Rethinking medical ward quality

Abstract

Rethinking medical ward qualityFor quality to improve, we need to embrace the complexities of general medical inpatient care, say Samuel Pannick and colleagues Medical wards deliver the majority of acute inpatient care in health systems worldwide. This care is expensive, costing the NHS around £5bn (€5.5bn; $6.2bn) a year, a quarter of its inpatient expenditure.1 Improving the performance of medical wards is an international priority, 2 3 not only because of the scale of care that they deliver. Their core workload-treating complex, increasingly frail patients in a time pressurised setting-represents the broader challenges facing healthcare. 4 Yet major gaps remain in our understanding of how wards perform. [5][6][7] Safety and quality interventions have been most effective in improving standardised clinical tasks in the operating theatre and intensive care unit, such as the insertion of central venous catheters. The processes of ward care require a more nuanced approach to improvement. Medical patients' clinical syndromes often fall between traditional diagnostic categories, 8 and specific organisational challenges exist for the teams that care for them. We discuss the unique properties of medical wards and the problems they face, before setting out a vision for ward improvement that embraces the complexity of ward care. The medical ward is a different animalImportant differences exist between medical wards and other clinical settings, from haemodialysis units to operating theatres. Medical ward teams care for a particularly heterogeneous group of patients, with no single best pathway for diagnosis or treatment. Staff are skilled in the management of a diverse range of conditions, from pyelonephritis to gastrointestinal bleeding and terminal cancer. Many patients arrive without a diagnosis; indeed, empirical treatment can be concluded with no definitive diagnosis ever established. This sets medical wards apart from other hospital settings, which typically manage more narrowly defined patient populations with more predictable care trajectories. With such heterogeneity, medical ward teams may struggle to articulate their clinical and business aims and are better defined by their interpersonal networks and the flow of information within them. 9Episodes of medical ward care can be long, involving large, dynamic, multidisciplinary teams. Team members are often dispersed throughout the hospital; physicians and allied health professionals are rarely located together on one unit with nurses and their patients. Frequent handovers are made more difficult by the absence of a central procedure around which a structured care narrative can be formed.Errors are common and often serious-medical ward patients have the same risks of preventable and fatal adverse events as those in intensive care, 7 10 and preventable hospital deaths are disproportionately caused by failures in general ward care. 6 Crucially, ward failures are different from the procedural misadventures of the operating theatre or intensive care unit, 10 re...

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