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Why Hospitals Fail pp 19–36Cite as

Factors Affecting Failure

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Abstract

At a time of global economic downturn, there is a temptation for healthcare organisations to focus on cost reduction rather than on quality improvement as a business strategy. However such a strategy can indeed be a dangerous one for patients, [1] with recommendations that the best strategy to advance cost savings is to improve the health status of patients through quality improvement [1–4].

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References

  1. Wagner E. Chronic disease management: what will it take to improve care for chronic illness. Eff Clin Pract. 1998;1:2–4.

    CAS  PubMed  Google Scholar 

  2. Deming WE. Out of crisis. Cambridge: MIT Press; 1998.

    Google Scholar 

  3. Donabedian A. Evaluating the quality of medical care. Milbank Q. 1966;83(4):691–729.

    Article  Google Scholar 

  4. Ovretveit J. Do changes to patient – provider relationships improve quality and save money? London: The Health Foundation; 2012.

    Google Scholar 

  5. Baker GR. The roles of leaders in high performing health care systems. London: Kings Fund; 2011.

    Google Scholar 

  6. Francis R. Report of the Mid Staffordshire NHS Foundation Trust public enquiry: executive summary. [Online]. London: Mid Staffordshire NHS Foundation Trust Public Inquiry; 2013. http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf.

  7. Berwick D. To err is human: building a safer health system. Washington: Institute of Medicine, National Academy Press; 1999.

    Google Scholar 

  8. Berwick D. A promise to learn – a commitment to act, improving the safety of patients in England. National Advisory Group on the Safety of patients in England; 2013.

    Google Scholar 

  9. Dazi A. High quality care for all NHS next stage review final report. London: Department of Health; 2008.

    Google Scholar 

  10. Ham C, Berwick D, Dixon J. Improving quality in the English NHS: a strategy for action. London: Kings Fund; 2016.

    Google Scholar 

  11. IHI. The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement. IHI innovation series white paper. Boston: Institute for Healthcare Improvement; 2003. www.IHI.org

    Google Scholar 

  12. Health Education England. Health Education England; Our Values. [Online]. 2016. Last updated unknown, accessed 22 May 2016. https://hee.nhs.uk/about-us/our-values.

  13. Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: an overview report. Wakefield: NHS England; 2013.

    Google Scholar 

  14. Penglington C, Marshall P. Why Junior Doctors are innovation leaders. [Online]. 2013. Last updated 12/0/2013. http://www.hsj.co.uk/topics/leadership/why-junior-doctors-are-innovation-leaders/5060206.fullarticle.

  15. The Health Foundation. Encourage, I.I.D. Evidence Scan: quality improvement training for healthcare professionals, 2012.

    Google Scholar 

  16. Langley G, et al. The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey Bass Publishers; 1996.

    Google Scholar 

  17. Vaux E. Quality improvement - training for better outcomes. London: Academy of Royal Medical Colleges; 2016.

    Google Scholar 

  18. Rae L. Assessing the value of your training. The evaluation process from training needs to the report to the board. Aldershot: Gower Publishing Limited; 2002.

    Google Scholar 

  19. Kirkpatrick D, Kirkpatrick J. Evaluating training programmes: the four levels. 3rd ed. Oakland: Bereett-Koehler Publishers; 2006.

    Google Scholar 

  20. O’Brien MA, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2).

    Google Scholar 

  21. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev. 1995;73(2):59–67.

    Google Scholar 

  22. West M, et al. Leadership and leadership development in healthcare: the evidence base. London: The Kings Fund; 2015.

    Google Scholar 

  23. King’s Fund. The future of leadership and management in the NHS: no more heroes. London: The King’s Fund; 2011.

    Google Scholar 

  24. Pastoriza D, Ariño MA. J Bus Ethics. 2013;118(1). doi:10.1007/s10551-012-1536-7

  25. Day D. The Oxford handbook of leadership and organizations. New York: Oxford University Press; 2014.

    Google Scholar 

  26. Care Quality Commission. Introducing the statutory duty of candour. [Online]. Leeds: Department of Health; 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295773/Duty_of_Candour_Consultation..pdf.

  27. National Patient Safety Agency. Being open, [Online]. National Health Service National Patient Safety Agency; 2009. http://www.nrls.npsa.nhs.uk/beingopen/?entryid45=83726.

  28. General Medical Council. Good medical practice. [Online]. London: General Medical Council; 2013. http://www.gmc-uk.org/static/documents/content/Good_medical_practice_-_English_0914.pdf.

  29. Nursing and Midwifery Council. The code: standards of conduct, performance and ethics for nurses and midwives. [Online]. London: Nursing and Midwifery Council; 2008. http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf.

  30. Dalton D, Williams N. Building a culture of candour: a review of the threshold for the duty of candour and of the incentives for care organisations to be candid. [Online]. London: Royal College of Surgeons of England; 2014. https://www.rcseng.ac.uk/policy/documents/CandourreviewFinal.pdf.

  31. Nolan J, Qian T. Impact assessment: duty of candour on providers. [Online]. London: Department of Health; 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295625/DoC_impact-assessment.pdf.

  32. Gallagher T, Studdert D, Levinson W. Disclosing harmful medical rrrors to patients. [Online]. N Engl J Med. 2007;356(26):2713–9.

    Article  CAS  PubMed  Google Scholar 

  33. Lu D, et al. Disclosure of harmful medical errors in out-of-hospital care. [Online]. Ann Emerg Med. 2013;61(2):215–21.

    Article  PubMed  Google Scholar 

  34. Miller L. Apology, disclosure and unanticipated outcomes. [Online]. J Perinat Neonatal Nurs. 2011;25(1):10–1.

    Article  PubMed  Google Scholar 

  35. Kaldjian LC, et al. An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors. [Online]. J Gen Intern Med. 2006;21(9):942–8.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Garbutt J, et al. Reporting and disclosing medical errors: pediatricians’ attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179–85.

    Article  PubMed  Google Scholar 

  37. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. [Online]. Soc Sci Med. 2005;60(9):1927–35.

    Article  PubMed  Google Scholar 

  38. Singh V, et al. Disclosure and documentation of reported unanticipated medical events or outcomes: need for healthcare provider education. [Online]. J Healthc Risk Manag. 2012;32(1):14–22.

    Article  PubMed  Google Scholar 

  39. Mccartney M. The assault on the Liverpool care pathway. [Online]. Br Med J. 2012;345. http://www.bmj.com/content/345/bmj.e7316.

  40. Neuberger J, Guthrie C, Aaronvitch D. More care, less pathway: a review of the Liverpool Care Pathway. Department of Health, Crown Copyright; 2013.

    Google Scholar 

  41. Great Britain, Department of Health. End of life care strategy: promoting high quality care for all adults at the end of life. [Online]. 2008. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/136431/End_of_life_strategy.pdf.

  42. The Leadership Alliance for the Care of Dying People. Once chance to get it right: improving people’s experience of care in the last few days and hours of life. [Online]. 2014. Last updated June 2014. www.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf.

  43. Cartwright A, Anderson J, Hockey L. Life before death. Abingdon: Routledge and Kegan Paul; 1973.

    Google Scholar 

  44. Iranmanesh S, Hosseini H, Esmaili M. EvaIuating the “good death” concept from Iranian bereaved family members’ perspective. J Support Oncol. 2011;9(2):59–63.

    Article  PubMed  Google Scholar 

  45. Morita T, Chihara S, Kashiwagi T. A scale to measure satisfaction of bereaved family receiving inpatient palliative care. Palliat Med. 2002;16(2):141–50.

    Article  CAS  PubMed  Google Scholar 

  46. Teno JM, et al. Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members. J Pain Symptom Manag. 2001;22(3):738–51.

    Article  CAS  Google Scholar 

  47. Teno JM, et al. Validation of toolkit after-death bereaved family member interview. J Pain Symptom Manag. 2001;22(3):752–8.

    Article  CAS  Google Scholar 

  48. Addington-Hall J, Mccarthy M. Regional study of care for the dying: methods and sample characteristics. Palliat Med. 1995;9(1):27–35.

    Article  CAS  PubMed  Google Scholar 

  49. Addington-Hall J, et al. A randomised controlled trial of postal versus interviewer administration of a questionnaire measuring satisfaction with, and use of, services received in the year before death. J Epidemiol Community Health. 1998;52(12):802–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. The staff engagement toolkit. An online resource, supporting you to increase staff engagement in your organisation. 2013.

    Google Scholar 

  51. Dawson J, West M. Summary of key research findings from the NHS staff survey. 2016.

    Google Scholar 

  52. Kings Fund. Leadership and leadership development in health care. London: FMLM, Centre for Creative Leadership and Kingsfund; 2015. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/leadership-leadership-development-health-care-feb-2015.pdf.

  53. Drath WH, Mccauley CD, Palus CJ, Van Velsor E, O’connor PMG, Mcguire JB. Direction, alignment, commitment: toward a more integrative ontology of leadership. Leadersh Q. 2008;19:635–53.

    Article  Google Scholar 

  54. Robinson D, Hayday S. The engaging manager. London: Institute for Employment Studies; 2009.

    Google Scholar 

  55. Atkinson S, Spurgeon P, Clark J, Armit K. Engaging doctors: what can we learn from trusts with high levels of medical engagement? London: NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges; 2011.

    Google Scholar 

  56. Schneider B, Ehrhart MG, Macey WH. Organizational climate and culture. Annu Rev Psychol. [Internet]. 2013 Jan 3 [cited 2016 Aug 19];64(1):361–88. Available from: http://www.annualreviews.org/doi/abs/10.1146/annurev-psych-113011-143809.

  57. Brooks C. Working with healthcare professionals. Open University Press final report. Healthc Manag. 2006;253–67.

    Google Scholar 

  58. Kahn WA. Psychological conditions of personal engagement and disengagement at work. Acad Manag J. 1990;33(334):692–724.

    Article  Google Scholar 

  59. Axelrod RH. Terms of engagement: changing the way we change organizations. Oakland: Berrett-Koehler; 2003. p. 240.

    Google Scholar 

  60. Robinson D, Perryman S, Hayday S. The drivers of employee engagement. 2004.

    Google Scholar 

  61. Hotten E, Jordan L, Pedan C. Improving incident reporting among junior doctors. BMJ Qual Improv Rep. 2014.

    Google Scholar 

  62. Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007;16(1):2–3.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Blom M, Alvesson M. All-inclusive and all good: the hegemonic ambiguity of leadership. Scand J Manag. 2015;31(4):480–92.

    Article  Google Scholar 

  64. Dickinson H, Ham C, Snelling I, Spurgeon P. Are we there yet? Models of medical leadership and their effectiveness: an exploratory study. Southampton: National Institute for Health Research; 2013.

    Google Scholar 

  65. IHI (2008) Achieving the vision of excellence in quality: recommendations for the English NHS system of quality improvement. Submitted to the Department of Health by the Institute for Healthcare Improvement. Boston: Institute for Healthcare Improvement.

    Google Scholar 

  66. Bohmer R. The instrumental value of medical leadership. London: The Kings Fund; 2012.

    Google Scholar 

  67. Mountford J, Webb C. When clinicians lead. McKinsey Q. 2009.

    Google Scholar 

  68. Spurgeon P, Long P, Clark J, Daly F. Do we need medical leadership or medical engagement? Leadersh Health Serv. 2015;28(3):173–84.

    Article  Google Scholar 

  69. Clark J. Medical leadership and engagement: no longer an optional extra. J Health Organ Manag. [Internet]. [cited 2016 Aug 18] 2012;26(4):437–43. Available from: http://www.emeraldinsight.com/doi/abs/10.1108/14777261211251517.

  70. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership development programs for physicians: a systematic review. J Gen Intern Med. 2014;30(5):656–74.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Addington-Hall J, Mcpherson C. After-death interviews with surrogates/bereaved family members: some issues of validity. J Pain Symptom Manag. 2001;22(3):784–90.

    Article  CAS  Google Scholar 

  72. Care Quality Commission. New acute hospital inspection model. [Online]. Last updated 19 August 2014. http://www.cqc.org.uk/public/about-us/our-inspections/our-new-acute-hospital-inspection-model.

  73. Claessen SJJ, et al. Measuring relatives’ perspectives on the quality of palliative care: the consumer quality index palliative care. J Pain Symptom Manag. 2013;45(5):875–84.

    Article  Google Scholar 

  74. Department of Health, NHS Medical Directorate. First national VOICES survey of bereaved people: key findings report. Online, Department of Health; 2012.

    Google Scholar 

  75. Morita T, et al. Measuring the quality of structure and process in end-of-life care from the bereaved family perspective. J Pain Symptom Manag. 2004;27(6):492–501.

    Article  Google Scholar 

  76. Sheffield Microsystems Coaching Academy. Improving a microsystem. [Online]. http://www.sheffieldmca.org.uk/improving_microsystems.

  77. Archer, G (2016) A Quality Improvement Project, South Yorkshire and the Humber Deanery (Unpublished).

    Google Scholar 

  78. Boaden R (2008) Quality Improvement: Theory and Pratice. British Journal of Healthcare Management Vol15 (1).

    Google Scholar 

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Acknowledgements

We would like to express our thanks and appreciation to the doctors who worked on this programme and who are Dr Ali Cheema, Dr Helena Parkinson, Dr Avril Kuhrt, Ms Halla Zaitoun, Dr Ellie Smith, Dr Irene Pepper, Dr Hannah Delaney and Mr Thomas Carroll.

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Authors and Affiliations

  1. Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

    Ahmed Nassef, James Davies & Kay Stewart

  2. Sheffield Children’s NHS Foundation Trust, Sheffield, UK

    Louise Ramsden

  3. Alumni Future Leaders Programme, Health Education England: Yorkshire and the Humber, Leeds Children’s Hospital NHS Foundation Trust, Leeds, UK

    Amanda Newnham

  4. Fellow in Cardiology, Sheffield, UK

    Gareth Archer

  5. Harrogate and District NHS Foundation Trust, Harrogate, UK

    Robert Jackson

Authors
  1. Ahmed Nassef
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  2. Louise Ramsden
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  3. Amanda Newnham
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  4. Gareth Archer
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  5. Robert Jackson
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  6. James Davies
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  7. Kay Stewart
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Corresponding author

Correspondence to Ahmed Nassef .

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Editors and Affiliations

  1. Department of Paediatric Surgery, Sheffield Children’s NHS Foundation Trust, Sheffield, United Kingdom

    Prasad Godbole

  2. Department of Emergency Medicine, Sheffield Children’s NHS Foundation Trust, Sheffield, United Kingdom

    Derek Burke

  3. Directorate for International MBA Programmes, International Academy of Medical Leadership, Sheffield, United Kingdom

    Jill Aylott

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Nassef, A. et al. (2017). Factors Affecting Failure. In: Godbole, P., Burke, D., Aylott, J. (eds) Why Hospitals Fail. Springer, Cham. https://doi.org/10.1007/978-3-319-56224-7_2

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  • DOI: https://doi.org/10.1007/978-3-319-56224-7_2

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