Quality and Safety Policy

Using research to make health care safer

Christine M Jorm and Sarah J White

Christine M Jorm, MB BS, MD, PhD, FANZCA, Senior Medical Advisor Sarah J White, BA(Hons), Research Officer Australian Commission on Safety and Quality in Health Care, Sydney, NSW.

Correspondence: Dr Christine M Jorm, Australian Commission on Safety and Quality in Health Care, Level 7, 1 Oxford Street, Darlinghurst, Sydney, NSW 2010. christine.jorm@safetyandquality.gov.au

Aust Health Rev ISSN: 0156-5788 1August 2009 33 3 400-407©Aust Health Rev 2009 www.aushealthre-view.com.auQuality and Safety Policy

with it? The moral imperative to improve care mhave been a distractor, preventing adequate attetion to research. Three research areas are pposed as current priorities for patient safegetting evidence into practice, measurement safety, and the evaluation of complex intervetions. A focus on these areas should ensure thresearch becomes more central to the process

AbstractThere is a fine balance that needs to be main-tained between research and improvement insafety and quality in health care — when do weneed more research and when can we just get on

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making health care safer.

WHAT PLACE DOES RESEARCH play in safety andquality and when should we just “get on with it”?The discourse of modern government is crisp, ifnot blunt: the National Health and HospitalsReform Commission had among its terms ofreference the requirement to “reduce inefficien-cies generated by cost-shifting, blame-shiftingand buck passing”.1 (p. 357) The development ofperformance indicators continues apace, and theresearch community is not always seen as essen-tial to the process of making health care safer.

The research–policy divide is well documentedand has led to the modern development of newspecialties such as knowledge transfer or transla-tion,2 and brokering and exchange.3 However,policy imperatives mean policy makers are impa-

tient with research timeframes and wary of rec-ommendations that may make compromisedifficult.4 Human interaction has been describedas “the engine that drives research into practice”,5

yet the inclusion of clinicians, managers andpolicy makers (or research users) into researchfunding programs is rare in Australia and onlypartial in Canada.5

In the case of quality and safety, however, thereare further problems. Traditional quantitativeresearch methods may be inadequate tools (par-ticularly for areas such as clinical handover andother health care communication), and in addi-tion, the need to improve safety and quality hasbeen associated with a moral imperative whichhas been held to obviate the need for research andhas been associated with denigration of its value.Berwick, in a recent piece advocating safety andquality research, used rhetoric displaying thecustomary antagonism of safety and quality expo-nents towards research: “Health care researchers

What is known about the topic?It is unsure how much safety and quality has improved over the last two decades. There is a deficiency of high quality research to support the design of safety improvement.What does this paper add?The lack of formal study means that neither clinicians nor policy makers understand the system in which they work sufficiently to reliably get evidence into practice. Inadequate measurement in safety prevents appropriate priority setting. Meaningful evaluations must include the study of failure. The use of a theoretical basis for both intervention and evaluation increases the likelihood of transferable learning.What are the implications for practitioners?Safety and quality advocates are requested to accompany their exhortations for change with funding for research. Researchers need to develop interdisciplinary capacities and collaborations that are required to evaluate interventions in our complex health system.

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who believe that their main role is to ride thebrakes on change — to weigh evidence withimpoverished tools, ill-fit for use — are not beingas helpful as they need to be”.6

The moral imperative to deliver safer careThe need to improve quality and safety in healthcare acquired urgency (the creation of what hasbeen described as the “patient safety jugger-naut”7) after the publication of a report from theUnited States Institute of Medicine (IOM) entitledTo err is human.7 This report used data from the1991 Harvard Medical Practice Study to estimatethat 44 000 to 98 000 deaths occur annually inUS hospitals due to medical error. The number ofdeaths attributed to error in both this and subse-quent studies were estimates that cannot be defin-itively substantiated.8-10 Still, a substantialincrease in patient safety publications followedthe To err is human report.11

The release of the Quality in Australian HealthCare Study in 1995 resulted in political uproar inAustralia and led to the formation and funding ofthe Australian Council on Safety and Quality inHealth Care. Several major public inquiries intodisturbing health care scandals have also been afeature of the last two decades.12 The trust of thepublic and of politicians in the health care systemhas been disturbed by revelations of poor qualityand unsafe care.13 Some harm is preventable.Thus it is not surprising that many discussions ofsafety and quality in health are dominated byethically based exhortation: “Australians deservebetter”14 or “While research is usually seen asoptional, quality improvement might well bemore often morally required, both for the patientas a citizen and for the care provider as aprofessional responsibility”.15

The place of researchIf we should “get on with it” to improve safety andquality, can we? There is a general lack of schol-arly accounts of methods, experiences, andresults in the area of safety and quality.16-20

Quality improvement interventions supported bytoo little evidence will be suboptimal at best,sometimes futile or may even cause harm.21 Formost safety and quality initiatives no cost–benefitanalysis has been performed. Therefore we do notknow the proportion of resources that should bedevoted to activities such as incident reportingand root cause analysis versus, for instance, elec-tronic decision support.22,23 There needs to be abalance between resources dedicated to qualityimprovement and those dedicated to research.The wrong balance means either delayed deliveryof a solution to a quality or safety problem or theimplementation of an inadequately evaluatedintervention.

Research approaches have been used for qualityand safety health service outcomes that are notwell suited to describing or solving the problemsthey have chosen to investigate. There is littleevidence to date supporting linkages betweenorganisational factors in health care, medicalerrors and patient safety.24 Yet the absence ofresearch or the existence of only research oflimited scope or poor design has been used toreject proposals with high face validity such as themedical emergency team.6,25 In light of theseissues, we have identified three research areas thatare priorities if patient safety is to be improved:getting evidence into practice; measurement ofsafety; and the evaluation of interventions. Argu-ment is made for each area, and the conclusiondevelops some specific tasks for researchers andpolicy makers to ensure that research betterunderpins safety and quality work.

1. Getting evidence into practiceA high percentage of medical care that is deliv-ered is not supported by evidence26,27 but theabsence of evidence does not mean that a treat-ment is not safe and effective. Of greater concernis that patients may only get 40%–50% of the carethat is recommended for them by evidence28 andthat it takes lengthy periods for evidence to betaken into practice.29 Where evidence is incom-patible with existing values or the prevailingmedical paradigm, for example treatment forscurvy, or germ theory, it may take 30–50 years

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for evidence to be adopted into practice.30 Itcould be argued that the teenaged field of safetyand quality has struggled both in specific clinicalcases and in general against prevailing medicalparadigms; we have to be able to first conceptual-ise the complex system responsible for the out-comes of care before we can improve it.Australian doctors have been shown to be dis-tanced and alienated by their very conceptualisa-tions of the health care system in which theywork.31

Let us take two specific clinical areas that havebeen safety and quality targets: the use of betablockers after myocardial infarction and deepvenous thrombosis (DVT) prophylaxis. In 2007,Lee wrote Eulogy for a quality measure.32 Themeasure was the percentage of patients with acutemyocardial infarction who receive a prescriptionfor beta blockers within 7 days of discharge.Twenty-five years after the convincing demonstra-tion of the significant reduction in mortality betablockers provide for this patient group, nearly allnow receive these drugs (in the US). The increasein prescription from one third of patients in themid 1990s to nearly all in 2007 was driven byguidelines and policy. Compliance was requiredfor accreditation; incentives and public reportingexperimented with; and systems developed “thatmade it easier to do the right thing”32 (p. 1177).Multiple interventions drove successful systemimprovement.

In contrast, the uptake of evidence-based riskassessment for DVT has been disappointing.33,34

Yet, in the United Kingdom, it is suggested thatDVT causes more than 25 000 potentially pre-ventable deaths per year.35 Mortality due to DVTafter hospital admission is 10 times greater thanafter infection with methicillin-resistant Staphylo-coccus aureus (MRSA) (10% of hospital deathsbeing due to pulmonary embolism). An agreedmeasure for DVT is extremely difficult to obtainand many patients present after discharge (andsome remain undiagnosed and untreated).Responsibility for assessment and prescription ofprophylaxis are often confused, and the conse-quences of failure are rarely faced by thoseresponsible for the former (indeed chronic

venous insufficiency and leg ulceration may beproblems that that patient faces 10–15 yearslater). Because policy designed to improve clinicalsafety and quality is rarely formally studied, itcould be speculated that it will be some timebefore compliance with a hard problem like DVTprophylaxis becomes a measurable success.

We also need to develop methods of presentingdata in ways that are able to educate and persuadepatients, clinicians, managers, government andother policy stakeholders to implement evidence-based change that will improve the safety andquality of health care. Statistical process controlcharting is an important method for routinelypresenting and tracking safety and quality data,36

and while use is increasing,37 it is still unfamiliarto many clinicians. The traditional randomiseddouble blind controlled trial, familiar to, andtherefore expected by clinicians, does not workwell for safety and quality issues (as noted by theanonymous reviewer). In fact the failure to pro-duce the kind of evidence that clinicians look forand that will convince clinicians amounts to acommunication problem.

It has been suggested that the traditional meth-ods of producing good science and disseminatingit through conventional means, such as reports,journals and conferences, are “simply inadequateto the humbling need for vast improvements inthe [US] health system”.38 (p. I-88) Social mar-keting aims to influence human behaviour on alarge scale, using commercial marketing princi-ples for the purpose of social benefit.39 The use ofsocial marketing techniques to get the attention ofboth the public and clinicians for specific safetyand quality issues is overdue.

Doctors’ knowledge about the evidence forsafety and quality has been shown to be weak inboth the US and Australia.40,41 US doctors rated34% of the six safety and quality interventionswith published evidence and 29% of the seveninterventions without published evidence as“very effective”.41 Clinicians have been shown tobe relatively poor users of explicit evidence in anumber of domains, yet collectively reinforcedinternalised tacit guidelines are important.42

Hence, improving quality and safety knowledge

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may require engaging with the local knowledgethat is developed during the collaborative pro-cesses of care. A composite tool has recently beendeveloped to measure the organisational contextfor evidence-based practice.43 Assessment oforganisational absorptive and receptive capacityshould then enable support for the elements oforganisational structure and culture that producethe capacity to implement evidence-based inno-vations. Similarly, it has been argued that usingmixed methods to study organisations that arepositive deviants, that is, those that deliver con-sistently excellent performance, can describe thedetails of their structure and practices so thatothers can learn how to improve.44

2. Measurement of safetyHow do we work out what is important? Meas-urement may bias attention and efforts towardeasily measured targets (eg, infection rates).45

Indeed “a dark side of measurement”,45 has beendescribed where less well developed measuresmean problems may be ignored. It has beensuggested that difficult areas to measure andresearch include diagnostic errors, errors in com-munication or errors due to discontinuous care.Diagnostic error has clearly been neglected, butwhat we do know is sobering. Studies comparingpatient notes with autopsy show diagnostic errorrates of 40%–60%.46 Major error occurs in 2%–20% of radiological investigations;47 1%–43% ofall anatomic pathology specimens;48 and 27% ofbiochemistry and microbiology investigations.49

Inter-observer diagnostic variability exists amongexperts,48,50 and no test may exist that providesperfect separation between normal and abnormalresults.47

Yet the IOM advocates “Six Sigma” reliabilityfor health care.7 This is a rate of fewer than 3.4errors per 1 million events (beyond 6 standarddeviations from the mean of a normal distribu-tion) which apparently has been achieved by theairline and the nuclear power industries. It isclear both that diagnostic error is a neglectedpatient safety problem and that the rhetoric of SixSigma may be less appropriate for health carethan once thought. There are few identically

repeated processes in health where deviationfrom procedures is an appropriate measure.51

Most health care situations involve considerablevariation and uncertainty.

Measurement also needs to include the patientperspective. A very low percentage of patientswho experience adverse events actually com-plain.52,53 However, of the complaints received bythe New Zealand Health and Disability Commis-sioner, a preventable adverse event was identifiedin 51% of cases.53 Patients, when given theopportunity, report quite different events com-pared with staff, for example, the medical recordor x-ray not being available when needed, orinsufficient painkillers being given.54 As there aredifferences in perceptions regarding adverseevents, involvement of health care consumers inunderstanding patient safety is essential.

Commonwealth Fund surveys in 2005 and2007 revealed that about one in four Australianpatients experienced a problem with coordinationof their care (tests or records not available whenneeded, or duplicate tests or conflicting informa-tion being given).55,56 The US and Australianrates were singled out for comment due to theirparticularly high rates of fragmented care.56 Inaddition, only 43% of Australian patients saidthat their doctors always told them about treat-ment choices and asked for patient opinion.55

In a recent call for clinically relevant reform,Scott et al challenge health care providers andinstitutions to reconsider their safety and qualityfocus, to “tackle the core of first-order clinicallyrelevant issues central to making hospital carevisibly safer”.57 To actually decide on the clini-cally relevant issues and to measure “visibly” safercare, research is needed on ways to routinely andeffectively include the patient view in decisionsand measures. In an Australian institution with aroutine comprehensive patient survey process,implementation of a new approach to clinicalhandover communications resulted in a measura-ble improvement in patient satisfaction abouthow staff work together.58 A clear place forpatient involvement has been recommended inthe safety performance framework proposed byWakefield and Jorm.59 Patient outcomes and

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experience may provide a new lens to define thatwhich is important to measure.

3. Evaluation of complex interventionsWensing, Wollersheim and Grol, while able todraw some conclusions, such as supportingmultidisciplinary teams, integrated care systemsfor chronic conditions, and the use of computers,suggest that “for no strategies can the effects bepredicted with high certainty”.60 Developingmethods of understanding complex interventionsis a research priority whether the intervention is amedical emergency team, root cause analysis orthe “bundles” of practices that have been shownas able to reduce central line infections. Thismeans a detailed examination of the nature of theintervention61 and a broad examination of itseffects, which may lay in other places than thepredetermined area of interest; for example theeffect of medical emergency teams on “not forresuscitation orders”62,63 and palliative care, orthe effect of participation in the root cause analy-sis process on improving organisational commun-ication.64 When the interventions themselveshave a clearly described theoretical framework,meaningful evaluation is more likely.65

The spread of best practice has proven an elusivegoal.66 A failed attempt at reform, though, is awaste of money and of human capital — ourenergy and enthusiasm. Successes and failures ofcollaborative initiatives have been documented.17

Many quality improvement approaches are predi-cated on standardising work processes that aregenerally much simpler than those found in thehighly complex “industry” of health care.51 Often,instead of confronting failures, advocates haveinvented language to justify them. They use termslike “barriers to change” and “culture” — termsthat conceal more than they reveal. Checkland andcolleagues suggest it is failures that harbour reallearnings.67 They ask what can be learned fromsomething not being achieved. The problem thatquality and safety work shares with more conven-tional medical research, they suggest, is that itsoutcomes are only regarded as adding to ourknowledge if they are successful. This runs parallelwith the well-documented academic publication

bias: an appreciably greater proportion of “success-ful” than “unsuccessful” trials are published.68 Sim-ilarly, failed improvement initiatives are rarelywritten up for publication or showcased by jour-nals, as if these are without interest. It is hardlysurprising then that public policy for the develop-ment and implementation of safety and qualityinitiatives69,70 may be underinformed by research.

ConclusionShould we just get on with it? This approach doesnot appear to have been as successful as hoped asthe lack of measurement while “getting on withit” means we are not at all sure about the state ofthe safety in the health care system. It is easy tostate that in 18 years since the Harvard MedicalPractice Study little has changed57 and the inade-quacy of measurement cannot be disputed. Yettoday multidisciplinary team work is normal,multidisciplinary stroke units are in widespreaduse and medical emergency teams are present inmore than 75% of Australian hospitals. We havespecialist emergency physicians in large numbersworking extended hours in our major emergencydepartments and we all wear gloves to put incannulas! We have pulse oximetry not just inoperating theatres but high dependency areas andincreasingly in all wards. Safer working hours area reality. Certainly it is believed that all of theseprocess improvements increase patient safety andimprove patient outcomes.

This is a good time to be considering thecontribution of research to safety and quality; at18 (years since the publication of the HarvardMedical Practice Study), the infant that was thesafety and quality movement has grown through arather passionate adolescence to have the matu-rity to appreciate the need for research. Grol,Berwick and Wensing argued recently that initia-tives to improve patient care have had onlylimited success and that to make bigger improve-ments we need rigorous studies using a variety ofmethods.71 However, old research paradigmsalone will not meet the needs of the energeticadult discipline of safety and quality. The safetyand quality movement is about drive; inspiring

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and committing people to work together to makepatient care much better and safer — change withpassion. It rightly remains impatient with tinyimprovements and research that is endlesslyinconclusive when faced with substantial num-bers of preventable errors and substandard care.It has been suggested that commissioning moreresearch sometimes may help to conceal ourcollective failure to have the societal will to usethe evidence we have.72

Safety and quality advocates now must stepback from their exhortations for change andinstead fund research while they “get on with it”,which must include experimenting with a rangeof policy levers via funding and reporting. Policymakers need to secure time for pilots that are welldesigned, with rigorous and honest evaluation,73

and employ new methods such as realist reviewto synthesise research findings.74 We need newand creative approaches to ensure safety andexcellence become widespread and systemic, notjust the province of exceptional units, or someelusive aspect of organisational culture.

For their part, the research community needsto find ways to better measure patient safety andfind the factors that increase the likelihood oftransferability (and sustainability) of change andimprovement initiatives. The obvious start pointis via developing increased capability in interdis-ciplinary research. This kind of research is moretime consuming as substantial communication isrequired,75 requiring funding for administration,meetings and travel. Current reward practices inacademia do not support this work.72 Also, thereis as yet little written about the benefits ofresearcher involvement in policy-making pro-cesses,3 and work is rarely designed in ways thatfacilitate this.

We have very few research groups able tointegrate quantitative and qualitative research;able to mix built design, microbiology andanthropology; regression analysis and conversa-tion analysis; and, most importantly, able toengage not just clinicians, but managers andpatients in the research process. Groups that areable to do this are able to truly analyse structure,process, outcome, and the social dimensions of

change, and by these means the researchcommunity will indeed be seen as central to theprocess of making health care safer and better.

AcknowledgementsThanks to Professor Chris Baggoley; many of thesearguments developed during our conversations.

Competing interestsThe authors declare that they have no competing interests.

References1 National Health and Hospitals Reform Commission. A

healthier future for all Australians. Interim reportDecember 2008. Canberra: NHHRC, 2008.

2 Scott I. The evolving science of translating researchevidence into clinical practice. Evidence-Based Medi-cine 2007; 12: 4-7.

3 Mitchell P, Pirkis J, Hall J, Haas M. Partnerships forknowledge exchange in health services research,policy and practice. J Health Serv Res Policy 2009; 14(2): 104-11.

4 Jorm C, Banks M, Twohill S. The dynamic of policy andpractice. In: Managing clinical processes in the healthservices. Sorenson R, Iedema R, editors. Sydney &London: Elsevier, 2008.

5 Conklin A, Hallsworth M, Hatziandreu E, Grant J.Briefing on linkage and exchange. facilitating thediffusion of innovation in health services. Rand Corp-oration Occasional Paper Series. 2008.

6 Berwick D. The science of improvement. JAMA 2008;299: 1182-4.

7 Kohn L, Corrigan J, Donaldson M, eds. To err ishuman: building a safer health system. Washington,DC: National Academy Press, 1999.

8 Thomas EJ, Studdert DM, Runciman WB, et al. Acomparison of iatrogenic injury studies in Australiaand the USA. I: Context, methods, casemix, popula-tion, patient and hospital characteristics. Int J QualHealth Care 2000; 12: 371-8.

9 Thomas EJ, Lipsitz SR, Studdert DM, Brennan TA. Thereliability of medical record review for estimatingadverse event rates. Ann Intern Med 2002; 136: 812-6.

10 Runciman WB, Webb RK, Helps SC, et al. A compari-son of iatrogenic injury studies in Australia and theUSA. II: Reviewer behaviour and quality of care. Int JQual Health Care 2000; 12: 379-88.

11 Stelfox HT, Palmisani S, Scurlock C, et al. The “To Err isHuman” report and the patient safety literature. QualSaf Health Care 2006; 15: 174-8.

Australian Health Review August 2009 Vol 33 No 3 405

Quality and Safety Policy

12 Hindle D, Braithwaite J, Travaglia J, Iedema R. Patientsafety: a comparative analysis of eight Inquiries in sixcountries. Sydney: Centre for Clinical GovernanceResearch, University of New South Wales, 2006.

13 Quick O. Outing medical errors: questions of trust andresponsibility. Med Law Rev 2006; 14: 22-43.

14 Wilson RM, Van Der Weyden MB. The safety ofAustralian healthcare: 10 years after QAHCS. Med JAust 2005; 182 (6): 260-1.

15 Lynn J. When does quality improvement count asresearch? Human subject protection and theories ofknowledge. Qual Saf Health Care 2004; 13: 67-70.

16 Davidoff F, Batalden P. Toward stronger evidence onquality improvement. Draft publication guidelines: thebeginning of a consensus project. Qual Saf HealthCare 2005; 14: 319-25.

17 Ovretveit J, Gustafson D. Evaluation of qualityimprovement programs. Qual Saf Health Care 2002;11: 270-5.

18 Smith W. An explanation of theories that guide evi-dence-based interventions to improve quality. ClinicalGovernance: an international journal 2003; 8 (3): 247-54.

19 Shojania K, Grimshaw J. Evidence-based qualityimprovement: the state of the science. Health Aff(Millwood) 2005; 24: 138-51.

20 Lohr K. Rating the strength of scientific evidence:relevance for quality improvement programs. Int JQual Health Care 2004; 16: 9-18.

21 Auerbach A, Landefeld C, Shojania K. The tensionbetween needing to improve care and knowing how todo it. N Engl J Med 2007; 357: 608-12.

22 Warburton R. Patient safety—how much is enough?Health Policy 2005; 71: 223-32.

23 Wu A, Lipshutz A, Provonost P. Effectiveness andefficiency of root cause analysis in medicine. JAMA2008; 299: 685-87.

24 Hoff T, Jameson L, Hannan E, Flink E. A review of theliterature examining linkages between organizationalfactors, medical errors, and patient safety. Med CareRes Rev 2004; 61: 3-37.

25 Kerridge R, Saul W. The medical emergency team,evidence-based medicine and ethics. Med J Aust2003; 179: 313-15.

26 Buchan H. Gaps between best evidence and practice:causes for concern. Med J Aust 2004; 180: S48-9.

27 Steinberg E, Luce B. Evidence based? Caveat emp-tor! Health Aff (Millwood) 2005; 24: 80-93.

28 McGlynn EA, Asch SM, Adams J, et al. The quality ofcare delivered to adults in the United States. N Engl JMed 2003; 348: 2635-45.

29 Dykes P. Translating evidence into practice for provid-ers and patients. Evid Based Cardiovasc Med 2005;9: 157-9.

30 Doherty S. History of evidence-based medicine.Oranges, chloride of lime and leeches: barriers toteaching old dogs new tricks. Emerg Med Australas2005; 17: 314-21.

31 Jorm C, Travaglia J, Iedema R. Why don’t doctorsengage with the system? In: Hospital communication:tracing complexities in contemporary healthcareorganisations. Iedema R, editor. Basingstoke: Pal-grave-MacMillan, 2006: 222-43.

32 Lee T. Eulogy for a quality measure. N Engl J Med2007; 357: 1175-7.

33 National Institute for Clinical Studies. Evidence-prac-tice gaps report, Volume 1. Melbourne: 2003.

34 Tooher R, Middleton P, Pham C, et al. A systematicreview of strategies to improve prophylaxis for venousthromboembolism in hospitals. Ann Surg 2005; 241:397-415.

35 Fitzmaurice D, Marray E. Thromboprophylaxis foradults in hospital. BMJ 2007; 334: 1017-18.

36 Thor J, Lundberg J, Ask J, et al. Application ofstatistical process control in healthcare improvement:systematic review. Qual Saf Health Care 2007; 16:387-99.

37 Duckett S, Coory M, Sketcher-Baker K. Identifyingvariations in quality of care in Queensland Hospitals.Med J Aust 2007; 187: 571-5.

38 McNeill D, Kelley E. How the National HealthcareQuality and Disparities Reports can catalyze qualityimprovement. Med Care 2005; 43 (3 Suppl): I82-8.

39 Morris ZS, Clarkson PJ. Does social marketing providea framework for changing healthcare practice? HealthPolicy 2009; in press.

40 Brand C, Ibrahim J, Bain C, et al. Engineering a safelanding: engaging medical practitioners in a systemsapproach to patient safety. Intern Med J 2007; 37:295-302.

41 Rosen AB, Blendon RJ, DesRoches CM, et al. Physi-cians’ views of interventions to reduce medical errors:does evidence of effectiveness matter? Acad Med2005; 80: 189-92.

42 Nicolini D, Conville P, Martinez-Solano LE. Managingknowledge in the healthcare sector. A review. Int JManag Rev 2007; 1-19.

43 French B, Thomas LH, Baker P, et al. What canmanagement theories offer evidence-based practice?A comparative analysis of measurement tools fororganisational context. Implement Sci 2009; 4: 28.

44 Bradley EH, Curry LA, Ramanadhan S, et al. Researchin action: using positive deviance to improve quality ofhealth care. Implement Sci 2009; 4: 25.

45 Wachter R. Is the measurement mandate diverting thepatient safety revolution? [Expert commentary.] 2008.Available at: www.guideline.gov/resources/commen-tary.aspx?file=Patient_Safety.inc (accessed Apr2008).

406 Australian Health Review August 2009 Vol 33 No 3

Quality and Safety Policy

46 Mangione S, Nieman L. Cardiac auscultatory skills ofinternal medicine and family practice trainees. A com-parison of diagnostic proficiency. JAMA 1997; 278:717-22.

47 Goddard P, Leslie A, Jones A, et al. Error in radiology.Br J Radiol 2001; 74 (886): 949-51.

48 Raab S. Improving patient safety by examining pathol-ogy errors. Clin Lab Med 2004; 24: 849-63.

49 Stroobants A, Goldschmidt H, Plebani M. Error budgetcalculations in laboratory medicine: linking the con-cepts of biological variation and allowable medicalerrors. Clin Chim Acta 2003; 333: 169-76.

50 Frable W. Surgical pathology — second reviews,institutional reviews, audits and correlations. What’sout there? Error or diagnostic variation? Arch PatholLab Med 2006; 130: 620-5.

51 Lillrank P, Liukko M. Standard, routine and non-routineprocesses in healthcare. Int J Health Care Qual Assur2004; 17: 39-46.

52 Murff HJ, France DJ, Blackford J, et al. Relationshipbetween patient complaints and surgical complica-tions. Qual Saf Health Care 2006; 15: 13-16.

53 Bismark MM, Brennan TA, Paterson RJ, et al. Relation-ship between complaints and quality of care in NewZealand: a descriptive analysis of complainants andnon-complainants following adverse events. Qual SafHealth Care 2006; 15: 17-22.

54 Agoritsas T, Bovier P, Perneger M. Patient reports ofundesirable events during hospitalization. J GenIntern Med 2005; 20: 922-8.

55 Schoen C, Osborn R, Huynh PT, et al. Primary careand health system performance: adults’ experiencesin five countries. Health Aff (Millwood) 2004; SupplWeb Exclusives: W4-487-503.

56 Schoen C, Osborn R, Doty MM, et al. Toward higher-performance health systems: adults’ health careexperiences in seven countries. Health Aff (Millwood)2007; 26: W717-34.

57 Scott I, Poole P, Jayathissa S. Improving quality andsafety of hospital care: a reappraisal and an agendafor clinically relevant reform. Intern Med J 2008; 38:44-55.

58 Hatten-Masterton S, Griffiths M. SHARED maternitycare: enhancing clinical communication in a privatematernity setting. Med J Aust 2009; 190: S150-1.

59 Wakefield J, Jorm C. Patient safety — a balancedmeasurement framework. Aust Health Rev 2009; 30(3): 400-407.

60 Wensing M, Wollersheim H, Grol R. Organizationalinterventions to implement improvements in patientcare: a structured review of reviews. Implement Sci2006; 1: 22.

61 Hulscher M, Laurant M, Grol R. Process evaluation ofquality improvement interventions. In: Quality improve-ment research. Understanding the science of change

in health care. Grol R, Baker R, Moss F, editors.London: BMJ Books, 2004.

62 Jones DA, McIntyre T, Baldwin I, et al. The medicalemergency team and end-of-life care: a pilot study.Crit Care Resusc 2007; 9: 151-6.

63 Bellomo R, Goldsmith D, Uchino S, et al. Prospectivecontrolled trial of effect of medical emergency team onpostoperative morbidity and mortality rates. Crit CareMed 2004; 32: 916-21.

64 Iedema RA, Jorm C, Braithwaite J, et al. A root causeanalysis of clinical error: confronting the disjunctionbetween formal rules and situated clinical activity. SocSci Med 2006; 63: 1201-12.

65 Walshe K. Understanding what works — and why — inquality improvement: the need for theory-driven evalu-ation. Int J Qual Health Care 2007; 19: 57-9.

66 Greenhalgh T, Robert G, Bate P, et al. Diffusion ofinnovations in health service organisations. a system-atic literature review. Oxford: Blackwell, 2005.

67 Checkland K, Harrison S, Marshall M. Is the metaphorof ‘barriers to change’ useful in understanding imple-mentation? Evidence from general medical practice. JHealth Serv Res Policy 2007; 12: 95-100.

68 McGavock H. Integrating evidence based medicineinto clinical practice. Pharmacoepidemiol Drug Saf2005; 14: 211-2.

69 Ovretveit J, Gustafson D. Improving the quality ofhealth care: using research to inform quality pro-grammes. BMJ 2003; 326: 759-61.

70 Oxman AD, Lavis JN, Fretheim A. The use of evidencein WHO recommendations. Lancet 2007; 369: 1883-9.

71 Grol R, Berwick D, Wensing M. On the trail of qualityand safety in health care. BMJ 2008; 336: 74-6.

72 Dieppe P, Ades A. Why does health services researchseem so hard to fund? J Health Serv Res Policy 2008;13: S1-5.

73 Government Chief Social Researcher’s Office. Trying itout. The role of ‘pilots’ in policy making. Report of areview of government pilots. London: Cabinet Office,2003.

74 Pawson R, Greenhalgh T, Harvey G, Walshe K. Realistreview — new method of systematic review designedfor complex policy interventions. J Health Serv ResPolicy 2005; 10 (Suppl 1): 21-34.

75 Canadian Academy of Health Sciences. The benefitsand barriers to interdisciplinary research in the healthsciences in Canada: framework document. 2005.

(Received 21/10/08, revised 21/06/09, accepted 23/06/09)

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