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Read all about it!!

August 28, 2012
Martin Marshall Martin Marshall is Lead for Improvement Science London and Professor of Healthcare Improvement at UCL.

There are some impressive quality improvement projects going on in the health service but the learning from them is rarely spread beyond the people directly involved. Quality improvement projects often make a difference but the improvers don’t seem to want to talk about it. In contrast, traditional research too often fails to have impact but researchers are pretty good at disseminating their work in leading journals.

The difference between ‘doers’ and ‘thinkers’ may be a stereotype but it cuts to the quick. Many quality improvers simply don’t think about publishing their work and some actively reject the scholarly tradition. A smaller number do want to publish but complain that journal editors aren’t interested.

They’re wrong. Take a look at an article in the 7th July issue of the BMJ about preventing venous thromboembolism (VTE). The BMJ has an impact factor of 14.093, for those who care about these things; it’s read by lots of clinicians and titillates the mass media, for those who don’t. A team from Johns Hopkins hospital in Baltimore, USA, carried out a prospective quality improvement programme in a single hospital which aimed to increase the proportion of patients who had their VTE risk formally assessed on admission to hospital, and were given preventative treatment where appropriate. Over a six year period from a base line in 2005, risk-appropriate VTE prophylaxis increased from 25% to 92% in medical patients and from 26% to 80% in surgical patients.

It’s not hard to see why the BMJ wanted to publish this work; so much about it is impressive. The project was designed and carried out in partnership between clinicians and managers in the hospital and a team of academics who have built an international reputation for their pragmatic but robust application of the science of improvement.  What brought the team together was a shared commitment to solving a practical problem which is known to cause significant complications, death and increased costs. They used an established framework to guide the project (the TRIP, or translating research into practice model) and a thoughtful set of theories about how they planned to change the mind sets and behaviours of practitioners and the environment of the organisation. They designed a set of evidence based interventions that combined technical (such as computer-based decision support) and social (such as pizza parties for the staff – honestly) elements and a judicious mix of ‘hard’ and ‘soft’ levers for change. They were self-critical, didn’t over-claim and demonstrated flexibility when their first approach was demonstrated to be ineffective. And they stuck at.

The end result is an elegant but honest account that others might not want to copy (would you prefer an evening in the pub or a pizza party?) but which they can learn from. It is the combination of scientific rigour and practical utility that brought this work to the attention of an international audience and it’s the same combination that will improve outcomes of patients. Simple and powerful.

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