31 October 2008
Worldwide, 30-40% of patients do not receive care that is based on the best available research evidence. How do we turn this around?
World renowned director of the Centre for Quality Care of Research in the Netherlands, Professor Richard Grol, says the answer lies in better organisation of care and improved communication between healthcare professionals. Here he tells Marilyn Chalkley that, although the concept of health professionals working together for the good of the patient appears obvious, this is sometimes difficult to apply in the busy and complex hospital environment. Care needs to be better organised to meet the needs of patients rather than those of health professionals. This can be achieved through evidence-based guideline implementation programs and a greater focus on standardisation of processes and procedures.
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Voice-over: Welcome to this National Health and Medical Research Council podcast. Our podcasts aim to keep you in touch with major health and medical research issues and the people who shape them.
Introduction: Professor Richard Grol is a world leader in improving health care and he’s on his fifth visit to Australia. He’s currently a guest of the NHMRC. If you’re a hospital patient you will want to know that your care is the best possible. Professor Grol is a man who in over 455 papers and several books has suggested ways that this can and should happen. Richard, sadly not all hospitals do as well as they should. Can you give us some examples of what you’re talking about?
Prof. Grol: I think it’s very important first of all to know the figures, to know what goes wrong and what’s going well. I think most people are shocked when they hear the figures, the data about actual care, actual quality and safety so we know we see it in studies all the time that around 30 to 40 per cent of the patients do not get evidence based care, care based on the best results of research we have and we see that many patients get unnecessary care that’s costly but can also be harmful for patients which I think we should really be aware of. I think most don’t know that if you go into a hospital you have between 5 and 10 per cent chance of getting out with an infection. In Australia this is around 8 per cent and it may differ between hospitals because you see I think a good example is for instance the infections after an ordinary hip operation — many old people get a hip operation and you see some hospitals where you have the chance of getting an infection is less than 1 per cent. In others it’s much, much higher, so it would be good to know what exactly the data are and to have an understanding where the problems are. I think only good data can show you where the improvements are needed.
Interviewer: And you’ve seen some quite dramatic examples of the kind of improvements that you can make, haven’t you in the Netherlands?
Prof. Grol: Yes I could give many, many examples. Let me give a few, recent examples for the Netherlands and I guess that most of these examples are more or less similar in the Australian setting. So we are again and again surprised when we look at hand hygiene routines which are so basic for normal care.
Interviewer: You mean just washing hands?
Prof. Grol: Just washing hands and or cleaning hands with alcoholrub and so studies showing that this is sometimes not better than in 50 per cent of the occasions where it should be done according to evidence based guidelines and we know that it really makes a difference. It’s one of the most important reasons for preventing hospital infections so this is quite an important issue. Recently — maybe it’s quite personal because this happened in our own academic medical hospital, our medical school — we had a few years ago a big, big problem we call it our own Bristol case after the Bristol case in the United Kingdom that started a lot of improvements there. It happened that in our heart centre in our academic hospital, we had a mortality rate in open heart operations of 6.7 per cent while the average in the Netherlands is 2.7 per cent. So it wasn’t that the data were not known before but it was suddenly brought into the open in the newspaper a lot of excitement around it, so our inspectorate really looked critically at it and closely at the centre for a while and this changed the whole situation. Actually the consequences were dramatic. The patients didn’t come to the hospital any more, the whole executive of the hospital quitted, the executive of the medical staff quitted, the leader of the department quitted so everything was changed. Part of the surgeons went away. So it started actually a new quality policy for the whole hospital with new methodologies for really looking deep into the different departments and see where were the risks, where was the answer on safety.
Interviewer: So you saw mortality rates — that is the number of people dying — just went from where to where?
Prof. Grol: After all these changes we saw people dying from the hospital going down from 6.7 to let’s say around 1 per cent in less than 2 years because of a complete change of attitude and when you analyse the problem I think that it was not only that people were dying from unsafe procedures but it was also related to the fact that people — for instance surgeons and anaesthesiologists — did not speak to each other, they were not communicating, they were not using standardised procedures which you should use during the operations, they were not discussing team meetings where they discussed the patients, all things that you can find in the literature that are important, leadership where they really control what is happening, staff that is really motivated to do a good job. So it’s sometimes shocking when you discover that but it’s also I think a good thing when you find ways to improve that and that’s particularly the type of business I’m in, finding new ways for improvement.
Interviewer: But it’s extraordinary when you talk about it because it seems both obvious and it seems commonsense doesn’t it that you would have people in the hospital talking to each other, that you would have strict procedures, so why is there such resistance and why does it take something like that event to make it all change?
Prof. Grol: Yep. So I think there are many reasons but I can imagine for someone looking from outside that you take this for granted. You take for granted that the care is of high quality and you can be certain that this is not in all hospitals the same situation.
There are many reasons why you won’t have the optimal care. I think this has to do with professionals on one side. Some professionals have been raised being in a let’s say a situation where they are the person who really does the job. They don’t need to account to others. It’s their work. They are responsible for it. They are seen often by other people as maybe a kind of god-like person who really performs and this can be a danger if you are not communicating with others and when others can’t give you comments and feedback on your own performance. So it’s not a natural situation in most hospitals that you work across departments, it’s mostly departments for themselves. So surgeons, radio therapists, anaesthesiologists, intensive care specialists all work within their own settings. So it demands a deliberate activity also by the leadership to bring these people together, not working in departments but working for patients. So what does a patient need and how to organise the care around the patient? That’s new for a lot of people and I would say it’s not particularly the case that people don’t want that. You need to accept and appreciate that the majority of the doctors and the nurses are very well motivated to do a good thing for patients but they are just not raised in this situation or the hospital is not organised in this way. So I think that one of the important things is much more organisation of processes so that doctors, nurses can do their work within a context where it is necessary that you meet other people that you check with other people what they are doing, that you share your experiences with them.
Interviewer: And I suppose that brings us to clinical guidelines which is the work of the National Institute of Clinical Studies which is part of the NHMRC and who you’re talking to this week, that they set in train a whole series of processes that people can follow and that you can make sure they do follow I suppose. Is that right?
Prof. Grol: Yes sure and I think one basic idea is that whenever you have good evidence from research what works for patients and what improves the outcomes in patients or their quality of life or their comfort or whatever it is, I think it’s very important that people use it. It’s not necessarily so that you present this always in the form of a guideline book where you can all read it etc. In some situations this is very helpful if you have an educational situation and then it’s very relevant to have a book and you can have all the evidence there. In some other situations it might be much more helpful if the whole, let’s say, standardised protocol is written down where the evidence is coming in on different places but it helps you to go through a process. For instance what they do now in the Netherlands in order to prevent surgical problems, they go to a kind of check list where they check all the steps the patient goes through in order to prevent making mistakes. For instance that they do something on the wrong leg or something on the wrong arm or where the check whether all the prevention of infection guidelines are followed so they standardise it. So a guideline can also be something also very helpful for real daily practice and it can also take the format of something to help doctor and patient sit together and then balance a little bit what to do, whether to take let’s say a person with a prostate problem, whether to take a PSA test yes or no, what are the advantages, what are the disadvantages, or a couple with a fertility problem sit together in an IVF procedure whether to take two embryos or one embryo, what are the advantages what are the disadvantages so you can also put the evidence into that type of tools. So if we speak about guidelines you need to think of a lot of different types of tools for real practice to help doctors/patients to get the best care possible. And I think it’s very important that NHMRC really spend energy on that in the widest possible ways.
Interviewer: Well I suppose it’s like any education isn’t it, you can provide the education, you can provide the written word but you’ve got to make it into practice which is what you’re on about really?
Prof. Grol: Yes, I would say that maybe one point to emphasise. I think I’m an lets say an improvement researcher, quality improvement researcher or an implementation scientist and I’m in this work now for almost 30 years and what I discovered is how important it is and that we have very good evaluations and science on what works and what doesn’t work because we often see that on the one side we see that researchers just take for granted that something happened with their hard work but that it is not true, it’s just not happening in real practice. On the other side we see policy makers making very quick decisions on doing this program or doing that program while often we don’t know whether it will work, under what conditions it will work. So we have seen in the course of the years rising a whole new science, implementation science, improvement science with new journals, research programs. You have a little bit here but we have nice programs in Canada and UK, in Holland really for researching what are the conditions for changing and improving practice and I think it’s very worthwhile that NHMRC really puts some energy on that as well.
Interviewer: Thank you very much it’s been very good to hear what you have to say Professor Richard Grol who is the director of the Scientific Institute for the Quality of Health Care in the Netherlands.
Prof. Grol: Thank you.
Voice-over: This podcast was brought to you by the National Health and Medical Research Council working to build a healthy Australia. You’ll find more information about this and other health and medical research issues on our website at www.nhmrc.gov.au.