Tuesday, 18 May 2010

Driving up quality while encouraging innovation? Yes we can!

Quality in healthcare has moved centre stage in the past few years. Quality healthcare isn’t just about treating diseases, it’s about treating people and indeed populations with or at risk of disease. Quality can be defined, it can be measured and it can be improved. The Institute of Medicine , in 2001 , proposed 6 specific aims for improvement. Healthcare should be: safe, effective, patient-centred, timely, efficient and equitable. To that we can now add a seventh, sustainable. In each of these dimensions we can develop metrics, quality indicators and quality standards to support improvements in direct patient care. These measures need to be based on evidence and comparison with what can be achieved in the best units. The measures can be displayed in clinical dashboards so that local renal unit teams can see immediately the effect of introducing Plan, Do, Study, Act (PDSA) cycles on the quality of care they are delivering. Quality indicators are published by the Renal Registry and these can now be incorporated into Trust’s quality accounts or form the basis of commissioning for quality and innovation the so called CQUIN scheme . Over the past 3 years, quality has become the organising principle of the National Health Service.

Quality can be defined in kidney disease right across the pathway: process measures for early detection of kidney disease in people with diabetes, blood pressure control, preparation for renal replacement therapy as evidenced by care planning, timely vascular access creation, pre-emptive transplantation, laparoscopic live donation, short cold ischaemic times for kidney transplantation, a host of biochemical measures for those on dialysis and preferred place of death for those who opt for conservative kidney care. Of course we don’t have all the answers and we don’t have the perfect indicators so we need to beware that we don’t make what is easy to measure important at the expense of what is truly important but perhaps difficult to measure . We need to increase our evidence base using clinical audit, quality improvement and a research to establish what are the best care bundles for certain populations at the different stages of chronic kidney disease or acute kidney injury.

Quality is not just about clinical outcomes but also includes the patient’s experience of treatment. In the recent mid-Staffordshire NHS Foundation Trust enquiry conducted by Robert Frances he commented “if there is one lesson to be learned it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks that matter”. Treating people with dignity, how would we wish to be treated and how we would wish our families to be treated is part of providing high quality care for all.

The quality and productivity challenge is immense. The NHS is being asked to save between £20-26 billion across the service over 3 years. This will need innovation and transformational change . The characteristics of a sustainable system have been identified as: care closer to home, earlier interventions, fewer acute beds, more standardisation, empowered patients and reduced unit costs. To achieve these changes we need to think in terms of the whole system rather than within traditional organisational boundaries. We need to change the nature of leadership with its focus on targets to prioritise quality in all its dimensions .Looking out to see what we can copy or who we can collaborate with not up for answers from on high .We must encourage innovation and not hold back the leading edge; we must learn from failure and become less risk averse; but we must avoid change for the sake of change or “messing about masquerading as action”.

The members of the Renal Association and the British Renal Society are uniquely placed to lead this change. Clinicians need to work closely with managers and commissioners. Collaborative working across the virtual (or is that virtually insurmountable !!!) boundaries and barriers of the NHS will be needed. High quality care is delivered locally by individual clinicians who must be the advocates for their patients and the agents for change and quality improvement. Local teams must find local solutions, professional bodies must encourage comparative audit, sharing of best practice and help address the gradients of inequality. The Department of Health, the NHS Board , the Strategic Health Authorities and the providers of services - the PCTs, health boards and Trusts must play their part in system alignment making sure all parts of the system work together and pull in the same direction so we have winners – our public and patients; not so that we have institutional winners and institutional losers – a situation in which we would all lose.

Will it be possible to move to a virtuous circle where improving quality eliminates waste and improves efficiency? You may think that money is someone else’s business but addressing financial inefficiencies is a key personal, professional and moral responsibility because it allows us to free up resources that can then be used to treat more patients more effectively. I BELIEVE WE CAN DO IT.

Opening address to the RA BRS in Manchester, 17 May 2010