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      Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study

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          Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS).


          Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary.


          We found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care.


          Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

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          Most cited references 14

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          The incidence and nature of in-hospital adverse events: a systematic review

          Introduction: Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on in-hospital adverse events. Methods: A formal search of Embase, Cochrane and Medline was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and endpoints. Primary endpoints were incidence of in-hospital adverse events and percentage of preventability. Secondary endpoints were adverse event outcome and subdivision by provider of care, location and type of event. Results: Eight studies including a total of 74 485 patient records were selected. The median overall incidence of in-hospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority. We present a summary of evidence-based interventions aimed at these categories of events. Conclusions: Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference.
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            Explaining Michigan: developing an ex post theory of a quality improvement program.

            Understanding how and why programs work-not simply whether they work-is crucial. Good theory is indispensable to advancing the science of improvement. We argue for the usefulness of ex post theorization of programs. We propose an approach, located within the broad family of theory-oriented methods, for developing ex post theories of interventional programs. We use this approach to develop an ex post theory of the Michigan Intensive Care Unit (ICU) project, which attracted international attention by successfully reducing rates of central venous catheter bloodstream infections (CVC-BSIs). The procedure used to develop the ex post theory was (1) identify program leaders' initial theory of change and learning from running the program; (2) enhance this with new information in the form of theoretical contributions from social scientists; (3) synthesize prior and new information to produce an updated theory. The Michigan project achieved its effects by (1) generating isomorphic pressures for ICUs to join the program and conform to its requirements; (2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; (3) reframing CVC-BSIs as a social problem and addressing it through a professional movement combining "grassroots" features with a vertically integrating program structure; (4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; (5) harnessing data on infection rates as a disciplinary force; and (6) using "hard edges." Updating program theory in the light of experience from program implementation is essential to improving programs' generalizability and transferability, although it is not a substitute for concurrent evaluative fieldwork. Future iterations of programs based on the Michigan project, and improvement science more generally, may benefit from the updated theory present here. © 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.
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              Synthesising qualitative and quantitative evidence: a review of possible methods.

              The limitations of traditional forms of systematic review in making optimal use of all forms of evidence are increasingly evident, especially for policy-makers and practitioners. There is an urgent need for robust ways of incorporating qualitative evidence into systematic reviews. In this paper we provide a brief overview and critique of a selection of strategies for synthesising qualitative and quantitative evidence, ranging from techniques that are largely qualitative and interpretive through to techniques that are largely quantitative and integrative. A range of methods is available for synthesising diverse forms of evidence. These include narrative summary, thematic analysis, grounded theory, meta-ethnography, meta-study, realist synthesis, Miles and Huberman's data analysis techniques, content analysis, case survey, qualitative comparative analysis and Bayesian meta-analysis. Methods vary in their strengths and weaknesses, ability to deal with qualitative and quantitative forms of evidence, and type of question for which they are most suitable. We identify a number of procedural, conceptual and theoretical issues that need to be addressed in moving forward with this area, and emphasise the need for existing techniques to be evaluated and modified, rather than inventing new approaches.

                Author and article information

                BMJ Qual Saf
                BMJ Qual Saf
                BMJ Quality & Safety
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                February 2014
                9 September 2013
                : 23
                : 2
                : 106-115
                [1 ]Department of Health Sciences, University of Leicester , Leicester, UK
                [2 ]Imperial College Centre for Patient Safety and Service Quality (CPSSQ) , London, UK
                [3 ]Institute of Work Psychology and School of Health and Related Research, University of Sheffield , Sheffield, UK
                [4 ]Aston Business School, Aston University , Birmingham, UK
                [5 ]Health Services Research Unit, University of Aberdeen , Aberdeen, UK
                [6 ]Department of Social and Policy Sciences, University of Bath , Bath, UK
                [7 ]National Association for Patient Participation , Surrey, UK
                [8 ]Lancaster University Management School , Lancaster, UK
                Author notes
                [Correspondence to ] Professor Mary Dixon-Woods, Department of Health Sciences, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK; md11@
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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