Effective, safe, and a good patient experience
Fiona Godlee, editor, BMJ
We talk a lot about improving the quality of health care. But until recently if you asked people what they meant by quality you got a range of unmemorable answers. Then came the cumulative work of Sheila Leatherman and her colleagues, and in the UK Ara Darzi’s 2008 High Quality Care for All. Now everyone I talk to is using the same language: quality means clinical effectiveness, safety, and a good experience for the patient. This week’s BMJ has something to say on all three.
On clinical effectiveness, Barbara Kuijper and colleagues ask what’s the right non-surgical approach for people with cervical radiculopathy (doi:10.1136/bmj.b3883). Patients with subacute onset have a good prognosis, so it’s reasonable to wait and see for the first six weeks. But there is little evidence on what works best to alleviate the pain, which can be excruciating, while waiting for things to resolve. So the authors evaluated two non-invasive approaches: immobilisation with a semi-hard collar versus mobilisation with physiotherapy. Intriguingly, both were similarly effective in reducing neck and arm pain compared with a wait and see policy. The authors recommend immobilisation because it’s cheaper than physiotherapy, but in his linked editorial David Cassidy says this is an opportunit y to let the patient decide (doi:10.1136/bmj.b3952).
On safety, Guy Haller and colleagues ask whether more mistakes happen at the beginning of the academic year (doi:10.1136/bmj.b3974). Their retrospective look at patients undergoing anaesthesia during one academic year in Australia finds that they do: the rate of undesirable events was significantly raised in the first month and only returned to the background level by the end of the fourth month. Interestingly, they found the same excess risk in all new trainees regardless of their experience, which suggests that this is not just a problem of newly qualified doctors needing to gain more experience but of new staff, however well trained, who are unfamiliar with their working environment.
In their linked editorial Paul Barach and Julie Johnson say we must see the safe maturation of trainees as a complex adaptive process (doi:10.1136/bmj.b3949). They call for more standardisation across health systems, better supervision, team training, graduated uptake of clinical responsibilities, and staggering of start dates for trainees over the year.
Finally, to patients’ experience. Scott Murray and colleagues (doi:10.1136/bmj.b3702) tell us that interviewing patients over the course of their illness gives a much better picture of their experience than single interviews. This is a million miles from the shallow snapshot of patients’ views gleaned from the 2009 survey of NHS general practice reported by Martin Roland and colleagues (doi:10.1136/bmj.b3851). Two questions on access to care were used to help judge GPs’ performance—not the best way to monitor access, says Chris Salisbury (doi:10.1136/bmj.b4224)—and decide on their pay. And there was a large non-response rate, but GPs may be reassured by Roland and colleagues’ conclusion that this did not make the pay for performance system unfair.
Cite this as: BMJ 2009;339:b4346