How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals

Why it matters

Despite an increased focus on quality and safety in recent years, certain problems in healthcare get more attention than others.

Efforts to make surgery safer, for example, have led to significant improvements, while safety issues in mental healthcare haven’t seen the same research and policy attention. It remains unclear how healthcare organisations identify problems, define them, prioritise them, and match them with solutions.

So how does a problem of quality or safety become a problem? And what implications does this have for what organisations do about it?

Our approach

Our study looked at three UK hospitals to examine how senior managers came to identify and characterise patient safety problems and organise responses.

We conducted interviews with managers, clinicians and other staff, observed hospital staff on the job, and reviewed relevant hospital documents.

To analyse our findings, we used insights from social and political science literature on how problems get prioritised or marginalised, and looked at how that affected improvement efforts in the three hospitals.

What we found

In each hospital, it took certain triggers to recognise quality and safety problems. And there were key differences in how they defined those problems.

How problems were ‘constructed’ influenced how they were received by frontline staff. It also impacted the perception of who ‘owned’ the problem and who was responsible for improving them.

When trying to engage staff in improvement efforts, it’s important to carefully balance personal accountability, systems improvement, and the use of data and feedback.

Hospital 1

• Senior managers identified a crisis in patient safety after a number of serious incidents involving patient harm.
• They saw staff behaviour as the problem, and used a stick-and-carrot approach to encourage staff to change their behaviour.
• A risk of this approach was that of alienating staff who ran up against system-wide problems.

Hospital 2

• An electronic prescribing system helped senior staff identify problems of staff behaviour and the wider system.
• This allowed for a more balanced approach to solutions.
• Some staff were more impacted by improvement efforts than others, and it inadvertently ‘excused’ some groups from work to improve safety.

Hospital 3

• A series of incidents and ‘near misses’ provided a basis for action by managers.
• Senior managers sought to work with frontline staff to understand the problems and their roots, and to agree upon solutions.
• Efforts to improve care used data to inspire staff, while seeking to avoid a punitive approach.

Related content from our open-access series, Elements of Improving Quality and Safety in Healthcare