Commentary: National clinical programmes in the Republic of Ireland: a qualitative study of acute hospitals

The challenge of scaling up and spreading quality improvements that appear to have worked at a local level is an international one. Ovretveit (2011) noted that there is little research from high-income countries about effective ways to spread improvements. Dixon Woods (2019) observes that quality improvements are like babies; everyone thinks theirs is beautiful (and effective) and it’s hard for others to come along and point out that it’s actually ugly.

So this small study from the Republic of Ireland adds to the debate on large-scale roll outs of programmes intended to improve quality. However, the paper makes an assumption that the intervention is indeed a ‘beautiful baby’ with no discussion of its merits or limitations. Instead the author focuses on the stakeholders’ experience and perceptions of the programmes.

Respondents appear to be talking about a number of different programmes, including the surgical care programme, stroke care and fracture care, and it is hard to discern perceived difference between them. The author reached a broad conclusion that programme implementation was inconsistent and discusses a number of possible reasons for this, and suggests this would be addressed by improved governance, communication, leadership and resources. The author seems to have made a leap from the perception of twenty people to policy recommendations. The next step would be to test out this logic model more widely before making changes to national policy.

The findings in this paper echo the recently published findings of a multiple-methods study of the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme in English acute hospitals. Robert et al. (2019) found that resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Its enduring impact was seen in places where the programme had developed lasting QI capabilities among those meaningfully involved in its implementation. Thus, in the case of Robert et al.’s study, the ‘beautiful baby’ was not the particular programme but the upskilling of staff who seek standardised outcomes (which may involve variable processes) rather than standardised processes (which may result in variable outcomes). All beautiful babies must grow up and begin to make their own decisions when the they hit the ‘terrible twos’. And, just like any other parent, designers of quality-improvement programmes need to prepare their protégées for increasing autonomy and self-determination.

Healthcare services operate in a complex and open system, and the idea that a national, standardised approach will deliver improvements across very different contexts is implausible. We are in danger of achieving fidelity to a design with standardised processes but variable outcomes unless we accept that individual circumstances need to be taken into consideration and processes adapted with intentional variation if we want good outcomes. What we are learning from other complex, high risk, industries is that we should be seeking reliability rather than standardisation (Sutcliffe et al., 2017).

Perhaps inconsistent implementation of national programmes is not the problem it is perceived to be, more a development milestone in its maturity.

Biography

Elaine Maxwell is a Clinical Advisor in the NHS and an associate professor of Leadership at London South Bank University. She is currently Clinical Adviser at the National Institute of Health Research Dissemination Centre, where she works to increase to knowledge transfer and uptake of evidence in healthcare services.