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Most references to "leadership" and "learning" as sources of quality improvement in medical care reflect an implicit commitment to the decision technology of "clinical judgement". All attempts to sustain this waning decision technology by clinical guidelines, care pathways, "evidence based practice", problem based curricula, and other stratagems only increase the gap between what is expected of doctors in today's clinical situation and what is humanly possible, hence the morale, stress, and health problems they are increasingly experiencing. Clinical guidance programmes based on decision analysis represent the coming decision technology, and proactive adaptation will produce independent doctors who can deliver excellent evidence based and preference driven care while concentrating on the human aspects of the therapeutic relation, having been relieved of the unbearable burdens of knowledge and information processing currently laid on them. History is full of examples of the incumbents of dominant technologies preferring to die than to adapt, and medicine needs both learning and leadership if it is to avoid repeating this mistake.

Background—The need for quality improvement and increasing concern about the costs and appropriateness of health care has led to the implementation of quality systems in healthcare organisations. In addition, nursing homes have made significant investments in their development. The effects of the implementation of quality systems on health related outcomes are not yet clear.

If professionals are to be equipped better to meet the needs of modern health care systems and the standards of practice required, significant educational change is still required. Educational change requires leadership, and lack of educational leadership may have impeded change in the past. In practical terms standards refer to outcomes, and thus an outcome based approach to clinical education is advocated as the one most likely to provide an appropriate framework for organisational and system change. The provision of explicit statements of learning intent, an educational process enabling acquisition and demonstration of these, and criteria for ensuring their achievement are the key features of such a framework. The derivation of an appropriate outcome set should emphasise what the learners will be able to do following the learning experience, how they will subsequently approach these tasks, and what, as a professional, they will bring to their practice. Once defined, the learning outcomes should determine, in turn, the nature of the learning experience enabling their achievement and the assessment processes to certify that they have been met. Provision of the necessary educational environment requires an understanding of the close interrelationship between learning style, learning theory, and methods whereby active and deep learning may be fostered. If desired change is to prevail, a conducive educational culture which values learning as well as evaluation, review, and enhancement must be engendered. It is the responsibility of all who teach to foster such an environment and culture, for all practitioners involved in health care have a leadership role in education.

To examine the influence of evidence-based guidance on health care decisions, a study of the use of seven different sources and types of evidence-based guidance was carried out in senior health professionals in England with responsibilities either for directing and purchasing health care based in the health authorities, or providing clinical care to patients in trust hospitals or in primary care.Postal survey.Three health settings: 46 health authorities, 162 acute and/or community trust hospitals, and 96 primary care groups in England.566 subjects (46 directors of public health, 49 directors of purchasing, 375 clinical directors/consultants in hospitals, and 96 lead general practitioners).Knowledge of selected evidence-based guidance, previous use ever, beliefs in quality, usefulness, and perceived influence on practice.A usable response rate of 73% (407/560) was achieved; 82% (334/407) of respondents had consulted at least one source of evidence-based guidance ever in the past. Professionals in the health authorities were much more likely to be aware of the evidence-based guidance and had consulted more sources (mean number of different guidelines consulted 4.3) than either the hospital consultants (mean 1.9) or GPs in primary care (mean 1.8). There was little variation in the belief that the evidence-based guidance was of "good quality", but respondents from the health authorities (87%) were significantly more likely than either hospital consultants (52%) or GPs (57%) to perceive that any of the specified evidence-based guidance had influenced a change of practice. Across all settings, the least used route to accessing evidence-based guidance was the Internet. For several sources an effect was observed between use ever, the health region where the health professional worked, and the region where the guidance was produced or published. This was evident for some national sources as well as in those initiatives produced locally with predominantly local distribution networks.The evidence-based guidance specified was significantly more likely to be seen to have contributed to the decisions of public health specialists and commissioners than those of consultants in hospitals or of GPs in a primary care setting. Appropriate information support and dissemination systems that increase awareness, access, and use of evidence-based guidance at the clinical interface should be developed.

A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.

Investigations of accidents in a number of hazardous domains suggest that a cluster of organisational pathologies—the "vulnerable system syndrome" (VSS)—render some systems more liable to adverse events. This syndrome has three interacting and self-perpetuating elements: blaming front line individuals, denying the existence of systemic error provoking weaknesses, and the blinkered pursuit of productive and financial indicators. VSS is present to some degree in all organisations, and the ability to recognise its symptoms is an essential skill in the progress towards improved patient safety. Two kinds of organisational learning are discussed: "single loop" learning that fuels and sustains VSS and "double loop" learning that is necessary to start breaking free from it.

The importance of good leadership is becoming increasingly apparent within health care. This paper reviews evidence which shows that it has effects, not only on financial management, but on the quality of care provided. Some theories of leadership are discussed, primarily in terms of how different types of leaders might affect quality in different ways, including the effects that they might have on the stress or wellbeing of their staff which, in turn, is related to the quality of care produced. Finally, the conflicts shown in terms of leadership within the context of health care are discussed, leading to the conclusion that development programmes must be specially tailored to address the complexities of this arena.

The National Health Service in England and Wales has recently adopted a policy aimed at embedding continuous quality improvement (CQI) at all levels and across all services. The key goal is to achieve changes in practice which improve patient outcomes. This paper describes the use of a training course for multiprofessional groups of participants tailored to offer them relevant knowledge, management and team working skills, and approaches to personal and career development. These were intended to assist them in changing their practice for the benefit of patients. The participants rated the course highly in fulfilling its objectives. One cohort followed up for 6 months named changes in practice which related specifically to learning from the course. This paper shows the important contribution of multiprofessional learning to CQI and presents a useful method of evaluating links between learning and performance.

To evaluate a programme introducing quality improvement (QI) in nursing education.Betanien College of Nursing and clinical practices at hospitals in Bergen.52 nursing students from a second year class working in 16 groups undertaking hospital based practical studies.Second year nursing students were assigned to follow a patient during a day's work and to record the processes of care from the patient's perspective. Data collected included waiting times, patient information, people in contact with the patient, investigations, and procedures performed. Students also identified aspects of practice that could be improved. They then attended a 2 day theoretical introductory course in QI and each group produced flow charts, cause/effect diagrams, and outlines of quality goals using structure, process, and results criteria to describe potential improvements. Each group produced a report of their findings. Main measures-A two-part questionnaire completed by the students before and after the intervention was used to assess the development of their understanding of QI. Evidence that students could apply a range of QI tools and techniques in the specific setting of a hospital ward was assessed from the final reports of their clinical attachments.The students had a significantly better knowledge of QI after the introductory course and group work than before it, and most students indicated that they considered the topic highly relevant for their later career. They reported that it was quite useful to observe one patient throughout one shift and, to some extent, they learned something new. Students found the introductory course and working in groups useful, and most thought the programme should be included in the curriculum for other nursing students. They considered it important for nurses in general to have knowledge about QI, indicating a high perceived relevance of the course. All 16 groups delivered reports of their group work which were approved by the tutors. Through the reports, all the groups demonstrated knowledge and ability to apply tools and techniques in their practical studies in a hospital setting.The introduction of a short experience-based programme into the practical studies of second year nursing students enabled them to learn about the concepts, tools, and techniques of continuous QI in a way that should provide them with the skills to undertake it as part of routine practice.

To identify the desirable characteristics of review criteria for quality improvement and to determine how they should be selected.Review criteria are the elements against which quality of care is assessed in quality improvement. Use of inappropriate criteria may impair the effectiveness of quality improvement activities and resources may be wasted in activities that fail to facilitate improved care.A two round modified Delphi process was used to generate consensus amongst an international panel of 38 experts. A list of 40 characteristics of review criteria, identified from literature searches, was distributed to the experts who were asked to rate the importance and feasibility of each characteristic. Comments and suggestions for characteristics not included in the list were also invited.The Delphi process refined a comprehensive literature based list of 40 desirable characteristics of review criteria into a more precise list of 26 items. The expert consensus view is that review criteria should be developed through a well documented process involving consideration of valid research evidence, possibly combined with expert opinion, prioritisation according to health outcomes and strength of evidence, and pilot testing. Review criteria should also be accompanied by full clear information on how they might be used and how data might be collected and interpreted.The desirable characteristics for review criteria have been identified and will be of use in the development, evaluation, and selection of review criteria, thus improving the cost effectiveness of quality improvement activities in healthcare settings.

Objectives—To describe the use, perceived eVectiveness, and predicted future use of organisational strategies for influencing clinicians’ behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. Design and setting—Whole population postal survey conducted between March and June 1999. Subjects—Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. Method—A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/ no) and Likert type ratings were used to assess the use, perceived eVectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. Results—All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as eVective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as eVective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be eVective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived eVectiveness. Barriers to change included lack of resources, mainly of money and staV time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). Conclusions—Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived eVectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are eVective from their own data and from external comparison. (Quality in Health Care 2001;10:76‐82)

Background —Patients' evaluations are an important means of measuring aspects of primary care quality such as communication and interpersonal care. This study aims to examine variations in assessments of primary care according to age, gender, socioeconomic, and ethnicity variables. Methods —A cross sectional survey of consecutive patients attending 55 inner London practices was performed over a 2 week period using the General Practice Assessment Survey (GPAS) instrument which assesses 13 important dimensions of primary care provision. Variations in scale scores were investigated for differences relating to age, gender, socioeconomic, and ethnic status as reported by respondents. Results —A total of 7692 questionnaires were returned (71% response rate). Valid information on age, gender, socioeconomic status, and ethnicity was available for 4819 out of 5496 adult respondents. Approximately half the respondents reported their ethnic group as “white” and most of the remaining respondents reported belonging to “black” or South Asian groups. Significant differences existed between groups of patients defined by age or ethnicity for most of the scale scores examined. Black, South Asian, and Chinese respondents reported lower scores (representing less favourable assessments) than white respondents; older respondents reported more favourable evaluations of care than younger respondents; and less affluent groups reported lower scores than more affluent groups for two of the 13 dimensions. There was no significant difference between gender groups with respect to assessment of primary care. Age and ethnicity were independent predictors of respondents' assessments of primary care. Conclusions —Differences exist between identifiable subgroups of the population in their assessments of primary health care measured using the GPAS instrument. This work adds to the literature on variation in healthcare experience and the potential for patient assessment of primary care. Further work is required to investigate these differences in more detail and to relate them to differences in the nature and process of primary care provision. Primary care providers need to ensure that services provided are appropriate for all patient groups within their communities.

Aim—To identify and describe current methods of making health related research evidence accessible to general practice staV in the Northern and Yorkshire Region. Method—A postal survey questionnaire of general practice staV in the Northern and Yorkshire Region. Results—At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of diVerential access to information resources between diVerent professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available. Conclusions—At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why diVerent professions working in the same practice setting have diVerential access to information resources available in primary care. (Quality in Health Care 2001;10:83‐89)

Objectives - The purpose of this study is to demonstrate to what extent an evidence based decision model can improve physicians' decisions and whether a selective use of the decision model is feasible. Methods - Four experienced vascular surgeons were asked to make a treatment decision for 137 "paper patient" cases with asymptomatic abdominal aneurysms. Their decisions were compared with the optimal treatment as calculated by a computerised evidence based decision analytical model. Results - Surgeons agreed with the model's advice based on life expectancy in 81% of the cases, and decided to operate in only 12% of the cases for which there was no agreement. Surgeons' decisions differed from the decision model's calculated optimal treatment, in particular for older patients with aneurysms of intermediate size and with many risk factors, and for younger patients with small aneurysms and few risk factors. Not all these decisions, however, were reported to be more difficult. Conclusion - Use of a decision analytical model might lead to more appropriate decisions and a better quality of care. Selective use of the decision tool for difficult decisions only would be more efficient but is not yet feasible because reported decision difficulty is not strongly related to disagreement with the decision tool.

Background —No published quantitative instrument exists to measure maternal satisfaction with the quality of different models of labour care in the UK. Methods —A quantitative psychometric multidimensional maternal satisfaction questionnaire, the Women's Views of Birth Labour Satisfaction Questionnaire (WOMBLSQ), was developed using principal components analysis with varimax rotation of successive versions. Internal reliability and content and construct validity were assessed. Results —Of 300 women sent the first version (WOMBLSQ1), 120 (40%) replied; of 300 sent WOMBLSQ2, 188 (62.7%) replied; of 500 women sent WOMBLSQ3, 319 (63.8%) replied; and of 2400 women sent WOMBLSQ4, 1683 (70.1%) replied. The latter two versions consisted of 10 dimensions in addition to general satisfaction. These were (Cronbach's alpha): professional support in labour (0.91), expectations of labour (0.90), home assessment in early labour (0.90), holding the baby (0.87), support from husband/partner (0.83), pain relief in labour (0.83), pain relief immediately after labour (0.65), knowing labour carers (0.82), labour environment (0.80), and control in labour (0.62). There were moderate correlations (range 0.16–0.73) between individual dimensions and the general satisfaction scale (0.75). Scores on individual dimensions were significantly related to a range of clinical and demographic variables. Conclusion —This multidimensional labour satisfaction instrument has good validity and internal reliability. It could be used to assess care in labour across different models of maternity care, or as a prelude to in depth exploration of specific areas of concern. Its external reliability and transferability to care outside the South West region needs further evaluation, particularly in terms of ethnicity and social class.

Background —Consumer involvement in clinical guidelines has long been advocated although there are few empirical accounts of attempts to do so. It is therefore not surprising that there is a lack of clarity about how and when to involve consumers and what to expect from them within the process of guideline development. Methods —The North of England evidence based guideline development programme has used four different methods of consumer involvement. Results —When individual patients were included in a guideline development group they contributed infrequently and had problems with the use of technical language. Although they contributed most in discussions of patient education, their contributions were not subsequently acted on. In a “one off” meeting with a group of patients there were again reported problems with medical terminology and the group were most interested in sections on patient education and self management. However, their understanding of the use of scientific evidence in order to contribute to a more cost effective health care remained unclear. In a workshop it was possible to explain the technical elements of guideline development to patients who could then engage with such a process and make relevant suggestions as a consequence. However, this was relatively resource intensive. A patient advocate within a guideline development group felt confidence to speak, was used to having discussions with health professionals, and was familiar with the medical terminology. Conclusions —Consumers should be involved in all stages of guideline development. While this is possible, it is not straightforward. There is no one right way to accomplish this and there is a clear need for further work on how best to achieve it.

Objectives—To describe the relationship between patient satisfaction with out of hours care provided by deputising and practice doctors in four urban areas in England and characteristics of the service provided and patients, the care given, and health outcomes. Setting—Fourteen general practices in four urban areas in England. Participants—People who requested out of hours care. Design—Analysis of data from a study of out of hours care. Patients were interviewed within 5 days of their request for out of hours care. Data on the service provided were obtained from medical records and all other data were collected at interview. Satisfaction was measured using a valid reliable instrument. Results—2152 patients were recruited to the study and 1466 were interviewed. Satisfaction data were available on 1402 patients. “Overall satisfaction” was associated with age, doctor type, lack of access to a car at the time of the request, and health outcome. The relationships between satisfaction subscales and patient characteristics (age, sex, ethnicity, and access to a car at the time of the request), service characteristics (doctor type and delay between the request and visit), whether a prescription was given, and health outcome were variable. If an expected home visit was not received, “overall satisfaction” and satisfaction with “communication and management”, “doctor’s attitude”, and “initial contact person” were reduced. Conclusion—Patient satisfaction is dependent on many factors. Mismatch between patient expectation and the service received is related to decreased satisfaction. This may increase as general practitioners delegate more out of hours care to cooperatives and deputising services. (Quality in Health Care 2001;10:23‐28)

J C B Litt, general practitioner and senior lecturer Background—Iatrogenic injuries are relatively common and a potentially avoidable source of morbidity. The economic evaluation of this area has been limited by the lack of good quality national data to provide an estimate of incidence, associated disability, and preventability of iatrogenic injuries. Two recent surveys, the Quality in Australian Health Care Study (QAHCS) and the Utah Colorado Study (UTCOS), have now made this feasible. Aims—To determine the direct costs associated with iatrogenic injuries occurring in a hospital setting. Methods—The QAHCS was used as a representative national source of information on the incidence, disability, and preventability of iatrogenic injuries. Costs were calculated using information from Australian disease related groups (AN-DRGs) relative to the injury categories. Results—The cost of just 12 preventable iatrogenic injuries is significant (0.25 million US dollars) and accounts for 2–3% of the annual budget of a typical Australian community based hospital of 120 beds. Costing data provide additional useful information for policy and decision makers. Conclusion—Costing iatrogenic injuries is an important component of the impact of these events. An ongoing national database of iatrogenic injuries is necessary to assist in identifying the incidence of these injuries, monitoring trends, and providing data for cost estimates and economic evaluations. (Quality in Health Care 2000;9:216–221) Key Words: iatrogenic injuries; costs

N Barber, professor of the practice of pharmacy M Schachter, senior lecturer and honorary consultant physician Objective—To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. Design—Two stage Delphi technique. Subjects—A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. Main outcome measures—The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. Results—Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Conclusions—Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives. (Quality in Health Care 2000;9:232–237) Key Words: prescribing errors; medication errors; definition of error

P Garnerin, quality manager and F Clergue, department head and professor J-F Sicard, anaesthetist and F Bonnet, department head and professor Background—Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. Objectives—To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. Methods—As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. Results—During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction). Conclusion—Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting. (Quality in Health Care 2000;9:203–209) Key Words: reporting system; correlation analysis; quality assessment; adverse events; anaesthesia

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure ( R2=.22 for CC, R2=.36 for PI) than normalised bytes ( R2=.18 for CC, R2=.35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

Health professionals need competencies in improvement skills if they are to contribute usefully to improving patient care. Medical education programmes in the USA have not systematically taught improvement skills to residents (registrars in the UK). The Accreditation Council for Graduate Medical Education (ACGME) has recently developed and begun to deploy a competency based model for accreditation that may encourage the development of improvement skills by the 100 000 residents in accredited programmes. Six competencies have been identified for all physicians, independent of specialty, and measurement tools for these competencies have been described. This model may be applicable to other healthcare professions. This paper explores patterns that inhibit efforts to change practice and proposes an educational model to provide changes in management skills based on trainees' analysis of their own work.

There is currently a political enthusiasm for the development and use of clinical guidelines despite, paradoxically, there being relatively few healthcare issues that have a sound research evidence base. As decisions have to be made even where there is an undetermined evidence base and that limiting recommendations to where evidence exists may reduce the scope of guidelines, thus limiting their value to practitioners, guideline developers have to rely on various different sources of evidence and adapt their methods accordingly. This paper outlines a method for guideline development which incorporates a consensus process devised to tackle the challenges of a variable research evidence base for the development of a national clinical guideline on risk assessment and prevention of pressure ulcers.To inform the recommendations of the guideline a formal consensus process based on a nominal group technique was used to incorporate three strands of evidence: research, clinical expertise, and patient experience.The recommendations for this guideline were derived directly from the statements agreed in the formal consensus process and from key evidence-based findings from the systematic reviews. The existing format of the statements that participants had rated allowed a straightforward revision to "active" recommendations, thus reducing further risk of subjectivity entering into the process.The method outlined proved to be a practical and systematic way of integrating a number of different evidence sources. The resultant guideline is a mixture of research based and consensus based recommendations. Given the lack of available guidance on how to mix research with expert opinion and patient experiences, the method used for the development of this guideline has been outlined so that other guideline developers may use, adapt, and test it further.

To develop and evaluate an information service in which a "clinical informaticist" (a GP with training in evidence-based medicine) provided evidence-based answers to questions posed by GPs and nurse practitioners.Descriptive pilot study with systematic recording of the process involved in searching for and critically appraising literature. Evaluation by questionnaire and semi-structured interview.General practice.34 clinicians from two London primary care groups (Fulham and Hammersmith).Number and origin of questions; process and time involved in producing summaries; satisfaction with the service.All 100 clinicians in two primary care groups were approached. Thirty four agreed to participate, of whom 22 asked 60 questions over 10 months. Participants were highly satisfied with the summaries they received. For one third of questions the clinicians stated they would change practice in the index patient, and for 55% the participants stated they would change practice in other patients. Answering questions thoroughly was time consuming (median 130 minutes). The median turnaround time was 9 days; 82% of questions were answered within the timeframe specified by the questioner. Without the informaticist, one third of questions would not have been pursued.The clinical informaticist service increased access to evidence for busy clinicians. Satisfaction was high among users and clinicians stated that changes in practice would occur. However, uptake of the service was lower than expected (22% of those offered the service). Further research is needed into how this method of increasing access to evidence compares with other strategies, and whether it results in improved health outcomes for patients.

This paper examines the issues that arise in the broad area of competence assessment in surgical practice, with particular reference to the objective assessment of technical skill which has historically been the weakest aspect of assessment in surgical training. To facilitate a thorough appraisal of competence, a simple model of surgical practice is advanced, followed by a review of both current and experimental methods of assessing technical skill. The review comprises not only the published literature, but also work (both from the authors' and other groups) that is in progress or under consideration for publication. Significant issues in the implementation of these new technologies, especially the necessary further validation, and the imperative to demonstrate that the process introduced does indeed improve the outcomes are discussed.

Leadership, whether it is nursing, medical or healthcare leadership, is about knowing how to make visions become reality. The vision that many nurses hold dear to their hearts is one where patients are treated with dignity and respect at all times; where systems are designed for the benefit of individual needs; and where the work performed by nurses and other carers is valued and respected. Achieving such a vision will require a paradigm shift in the philosophy, priorities, policies, and power relationships of the health service. Fundamentally, it will require the rhetoric of patient centred care to become a reality. The following scenario is set in the UK in the year 2012 and describes a health service that is on the pathway to achieving this vision. It tells the story from a nursing perspective and outlines the three key foundation stones that helped nursing achieve the vision of a patient centred health service: (1) development of patient centred care measures as part of performance management and the clinical governance agenda; (2) leadership based on personal growth and development principles; (3) new clinical career and competency framework for nursing.

Objective - To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring. Design and participants - Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home. Setting - Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam. Results - Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period. Conclusions - A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.

Educating healthcare professionals is a key issue in the provision of quality healthcare services, and interprofessional education (IPE) has been proposed as a means of meeting this challenge. Evidence that collaborative working can be essential for good clinical outcomes underpins the real need to find out how best to develop a work force that can work together effectively. We identify barriers to mounting successful IPE programmes, report on recent educational initiatives that have aimed to develop collaborative working, and discuss the lessons learned. To develop education strategies that really prepare learners to collaborate we must: agree on the goals of IPE, identify effective methods of delivery, establish what should be learned when, attend to the needs of educators and clinicians regarding their own competence in interprofessional work, and advance our knowledge by robust evaluation using both qualitative and quantitative approaches. We must ensure that our education strategies allow students to recognise, value, and engage with the difference arising from the practice of a range of health professionals. This means tackling some long held assumptions about education and identifying where it fosters norms and attitudes that interfere with collaboration or fails to engender interprofessional knowledge and skill. We need to work together to establish education strategies that enhance collaborative working along with profession specific skills to produce a highly skilled, proactive, and respectful work force focused on providing safe and effective health for patients and communities.

Improvements in patient safety result primarily from organisational and individual learning. This paper discusses the learning that can take place within organisations and the cultural change necessary to encourage it. It focuses on teams and team leaders as potentially powerful forces for bringing about the management of patient safety and better quality of care.

Objective—To develop and examine the psychometric properties of the Satisfaction with Information about Medicines Scale (SIMS), a new 17-item tool designed to assess the extent to which patients feel they have received enough information about prescribed medicines.

To evaluate the use of a multidisciplinary record held by patients with cancer in the community.Pragmatic randomised controlled trial.The environs of Swansea in south west Wales.501 patients under the care of the Department of Oncology, Singleton Hospital, Swansea.A patient held record used by the patient and healthcare professionals. Main outcome measures-Health related quality of life (EORTC QLQ-C30) measured at entry into the study and at 6 months; patients' views at 6 months; healthcare professionals' views collected after the completion of patient follow up; NHS resource and booklet use.1148 patients were eligible for the study; 501 were recruited (44%) and 344 completed the study (172 in each group). There was no significant difference between the two groups in change in quality of life or NHS resource use. The patient held record did not have an impact on communication but was significantly helpful to patients in preparing for appointments, reducing difficulties in monitoring their own progress, and helping them to feel more in control (p0.05). Fifty three percent of patients would have preferred not to have a patient held record. There was a low level of use of the record by healthcare professionals but most of those who remembered using it indicated that they would prefer patients to have it.The patient held record is valued by some patients and professionals but has no significant impact on the quality of life of patients or NHS resource use. It has a positive impact on quality by helping patients feel more in control and prepare for meetings with healthcare staff. Patients who find it useful tend to be younger and have more professionals involved in their care. It is recommended that it should be made available to patients on request and used by them according to need.

Evidence based guidelines are regarded as an appropriate basis for providing effective health care, but few guidelines incorporate the views of users such as carers.To develop guidelines to assist primary health care teams (PHCTs) in their work with carers within South Asian communities.The guidelines were drawn up by a development group consisting of members of teams in areas with South Asian communities (Leicester and Bradford). The teams were invited to make their recommendations based on a systematic review of literature on minority ethnic carers and the findings of a study of the needs and experiences of local South Asian carers. A grading system was devised to enable the teams and a group of expert peer reviewers to assess the quality of evidence in support of each recommendation.The teams agreed seven recommendations, graded according to available evidence and strength of opinion. External peer review supported the PHCTs' interpretation of evidence and their recommendations. The recommendations included consideration of communication and information for carers, coordination of care within teams, and recognition by team members of the roles of carers and their cultural and religious beliefs.There are particular steps that PHCTs can take to improve their support of South Asian carers. It is possible to develop guidelines that take users' views into account and incorporate evidence from qualitative studies.

Teams make up the building blocks of health care and every team—from the executive to the coal face—is composed of different professionals, ideally possessing a variety of skills necessary to produce safe and effective care.1 We are constantly reminded of the value of diversity within teams, but the reality is that working together from a variety of perspectives is sometimes difficult to achieve. The paper by Jenkins et al 2 in this issue of Quality in Health Care shows, for example, that, unless roles are well defined and understood, responsibility for giving different types of information to patients could easily result in overload to the patient, differences in messages, and gaps in certain areas. The difficulties of multidisciplinary teamwork are also apparent in differing attitudes towards the way to bring about a good outcome, and even what actually constitutes a good outcome. For example, in teams caring for patients with …

To assess the effects of feedback of patients' evaluations of care to general practitioners.Randomised trial.General practice in the Netherlands.55 GPs and samples of 3691 and 3595 adult patients before and after the intervention, respectively.GPs in the intervention group were given an individualised structured feedback report concerning evaluations of care provided by their own patients. Reference figures referring to other GPs were added as well as suggestions for interpretation of this feedback, an evidence-based overview of factors determining patients' evaluations of care, and methods to discuss and plan improvements.Patients' evaluations of nine dimensions of general practice measured with the CEP, a previously validated questionnaire consisting of 64 questions, using a six point answering scale (1= poor, 6 = very good).Mean scores per CEP dimension varied from 3.88 to 4.77. Multilevel regression analysis showed that, after correction for baseline scores, patients' evaluations of continuity and medical care were less positive after the intervention in the intervention group (4.60 v 4.77, p0.05 and 4.68 v 4.71, p0.05, respectively). No differences were found in the remaining seven CEP dimensions.Providing feedback on patients' evaluations of care to GPs did not result in changes in their evaluation of the care received. This conclusion challenges the relevance of feedback on patients' evaluations of care for quality improvement.

To describe the standards of care for stroke patients in England, Wales and Northern Ireland and to determine the power of national audit, coupled with an active dissemination strategy to effect change.A national audit of organisational structure and retrospective case note audit, repeated within 18 months. Separate postal questionnaires were used to identify the types of change made between the first and second round and to compare the representativeness of the samples.157 trusts (64% of eligible trusts in England, Wales, and Northern Ireland) participated in both rounds.5589 consecutive patients admitted with stroke between 1 January 1998 and 31 March 1998 (up to 40 per trust) and 5375 patients admitted between 1 August 1999 and 31 October 1999 (up to 40 per trust). Audit tool-Royal College of Physicians Intercollegiate Working Party stroke audit.The proportion of patients managed on stroke units rose between the two audits from 19% to 26% with the proportion managed on general wards falling from 60% to 55% and those managed on general rehabilitation wards falling from 14% to 11%. Standards of assessment, rehabilitation, and discharge planning improved equally on stroke units and general wards, but in many aspects remained poor (41% formal cognitive assessment, 46% weighed once during admission, 67% physiotherapy assessment within 72 hours, 24% plan documented for mood disturbance, 36% carers' needs assessed separately).Nationally conducted audit linked to a comprehensive dissemination programme was effective in stimulating improvements in the quality of care for patients with stroke. More patients are being managed on stroke units and multidisciplinary care is becoming more widespread. There remain, however, many areas where standards of care are low, indicating a need for investment of skills and resources to achieve acceptable levels.

Objectives—Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

The role of the chief executive in the NHS is to act as organisational head, with financial and managerial responsibility, and now responsibility has been extended to include clinical standards as part of the duty of quality and the introduction of clinical governance. These new responsibilities have implications for relations with staff inside the organisation and, in particular, with clinicians, as well as adding to the overall public accountability of chief executives. As well as increasing expectations of chief executives to meet performance objectives and other targets within the organisation, their role remains relatively new and sometimes contentious in the health service, forming part of the history of NHS management reform. The developing role of chief executives and the complex world in which they operate in the health service is discussed. It is suggested that support from colleagues at both the organisational and national levels is required to help them discharge their new responsibilities, together with a greater focus on the development of their role and skills.