>
<p>Within the residential aged care sector, <a href="https://agedcare.royalcommission.gov.au/system/files/2020-06/CTH.0001.1001.2805.pdf">approximately 9%</a> of all the registered nurses, enrolled nurses and personal care workers are external contractors. Employed by third-party labour hire agencies, these “agency” staff work across different aged care homes on a temporary basis.</p>
<p>This sort of employment arrangement can help homes deal with short-term fluctuations in demand and staffing shortfalls. So it’s not surprising that as shortages have become more acute, this workforce strategy has become more commonplace. </p>
<p>In particular, as homes have struggled to maintain sufficient staff during the COVID pandemic, the use of agency staff <a href="https://opus.lib.uts.edu.au/bitstream/10453/157405/2/UARC_Aged%20Care%20Sector%20Mid%20Year%20Report%202021-22.pdf">has increased</a> across the sector.</p>
<p>As agency staff tend to work intermittently, there are concerns they <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2020-10/research-paper-13.pdf">lack familiarity</a> with individual residents and their unique needs. This can be disruptive and distressing for residents and their families and undermine the continuity of their care. </p>
<p>Also, as agency staff frequently work across different homes, they tend to be less efficient and require more supervision. This can can <a href="https://journals.sagepub.com/doi/10.1177/0022185616673867">increase</a> workload pressures, stress and turnover of permanent workers. </p>
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<h2>The relationship between staffing and quality care</h2>
<p>Our <a href="https://onlinelibrary.wiley.com/doi/10.1111/ajag.13132">study</a> of 1,709 aged care homes over five years investigated the relationship between the quality of care provided by aged care homes and their reliance on agency contract care staff. </p>
<p>We found the use of agency staff was relatively common, with the majority of homes using agency care staff at some point. </p>
<p>More importantly, we found homes that rely more heavily on agency staff have worse quality of care. Specifically, they have higher rates of workforce-related complaints to the regulator, occurrences of missing residents, reportable assaults, preventable hospitalisations and instances of non-compliance with accreditation standards.</p>
<p>While this is the first such study in Australia, these results align with <a href="https://pubmed.ncbi.nlm.nih.gov/20078009/">international evidence</a>. One striking similarity is how sensitive care quality is to even tiny increments of agency staffing. We found that even if just 5% of care time is delivered by agency staff, homes deliver significantly poorer quality outcomes.</p>
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<a href="https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&rect=36%2C36%2C5970%2C3971&q=45&auto=format&w=1000&fit=clip"><img alt="health worker helps older woman" src="https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&rect=36%2C36%2C5970%2C3971&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480696/original/file-20220824-24-6zue4j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Agency staff are less likely to be aware of residents’ individual needs and preferences.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/gentle-trained-nurse-helping-mature-600w-645695308.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/fixing-the-aged-care-crisis-wont-be-easy-with-just-5-of-nursing-homes-above-next-years-mandatory-staffing-targets-184238">'Fixing the aged care crisis' won't be easy, with just 5% of nursing homes above next year's mandatory staffing targets</a>
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<h2>But we’re in the middle of a workforce crisis</h2>
<p>Our findings suggest one way to improve quality of care is for homes to reduce their reliance on contract care staff. This could involve efforts to improve the recruitment, retention and rostering of permanent nurses and care workers. </p>
<p>However, in the current context, this might be easier said than done. With the industry in the midst of a <a href="https://cedakenticomedia.blob.core.windows.net/cedamediacontainer/kentico/media/attachments/duty-of-care-aged-care-sector-in-crisis.pdf">massive workforce crisis</a>, homes may have no choice but to continue to rely on agency workers. </p>
<p>In such cases, homes should adopt strategies to mitigate the potential for bad outcomes. For example, they might improve residents’ continuity of care by drawing from a pool of regular agency workers and investing in better orientation and shift handover processes. </p>
<p>In terms of policy, much of the recent reform agenda has focused improving staffing numbers and skills in aged care, through funding for training programs, mandatory care minutes, 24/7 registered nurses and addressing workers pay. </p>
<p>Another of Labor’s election promises was to implement a recommendation from the Royal Commission to require aged care providers to <a href="https://www.alp.org.au/policies/a-nurse-in-every-nursing-home">preference direct employment</a> over using contracted “agency” workers. This issue is now being <a href="https://www.pc.gov.au/inquiries/current/aged-care-employment#report">investigated</a> by the Productivity Commission, which will hand its report down next month. </p>
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<h2>No quick fixes</h2>
<p>Simply putting limits on agency staff is unlikely to work in the current context. Imposing caps may result in homes providing less total care to residents. </p>
<p>Rather, the widespread use of agency across the sector reflects a need to understand and address its root causes. As will be discussed next week at the <a href="https://treasury.gov.au/employment-whitepaper/jobs-summit">jobs summit</a>, staffing shortages are not isolated to aged care but widespread across the economy. </p>
<p>Policymakers also will have to be mindful of the impact of other reforms in play. For instance, the use of contractors may well increase as providers attempt to increase staffing levels to meet <a href="https://www.smh.com.au/politics/federal/aged-care-homes-will-struggle-to-meet-staff-ratios-as-losses-pile-up-report-20220517-p5am2g.html">incoming mandatory minimum standards</a>, while managing the demands and disruptions of COVID outbreaks.</p>
<p>Despite these challenges our research highlights the importance of finding ways to sustainably curb the use of contract staff so as to deliver the quality of care all senior Australians deserve.</p><img src="https://counter.theconversation.com/content/188745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Sutton is the current Treasurer of Palliative Care Association of N.S.W.</span></em></p><p class="fine-print"><em><span>Nelson Ma does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We studied 1,709 aged care homes over five years and found increases in the use of ‘agency’ staff impacted quality of care. Ahead of the federal jobs summit, the sector faces ongoing challenges.Nicole Sutton, Senior Lecturer in Accounting, University of Technology SydneyNelson Ma, Senior Lecturer, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/878542018-02-15T17:58:53Z2018-02-15T17:58:53ZHospital staff – don’t hide when something goes wrong, listen to patients and ask what they need<figure><img src="https://images.theconversation.com/files/206107/original/file-20180213-44627-3k7qpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When staff make a mistake, hospitals should follow three simple steps to better care for patients and avoid litigation.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/k7lWhRlO53U">Nick Cooper</a></span></figcaption></figure><p>Litigation may sound like an obvious route for someone who experiences a medical injury. But it’s a lengthy and stressful process, and may not provide relief to patients and their families. </p>
<p>In the past, hospitals <a href="http://www.med.umich.edu/news/newsroom/Boothman-ACHE-Frontiers.pdf">used the “deny and defend”</a> approach to potential lawsuits. This had a significant impact on patient safety. When protecting the institution was the primary goal, <a href="http://www.med.umich.edu/news/newsroom/Boothman-ACHE-Frontiers.pdf">poor practices were excused and justified</a>, and patients remained at risk of similar injuries.</p>
<p>Since the mid-2000s, Australia has adopted an <a href="https://www.safetyandquality.gov.au/our-work/open-disclosure/the-open-disclosure-framework/">open disclosure</a> policy. When something goes wrong, hospitals should apologise to the patient and their family, provide an explanation of what happened and outline the steps taken to ensure it won’t happen again. The United States has a similar system called a Communication and Resolution Program. </p>
<p>The problem is, these processes <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/hospital-safety-and-quality-review">do not always meet patients’ expectations</a>. </p>
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<p>In its landmark report <a href="http://www.nationalacademies.org/hmd/%7E/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf">To Err is Human: Building a Safer Health System</a>, the US Institute of Medicine recognised that errors are commonly caused by faulty systems and processes that lead to people making mistakes. </p>
<p>Our interview-based research, published in the <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2656885">Journal of the American Medical Association Internal Medicine</a>, shows that when staff make a mistake, hospitals should follow three simple steps to better care for patients and avoid litigation: reach out, listen, and advise the patient to consult a lawyer. </p>
<h2>How the process can work: Thomas’ story</h2>
<p>Several years ago, Thomas, a businessman in his 40s, went to hospital for a routine scan of his injured shoulder. He was on an elevated examination table waiting to receive a dye injection. But the doctor didn’t insert the injection correctly. </p>
<p>Thomas described the resulting pain as “excruciating”. He felt light-headed and weak, and experienced what medical practitioners call a “vasovagal reaction”. He told the clinicians he was not ready to get off the table because he felt unwell. </p>
<p>The clinicians walked away from the table. Thomas then lost consciousness. His legs tucked under the table and he fell, face first, to the floor. </p>
<p>Thomas’s injuries were severe. His teeth went through his bottom lip. His nose was broken. His eyes and face were black with bruising. </p>
<p>Thomas wasn’t able to think clearly for months after the injury. He couldn’t drive a car or go to work for almost a year. He had to undergo extensive procedures to fix his injuries.</p>
<p>Thomas decided not to sue the hospital for medical malpractice. Instead, he went through the hospital’s Communication and Resolution Program; a process that took him through the three key steps and that he was ultimately happy with. </p>
<p><strong>1. Reach out</strong></p>
<p>Many health professionals <a href="https://www.ncbi.nlm.nih.gov/pubmed/7911925">are reluctant to reach out to patients</a> when they make a mistake. They worry the patient will be so angry and upset that they’ll sue the health provider. But failing to make contact is actually more likely to result in legal action.</p>
<p>During our interview, Thomas explained that the doctor who made the mistake visited him at his hospital bed shortly after he regained consciousness. Thomas felt that the doctor’s effort to approach him promptly after the event “set the right tone”. </p>
<p>Other patients and family members who participated in the study reported feeling more angry if the health providers either did not reach out, or took too much time to do so. </p>
<p><strong>2. Listen attentively</strong> </p>
<p>Thomas appreciated his doctor’s communicative approach. His doctor asked, “how can I help you? What can we do?” </p>
<p>Patients in our study reported feeling annoyed when doctors assumed they knew what the patient wanted. Often, they didn’t want to talk about matters that health professionals would call “clinically relevant”. </p>
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<p>Instead, patients wanted to tell their doctors about how the injury prevented them from cleaning the house or playing with their children, and how challenging they found these experiences. </p>
<p>Health providers may feel they are wasting precious time that could be spent on clinical work. But failing to provide sufficient time to listen to patients’ concerns will likely mean that more time will be required later on. </p>
<p><strong>3. Advise the patient to talk to a lawyer</strong> </p>
<p>Good plaintiffs’ lawyers, who understand the communication and resolution approach, can play important roles in rebuilding trust between injured patients and hospitals. </p>
<p>In our study, lawyers discussed the doctor-patient relationship with their clients. These discussions often transformed patients’ opinions of the doctors. When lawyers did a good job, the patients often felt comfortable continuing to receive care at the same hospital. </p>
<h2>Litigation vs open disclosure</h2>
<p>Patients and families who choose to litigate rarely report feeling satisfied with the process or outcome. The long duration of litigation often exacerbates the financial and emotional costs. </p>
<p><a href="http://www.med.umich.edu/news/newsroom/Boothman-ACHE-Frontiers.pdf">Injured patients are infrequently compensated</a>. They may spend several expensive and stressful years in court, while they are recovering from injuries, <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa054479">only to be without compensation</a> at the end of this journey.</p>
<p>Some injured patients find it difficult to find a lawyer who is able to take their case, while other groups (such as the elderly and ethnic minorities) are <a href="https://www.researchgate.net/publication/7318435_Relationship_between_complaints_and_quality_of_care_in_New_Zealand_A_descriptive_analysis_of_complainants_and_non-complainants_following_adverse_events">unlikely to complain</a> or file a lawsuit in the first place. </p>
<p>Compensation is important for some patients. However, compensation alone is rarely adequate to successfully resolve medical injuries. </p>
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Read more:
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<p>In comparison to litigation, open disclosure and Communication and Resolution programs are <a href="https://www.ncbi.nlm.nih.gov/pubmed/20713789">less costly for hospitals</a> and may conclude within months, rather than years, depending on the severity and complexity of the injury. </p>
<p>Ideally, they result in corrective action to prevent the mistake from happening again. </p>
<p>As part of Australia’s open disclosure process, injured patients and families may also be reimbursed for out of pocket expenses such as transport, childcare, accommodation and meals. </p>
<h2>Putting it into practice</h2>
<p>While Australia has adopted the open disclosure approach, the system sometimes falls short of patients’ expectations. </p>
<p>A <a href="http://www.bmj.com/content/343/bmj.d4423">2011 Australian study found</a> that open disclosure processes were failing to meet patients’ and family members’ needs and expectations of openness about what went wrong and the steps being taken to ensure it doesn’t happen again. Patients also felt they weren’t given enough follow-up support.</p>
<p>A <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/hospital-safety-and-quality-review">2016 Victorian review</a> of a number of baby deaths at a regional hospital found hospital cultures sometimes prevented the disclosure of mistakes to patients and their families. It made numerous recommendations to improve quality and safety in health care. </p>
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Read more:
<a href="https://theconversation.com/how-can-we-save-lives-in-hospitals-start-by-looking-for-and-investigating-red-flags-52287">How can we save lives in hospitals? Start by looking for and investigating red flags</a>
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<p>One recommendation was to introduce a statutory <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/better-safer-care/statutory-duty-of-candour">Duty of Candour</a> that would require hospitals to explain and apologise to injured patients in a way that is consistent with the national <a href="https://www.safetyandquality.gov.au/our-work/open-disclosure/the-open-disclosure-framework/">Open Disclosure Framework.</a></p>
<p>For now, we know what patients want when they are harmed by medical care. They want their health providers to reach out, ask what they want and let their priorities lead the conversation. Listening to patients’ experiences can help health systems to better meet injured patients’ needs.</p><img src="https://counter.theconversation.com/content/87854/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This study was supported by The Commonwealth Fund, a private independent foundation based in New York City, United States. The views presented herein are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.</span></em></p>Litigation may sound like an obvious route for someone who experiences a medical injury. But it’s a lengthy and stressful process, and rarely provides relief to patients and their families.Jennifer Moore, Senior Lecturer in Health Law and Torts, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/837002017-09-11T23:26:28Z2017-09-11T23:26:28ZFive simple ways to improve Canadian health care<figure><img src="https://images.theconversation.com/files/185203/original/file-20170908-3042-qs127m.jpg?ixlib=rb-1.1.0&rect=1135%2C0%2C3265%2C3325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is that needle really necessary, doctor? A new list of recommendations by Canadian resident physicians suggests it might not be.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Up to 30 per cent of health care is unnecessary.</p>
<p>That’s <a href="https://beta.theglobeandmail.com/news/national/up-to-30-per-cent-of-medical-care-canadians-receive-is-unnecessary-report/article34611808/?ref=http://www.theglobeandmail.com&">according to a study</a> by the Canadian Institute for Health Information. Alarmist in its extrapolation, perhaps, but certainly indicative of a true problem.</p>
<p>Granted: Unnecessary care is wasted time and expenditure in a system that buckles under the cost of designer drugs and an aging population. More subtle — but more important — is the actual <em>harm</em> caused by unnecessary health care.</p>
<p>We are resident physicians-in-training, and we’ve joined <a href="https://choosingwiselycanada.org/">Choosing Wisely,</a> Canada’s grassroots movement to re-evaluate health care. </p>
<p>Chances are that if you visit a Canadian hospital, you will at some point receive care from a resident physician. Resident physicians like us earn the title of doctor after eight years of medical and post-secondary training, but our training continues in practice as we become experts in our chosen fields of specialty. </p>
<p>We provide round-the-clock coverage, staying in-house for our 26-hour call shifts.</p>
<h2>Quality of care the No. 1 priority</h2>
<p>Resident Doctors of Canada, representing more than 9,000 resident physicians from coast to coast, has joined the campaign with the recent release of our list <em>Five Things Residents and Patients Should Question.</em> </p>
<p>We developed the list by reviewing existing research and generating a short list of candidate recommendations. More than 750 residents across Canada voted on the list, resulting in our final five recommendations.</p>
<p>The recommendations focus on measures we can take as residents to make the quality of patient care the first priority.</p>
<p>Our first recommendation is undeniably simple: we should only order tests that may affect our patient’s care plan. </p>
<p>Consider pneumonia, among the most common infections to land someone in the hospital. Despite appropriate treatment, X-rays will demonstrate pneumonia for six weeks, even after the infection has resolved. Thyroid levels, similarly, will remain unchanged for up to six weeks after medication adjustments.</p>
<p>And so frequent testing offers no advantage – unless you suffer from too many red blood cells (polycythemia vera) – and may tempt clinicians to tinker unnecessarily.</p>
<h2>Needles: Not a fan favourite</h2>
<p>Needles for blood work aren’t a highlight of anyone’s health-care experience, with the possible exception of masochists. Worse yet, the evidence is accumulating that <a href="http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/GIM/education/DoNoHarmProject/Documents/DNHP%20alia%20moore%20may%202014.pdf">we are basically blood-letting our patients</a> with daily blood work while they’re hospitalized. </p>
<p>This is our second recommendation: Avoid daily blood work in stable patients. As a patient, you should ask your physicians why we do each test and what we’re looking for, especially if you’re subjected to daily blood work.</p>
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<img alt="" src="https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185207/original/file-20170908-19097-1hn2nja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Canadian resident physicians say oral meds are a better option than being tethered to an IV pole.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Still on the topic of needles, why poke you with one unnecessarily? If you’re able to drink and you’re not nauseated, many of our medications are as effective by mouth as they are via your veins. </p>
<p>Allowing you to get up and move without being tethered to an IV (intravenous) pole decreases your risk of infection and clots, and shortens your hospital stay.</p>
<p>And so our third recommendation is to choose an oral medication whenever appropriate and tolerated, rather than an IV.</p>
<h2>Avoiding invasive procedures</h2>
<p>When investigating the cause and prognosis of illness, we have a dizzying array of options. (We find our toolbox fascinating, but we digress.) Our fourth recommendation is to use the least invasive option that is appropriate. </p>
<p>If a patient is in heart failure, we could order an X-ray or blood test, but we should be primarily relying on physical examination. The latter represents a cheaper, safer alternative to radiation or introducing a foreign instrument into a patient’s bloodstream.</p>
<h2>Liberate the healthy</h2>
<p>Finally, we strive to get patients back home without undue delay. </p>
<p>If you’re sick and need immediate intervention, you should certainly stay in hospital. But the hospital has its risks too, from being bed-bound to antibiotic-resistant “superbugs.” That’s why our fifth recommendation is to arrange for non-urgent tests to be done outside the hospital if patients are well enough to go home. </p>
<p>By publishing this list, Canadian resident physicians are demonstrating our commitment to improving quality and patient safety. The next time you encounter a resident physician on the job, have a conversation with us about why more might not always be better.</p><img src="https://counter.theconversation.com/content/83700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Reza Mirza worked closely with Choosing Wisely Canada in developing these recommendations. </span></em></p><p class="fine-print"><em><span>Justin Hall worked with Resident Doctors of Canada and Choosing Wisely Canada to develop these recommendations.</span></em></p>A recent study found that 30 per cent of Canadian health care is unnecessary. Here are five recommendations to avoid pointless health care – for doctors and patients.Reza Mirza, Resident Physician, McMaster UniversityJustin Hall, Resident Physician in Emergency Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/542482016-03-14T19:15:02Z2016-03-14T19:15:02ZThe problems with Australia’s hospitals – and how they can be fixed<figure><img src="https://images.theconversation.com/files/114411/original/image-20160309-22147-11auudw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The solution is not necessarily more of the same, or more funding.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-157681805/stock-photo-woman-lying-down-in-hospital-bed.html?src=haAuf4sFRybCvVmwNLcw_g-4-52">wandee007/Shutterstock</a></span></figcaption></figure><p>Australia’s public hospitals – and those responsible for funding them – face a number of pressing challenges. In a time of growing populations, they must guarantee access, ensure quality, minimise the chances of anything going wrong, and do it all within the available budget. </p>
<p>Costs are going up, as is demand, putting pressure on Commonwealth and state budgets. </p>
<p>But the solution is not necessarily more of the same, or more funding. Public hospitals are already changing the way they do things, but they need to change more.</p>
<h2>The entry squeeze</h2>
<p>As the population grows, and as rates of chronic diseases (such as heart disease and diabetes) rise, demand for hospital services increases. Between 2009-10 and 2013-14, <a href="http://www.aihw.gov.au/haag13-14/admitted-patient-care/#t1">hospital admissions increased at twice the rate of population growth</a> (an average of 3.3% each year compared to 1.6% population growth). </p>
<p>In the public sector, tight budget control and poor planning mean there is a gap between the services required and the services available. The consequences are long waiting times for elective procedures and ever-longer waiting queues for treatment in emergency departments. </p>
<p>In extreme cases, ambulances are redirected away from the hospital of choice, or ambulance staff have to care for patients in the hospital emergency department before they can be accepted for treatment by hospital staff.</p>
<p>The solution is not necessarily more hospital beds. A better answer might be to use existing beds better through better prevention, better discharge planning and improved efficiency.</p>
<h2>Using beds more efficiently</h2>
<p>In 2013-14, <a href="http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_PPH_December_2015.pdf">around 6% of all hospital admissions</a> were for 22 conditions that were considered “potentially preventable”. These admissions comprised 8% of all “bed days”(the 24-hour period a patient spends in a hospital bed). </p>
<p>There is <a href="http://www.safetyandquality.gov.au/atlas/">considerable variation</a> across the country. The admission rates for these potentially preventable conditions is three times higher in some parts of the country. In the Sydney suburb of Blacktown, for instance, there were more than <a href="http://www.safetyandquality.gov.au/wp-content/uploads/2015/11/SAQ201_07_Chapter6_v7_FILM_tagged_merged_6-8.pdf">30 hospital admissions per 100,000 people</a> for diabetes-related lower limb amputations in 2012-13, compared with fewer than ten in North Sydney. </p>
<p>Reducing these rates in higher prevalence areas to approximate the rates in “benchmark” areas would save thousands of bed days a year.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114739/original/image-20160310-26261-100lb9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Admission rates for potentially preventable conditions are three times higher in some parts of the country.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-326863622/stock-photo-blurred-image-of-patient-with-drip-in-hospital-for-background-usage.html?src=QJBDWUepQM5k99Ao0UV17Q-2-55">Suwatchai Pluemruetai/Shutterstock</a></span>
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<p>Another way to ensure beds are being used efficiently is to ensure that patients only undergo procedures with proven effectiveness. There is <a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">evidence</a> that some hospitals are admitting patients for operations that have little evidence of benefit, such as <a href="http://www.bmj.com/content/350/bmj.h2747">knee arthroscopy for osteoarthritis</a>. </p>
<p>Not all beds are occupied by people who still need the care that hospitals are staffed and equipped to provide. <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551484">Almost 2% of all hospital beds</a> are occupied by “maintenance care” patients. Many of them may be waiting to have home care arranged or are waiting for a bed in residential aged care.</p>
<p>Although many of these bed days are in small rural hospitals – where a bed occupied for “maintenance care” may not preclude another patient being admitted to hospital – an acute hospital bed is rarely a good long-term location for any person.</p>
<p>Average length of stay is a key measure of how beds are used in hospitals, and duration of stays has changed dramatically over the last 30 years, more than halving over that period. </p>
<p>Two separate trends have driven the change. First, the proportion of patients who are able to be treated in one day has increased significantly: more than half of all patients are now “same day”. </p>
<p>Second, the length of stay of patients who stay overnight has declined, though not as dramatically as the overall pattern. </p>
<iframe src="https://charts.datawrapper.de/CiU5k/index.html" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="400"></iframe>
<p>Advances in treatment technologies, improved efficiencies in hospitals and better home care support could allow more patients to be treated in existing hospital beds. </p>
<h2>Quality of care</h2>
<p>The states have moved ahead in fits and starts with improving quality of care. </p>
<p>All states have had their quality scandals. The latest is the <a href="https://theconversation.com/how-can-we-save-lives-in-hospitals-start-by-looking-for-and-investigating-red-flags-52287">avoidable deaths of seven babies</a> in Victoria’s Bacchus Marsh Hospital.</p>
<p>All states are in the process of improving their quality-management processes. This means providing more information to hospitals to allow them to compare where they stand, analyse critical incidents and provide better education and support.</p>
<p>Some comparative information is also available publicly – for example, comparing hospitals nationwide on <a href="http://www.myhospitals.gov.au/our-reports/healthcare-staphylococcus-aureus-bloodstream/april-2015/report">hospital-acquired infections</a>. States are also <a href="http://www.legislation.vic.gov.au/domino/Web_Notes/LDMS/PubPDocs.nsf/ee665e366dcb6cb0ca256da400837f6b/b8155fc7b6e97e38ca257f150014852c!OpenDocument">making more information available</a> about comparative quality performance, such as surgical site infections. Many hospitals in the United States are now making their own <a href="http://www.bidmc.org/Quality-and-Safety/Quality-and-Safety-Performance-Reports.aspx">quality performance data publicly available</a>.</p>
<p>But there is much room for improvement. <a href="https://www.mja.com.au/journal/2013/199/8/measuring-incidence-hospital-acquired-complications-and-their-effect-length-stay">More than one in every ten patients</a> admitted to hospital for an overnight stay has a “hospital-acquired diagnosis” – an additional health problem, such as an infection, that they didn’t have when first admitted. These additional diagnoses may result in significant risk or harm to a patient (such as an additional operation to remove an object left in the patient after the initial surgery) and <a href="http://www.ncbi.nlm.nih.gov/pubmed/21719478">add significantly to costs</a>.</p>
<p>Reducing avoidable harm in hospitals remains a major challenge for boards, management and clinicians.</p>
<h2>The 2014 budget cliff</h2>
<p>Despite an explicit promise to maintain pre-existing arrangements for hospital funding, the 2014 Commonwealth budget <a href="https://theconversation.com/federal-budget-2014-health-experts-react-26577">cut more than A$1.5 billion a year</a> from state hospital funding from July 1 2017. </p>
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<a href="https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114785/original/image-20160311-11277-13aegrh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>So far the states’ response to this has mostly been a combination of hope and wishful thinking. Although there is scope to <a href="https://theconversation.com/public-hospital-efficiency-gains-could-save-1-billion-a-year-23779">improve hospital efficiency</a>, the funding gap created by the Commonwealth change is bigger (and differently distributed) than what could be made up in potential savings.</p>
<p>States initially argued for increased taxes, particularly an increase in the GST or the Medicare levy, to bridge the funding gap. This path has now been closed off.</p>
<p>States then knocked on the Commonwealth’s door with their begging bowls in hand, hoping a Turnbull government might be more munificent than an Abbott one. This door <a href="http://www.abc.net.au/news/2016-03-04/hall-are-we-finally-seeing-headway-on-hospital-funding/7221262">appears to be still ajar</a>.</p>
<p>July 2017 is just over a year away, so action on this front needs to occur soon to allow hospitals and states to plan their responses to the budget cliff.</p>
<h2>Innovation is necessary</h2>
<p>The challenges facing hospitals and states are great. Meeting them will require sophisticated strategies and innovation. More of the same won’t cut it.</p>
<p>Those wedded to the old ways may resist change, but change is what we need to ensure the hospital system meets the care needs of the population into the future.</p>
<hr>
<p><em><strong>This article is part of our series <a href="https://theconversation.com/au/topics/hospitals-in-australia">Hospitals in Australia</a>. Click on the links below to read the other instalments:</strong></em></p>
<ul>
<li><p><strong><a href="http://theconversation.com/infographic-a-snapshot-of-australias-hospitals-56139">Infographic: a snapshot of Australia’s hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user’s guide to navigating hospitals</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/heres-how-to-boost-hospital-funds-and-end-the-blame-game-54247">Here’s how to boost hospital funds and end the blame game</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/what-are-better-public-or-private-hospitals-54338">What are better, public or private hospitals?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/do-you-really-need-to-go-to-hospital-time-to-recentre-the-health-system-54406">Do you really need to go to hospital? Time to recentre the health system</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/no-one-should-get-dud-hospital-care-its-time-to-lift-our-game-on-quality-and-safety-54561">No-one should get dud hospital care – it’s time to lift our game on quality and safety</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">Hospitals don’t need increased funding, they need to make better use of what they’ve got</a></strong></p></li>
</ul><img src="https://counter.theconversation.com/content/54248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In a time of growing populations, hospitals must guarantee access, ensure quality, minimise the chances of anything going wrong, and do it all within the available budget. So they need to change.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/522872015-12-16T05:10:53Z2015-12-16T05:10:53ZHow can we save lives in hospitals? Start by looking for and investigating red flags<figure><img src="https://images.theconversation.com/files/106160/original/image-20151215-25618-tvrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">State health departments should continuously monitor the hospital activity data it collects for red flags. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-162942002/stock-photo-side-view-of-thoughtful-pregnant-woman-with-hands-on-stomach-sitting-on-hospital-bed.html?src=qUxHZNLTGCubfBzBXNnwwA-3-61">Tyler Olson/Shutterstock</a></span></figcaption></figure><p>Earlier this month, the Victorian Health Department released the results of an <a href="https://www2.health.vic.gov.au/about/publications/researchandreports/review-dhhs-management-djerriwarrh-health-services">independent review</a> into its handling of the tragic events at Bacchus Marsh hospital between 2013 and 2014. </p>
<p>Over this period, seven babies suffered avoidable deaths as a result of deficiencies in clinical care. The review shows a serious failure of clinical governance, with the responsible health service (Djerriwarrh) failing to respond appropriately to a number of serious safety breaches and complaints about the hospital.</p>
<p>The report raises the question: would public reporting of hospital safety measures have brought unsafe practices to light much earlier, perhaps triggering timely and potentially life-saving intervention?</p>
<p>Public reporting has a <a href="http://www.sciencedirect.com/science/article/pii/S0003497511016651">long history</a> – dating back at least to Florence Nightingale – but its effect is at best indirect. It relies on hospitals acting to improve performance because of perceived reputational risk or from market pressure. In situations of oversupply or monopoly supply, neither motivation may be important.</p>
<p>Public reporting is a second-best solution. A far better improvement strategy is to make sure, through performance monitoring and regulatory strategies, that hospitals own their performance issues and act on them.</p>
<h2>Public in the dark about poor safety</h2>
<p>Before news of the deaths broke in October, the Bacchus Marsh community would have had no idea how unsafe their hospital’s obstetric practice was.</p>
<p>The My Hospitals website <a href="http://www.myhospitals.gov.au/hospital/210203020/djerriwarrh-health-service-bacchus-marsh/healthcare-associated-infections">gave no sign</a> of any problems. Though it was designed to give the public easy access to hospital performance information, My Hospitals publishes only two indicators for hospital safety: hand hygiene compliance and rates of staph infections. Neither tells you much about overall safety at a hospital, particularly in smaller hospitals where staph cases are extremely rare.</p>
<p>Those who like to keep a close eye on their local health service’s <a href="http://djhs.org.au/fileadmin/filemount/pdf_files/DjHS_Annual_Report_2013-14.pdf">annual report</a> might have noticed that Bacchus Marsh hospital failed a safety review in 2013. As is the case with most official reports, however, the information was strategically presented, so readers could easily have missed the gravity of this disclosure.</p>
<p>The public would have known that one of the obstetricians at the hospital had been reported for unsafe practice, had the responsible body investigated the complaint in a timely fashion. As it was, it took the Australian Health Practitioner Regulation Agency (AHPRA) <a href="https://www.ahpra.gov.au/News/2015-10-16-media-release.aspx">28 months</a> to conduct its investigation. The restricted conditions on the doctor’s registration were not made public until June 2015, by which time he had retired.</p>
<p>Finally, the public did not know about the hospital’s high fetal and infant (perinatal) death rate. These rates are calculated from five years of data and <a href="https://www2.health.vic.gov.au/about/publications/ResearchAndReports/2/3/0/1/9/victorian-perinatal-services-performance-indicators-2012-13">published for all hospitals</a> – except those with fewer than five perinatal deaths in any one year of analysis. This rule excluded Bacchus Marsh.</p>
<h2>Pros and cons of public reporting</h2>
<p>Public reporting in Australia is in its infancy and its impact has not been evaluated. The research evidence, mainly from the United States’ experience, on the value of performance “report cards” is <a href="http://annals.org/article.aspx?articleid=738899">mixed</a>. </p>
<p>Well-designed information can be <a href="http://journals.lww.com/lww-medicalcare/Abstract/2009/01000/Public_Reporting_in_Health_Care__How_Do_Consumers.1.aspx">useful to patients</a>, though surgeons <a href="http://circoutcomes.ahajournals.org/content/6/6/643.short">may not alert their patients</a> to it. A bad report card also doesn’t seem to affect the number of referrals a surgeon gets from doctors and specialists. Report cards may therefore <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa064964">not stimulate</a> improvement in hospital quality.</p>
<p>Inevitably, things will sometimes go wrong in hospitals. What matters is that the organisation is able to learn from those events and reduce the likelihood they will happen again. That will happen if clinicians have information about their performance relative to peers in other hospitals. </p>
<p>Such a change <a href="http://www.ncbi.nlm.nih.gov/pubmed/26308399">relies on everyone</a> involved feeling able to report errors and “near misses” without thinking they will be singled out and blamed. What hospitals must aim for is a “just and trusting culture”. </p>
<p>One problem with report cards is that it is easy for a hospital to be “named and shamed” in the media, as has <a href="http://www.theage.com.au/victoria/victorias-worst-hospitals-for-baby-deaths-revealed-20151020-gkdy82.html">happened recently</a>. </p>
<p>This in turn may create a “name and shame” culture internally. When people fear adverse consequences from reporting problems, they tend to stop reporting them. The problems may never be picked up at all, whether internally or by the public. Report cards thus need to be handled with care.</p>
<h2>A better way</h2>
<p>A much better solution is for state health departments themselves to monitor continuously the hospital activity data they collect for red flags. </p>
<p>If departments follow up early danger signs with clinical audits that are designed to support improvement, rather than punish failure, the government can strengthen safety while minimising the risk of hospitals under-reporting. </p>
<p>Routine use of data to monitor performance and prioritise safety audits should already be commonplace. The data has been available for decades now and is still under-used. </p>
<p>Only after its own safety scandal in 2005 did Queensland Health <a href="https://www.health.qld.gov.au/psu/reports/docs/lta5.pdf">begin using such data</a> to monitor safety. The case will probably be the same in Victoria, if the department draws the right lessons from the wrongs at Bacchus Marsh.</p><img src="https://counter.theconversation.com/content/52287/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett was responsible for the design of Queensland's approach to monitoring quality and safety of health care following the Bundaberg Hospital scandal.</span></em></p><p class="fine-print"><em><span>Terri Jackson has previously received research funding from the Australian Commission on Safety and Quality in Health Care, and from the Victorian Department of Health and Human Services. </span></em></p><p class="fine-print"><em><span>Danielle Romanes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Seven babies died unnecessarily at Bacchus Marsh hospital between 2013 and 2014. The My Hospitals website and other reporting mechanisms gave no sign of any problems.Stephen Duckett, Director, Health Program, Grattan InstituteDanielle Romanes, Associate, Grattan InstituteTerri Jackson, Adjunct associate professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/362672015-01-16T14:05:04Z2015-01-16T14:05:04ZMaking guys play with dolls won’t create an army of men working as carers<figure><img src="https://images.theconversation.com/files/69252/original/image-20150116-5188-f3zp2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Let's bring out the dolls. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-200013182/stock-photo-two-girls-and-boy-with-toys-on-floor-at-home.html?src=veda58e1wTs_2QYlnv2v0w-1-21">Toddlers playing via Daria Filimonova/Shutterstock</a></span></figcaption></figure><p>The equalities minister, Jo Swinson, <a href="http://www.bbc.co.uk/news/uk-politics-30794476">has suggested that boys</a> should be encouraged to play with dolls to make them more “nurturing and caring”. This is apparently in the hope that they will become more likely to work in the adult care sector when they grow up and help to avoid a predicted future shortage of professional carers.</p>
<p>Her comments suggest that boys are less caring than girls, that playing with dolls will make you more caring, and that being more caring will make you want to become a professional carer. If only fixing the <a href="https://theconversation.com/care-workers-need-support-instead-of-being-scapegoated-26257">problems in our caring professions</a> were that simple. </p>
<h2>Same tired rhetoric</h2>
<p>The idea that boys need any training of this sort is buying into a popular stereotype that only girls are nurturing and caring. It is unfortunate that an equalities minister is seen to be emphasising such differences. Much has been written about the realities (or otherwise) of <a href="http://books.google.co.uk/books/about/Delusions_of_Gender.html?id=PXhyRAAACAAJ">gender differences</a>, demonstrating that where there are differences they are very small and that the differences within groups of females and males are much greater than any <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-psych-010213-115057">differences between them</a>. </p>
<p>It has also been shown that almost all of the psychological “categories” to which the sexes tend to be assigned (girls are empathic, boys like science) are actually “dimensions”, with a wide range of scores, throughout which males and females are pretty equally spread. This includes empathy and “care orientation”. As American psychologists Bobbi Carothers and Harry Reis <a href="https://www.psych.rochester.edu/people/reis_harry/assets/pdf/CarothersReis_2012.pdf">put it</a>: “Men and women are from earth” or, even better, gender differences are: “<a href="http://cdp.sagepub.com/content/23/1/19.abstract?rss=1">Black and white or shades of gray</a>”. </p>
<h2>What qualities a carer needs</h2>
<p>But are too many boys lacking in the “right stuff” to be carers? A search of <a href="http://www.thecareagency.co.uk/index.php/become-a-carer">job description sites</a> reveals an emphasis on patience and the fact that no academic qualifications are necessary. There is no clear definition of what qualities a carer needs. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/69236/original/image-20150116-5206-fazxpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More men needed.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-224070475/stock-photo-male-nurse-assisting-senior-man-in-using-laptop-at-nursing-home-porch.html?src=RFqzY9D5kL02Wu0GBs40RA-1-96">Male nurse via Tyler Olson/Shutterstock</a></span>
</figcaption>
</figure>
<p>But if we settle on “agreeableness and tendermindedness”, <a href="http://psychology.about.com/od/personalitydevelopment/a/bigfive.htm">one of the big five personality traits</a>, and “empathy”, there is some evidence of relevant <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-psych-010213-115057">differences between the genders</a> in large populations of adults. But the effect sizes are small and the size of the differences <a href="http://www.ncbi.nlm.nih.gov/pubmed/11519935">vary across cultures</a>. This flexibility would counteract the suggestion that traits such as empathy are biologically determined and that sex differences in empathic behaviour are related to fixed <a href="http://books.google.co.uk/books/about/Essential_Difference.html?id=6xyPPPDo0KkC&redir_esc=y">sex-differences in brain function</a>. </p>
<p>Recent research found that although a group of girls rated themselves as more empathic than a group of boys, there <a href="http://www.sciencedirect.com/science/article/pii/S1878929312000710">were no sex differences</a> in brain responses to animated clips of people being hurt. As these type of behavioural findings are almost invariably based on self-reported measures, we may be looking at an element of self-fulfilling prophecy here, with women and men aware of the different characteristics attributed to their particular gender and describing themselves accordingly.</p>
<h2>Toys and careers</h2>
<p>The question then falls to whether a choice or preference for a type of toy can affect a person’s eventual career choice. There has certainly been <a href="http://www.lettoysbetoys.org.uk/about-2/">much criticism</a> of the way in which the clear gender divide in toy marketing could contribute to the maintenance of sex or gender stereotypes which could in turn influence the <a href="http://www.bbc.co.uk/news/magazine-25857895">types of careers </a> that people feel are open to them. </p>
<p>Much of this criticism has been in the arena of <a href="https://theconversation.com/arguing-over-whether-girls-cant-or-wont-study-science-stops-us-fixing-the-problem-29725">overcoming the gender gap</a> in science and maths subjects. The under-representation of women has been <a href="http://www.imeche.org/news/engineering/toy-story">explicitly linked, among other things, to the lack of early experiences</a> with construction toys such as LEGO, as opposed to a biological determinist view that poor spatial skills are linked to genetically determined brain differences.</p>
<p>Jo Swinson likened her suggestions about boys and dolls to these campaigns. But there is a well-defined profile of the type of specific cognitive skills that are needed in science, technology, engineering and maths subjects. There is a considerable <a href="http://www.ncbi.nlm.nih.gov/pubmed/21906988">body of research</a> that shows how these skills can be acquired, improved and maintained. The same does not appear to be true of the caring profession. The necessary, though ill-defined, skills appear to be much more in the domain of personality characteristics, where there is much less evidence of how experiences can alter somebody’s personality profile. </p>
<p>I am absolutely in favour of findings ways to encourage all children to be nurturing and caring and be responsible for other people’s well-being. It doesn’t have to be dolls – caring for an animal or tending a garden can have the same effect. If the shortage of professional carers is the problem, then a better solution for this government might be to address the absence of a decent career structure and the low rates of pay, rather than embark on a “grow-your-own” social engineering project.</p><img src="https://counter.theconversation.com/content/36267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gina Rippon is affiliated with ScienceGrrl , a broad-based, grassroots organisation celebrating and supporting women in science - <a href="http://sciencegrrl.co.uk/">http://sciencegrrl.co.uk/</a>.
</span></em></p>The equalities minister, Jo Swinson, has suggested that boys should be encouraged to play with dolls to make them more “nurturing and caring”. This is apparently in the hope that they will become more…Gina Rippon, Professor of Cognitive NeuroImaging, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/253002014-05-02T05:07:45Z2014-05-02T05:07:45ZQuality of hospital care varies more within countries than between them<figure><img src="https://images.theconversation.com/files/47577/original/3cdy4jrh-1398962565.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Effective, safe and patient-centred care is needed across the board.</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/File:Relaci%C3%B3n_M%C3%A9dico_Paciente.png">Jorgejesus4</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>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 <a href="http://intqhc.oxfordjournals.org/content/26/suppl_1/2.full">we recently published</a>, we found that a concerning number were failing to reach key quality requirements.</p>
<p>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 <a href="http://intqhc.oxfordjournals.org/content/26/suppl_1/47.full">only half of wards met the standard</a> to be able to identify patients by a wristband.</p>
<p>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. </p>
<p>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.</p>
<h2>Across Europe</h2>
<p>Our research was the culmination of over three years of work on the <a href="http://www.duque.eu/">DUQuE Project</a> (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. </p>
<p>Our research published in 12 papers in the <a href="http://intqhc.oxfordjournals.org/content/26/suppl_1.toc">International Journal of Quality in Health Care</a> revealed that quality of care varies even more within countries than between them. </p>
<p>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.</p>
<h2>Patients want to be involved</h2>
<p>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.</p>
<p>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 <a href="http://intqhc.oxfordjournals.org/content/26/suppl_1/81.full">are no more patient-centred</a> than hospitals that don’t.</p>
<p>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?</p>
<h2>Not about individual doctors</h2>
<p>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. </p>
<p>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.</p><img src="https://counter.theconversation.com/content/25300/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oliver Groene does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>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…Oliver Groene, Lecturer in Health Services Research, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.