Summer’s over and we’re approaching the end of induction season. Hopefully most of you are settled into the new year. Induction at Northampton General Hospital had three key messages a) The QI department is world-beating so get involved, b) Here’s a long list of eLearning modules, and c) Try not to worry about the Bawa-Garba thing.
All of this brought to mind a recent paper in Harvard Business Review called “Getting Doctors To Make Better Decisions Will Take More Than Money And Nudges”.
The authors, from Geffen Medical School, argued that there plenty of guidelines in modern medicine. The issue is that “clinicians often don’t respond to them”. But changing this is tough; clinical decision-making is “far too complex to be consistently improved” by financial incentives or by nudges.
I was surprised by this because I think nudging is a promising solution to lots of the problems in medicine. However the authors argued that complexity is not easily amenable to nudging. Although they may get doctors to follow the guidelines, that is a surrogate marker: nudges have not been shown to improve patient outcomes.
They also discussed QOF, the financial incentives system for primary care. The authors claim this has failed to improve patient outcomes; the health of the UK population has not improved since QOF’s introduction in 2004. Those of us working in the system might counter that it is remarkable that health outcomes have not worsened given deep cuts over 10 years. Nevertheless, it is difficult to extrapolate either way from the last 14 years of the NHS.
Given the difficulties of financial incentives and cognitive nudges, the authors suggest that improved decision-making will come from changing Organizational Culture, which they define pretty loosely:
“The systems of shared assumptions, values, beliefs, and norms within an environment”
Here are some elements of positive organizational culture:
- Creative problem solving
- Speaking up about problems and mistakes
- Support from leadership
The authors cite some papers. One paper shows that a well-supported, blame-free clinician environment is associated with improved quality of care (of course this is a surrogate marker and we really want to improve outcomes, not quality of care, so it’s cheeky of the authors to include this). Nevertheless these are the key concerns among the junior doctors following the Bawa-Garba case.
Here’s how the authors sum up:
“Bottom up approaches which empower clinicians to lead and monitor local improvement … are far superior than top-down dictates, generic slogans, and online training modules”
So, although of course I’m going to have to do my eLearning, it’s a good reason to get excited about being at a hospital that is serious about empowering clinicians to monitor local improvement through audit and QI.