Editorial |
Make it boring
E. G. Jessop
Editor, Journal of Public Health
We published a paper online on 5 April 2006 (scheduled for our September issue) looking at outcomes after hip and knee replacement in hospitals in England.1 Andy Judge and colleagues used the Hospital Episode Statistics database to analyse predictors of adverse outcomes. These included 30-day in-hospital mortality and revision surgery within 5 years. The key observation was that centres which did many hip or knee replacements, and training centres, had fewer adverse outcomes.
Any study based on routine data does of course have many limitations (which the authors acknowledge in their discussion). Indeed some commentators doubt whether we can learn anything from this type of study.23
But the extraordinary thing about Judge’s findings, if we accept them at face value, is that they are not describing some rare surgical procedure undertaken in an emergency in mortally ill patients. On the contrary, joint replacement is one of the commonest operations in orthopaedic practice. For this common procedure, centres which did more got better results.
Even more remarkable is the fact that the results went on getting better across five categories of annual volume: 1–50, 51–100, 101–250, 251–500 and >500. So, results continued to improve up to levels 10-fold higher than the ‘50 per year’ threshold of national guidance for, say, breast cancer.4 At over 10 hip replacements per week for 50 weeks of the year, the operation must become not merely routine but, one might think, boringly so.
All of this made me wonder: what if this phenomenon applies to those of us who practice not orthopaedic surgery but public health?
The UK has done well over the past few years in concentrating expertise for the rare and difficult problems of public health practice: a possible case of rabies, a cluster of a radiation-induced cancer or a general practitioner (GP) accused of sexually assaulting a young patient. In the past, we muddled through with a one-off ad hoc response to problems such these. Nowadays at organizations such as the Centre for Infections at Colindale, the Small Area Health Statistics Unit and the National Clinical Assessment Service, we have well-practiced teams ready to respond.
But these examples are the heart transplants of public health practice, not the hip replacements—what about common problems of health protection, health promotion, commissioning or health intelligence? What elements of our practice do we do often enough to be bored by them? Gaining direct evidence on volume and quality in public health practice is almost impossible, except perhaps in one or two specifics—we may in theory be able to show that well-practiced teams achieve higher quit rates in smoking cessation or better media penetration in public campaigns. But most of what we do is not susceptible to such analysis. Perhaps we should merely observe that if the orthopaedic example applies to public health practice, then the general direction of our latest NHS reorganization in England towards larger public health organizations, with a greater volume of work, should lead to better outcomes.
Judge et al. also found that the results were better in training centres.1 They speculate that the standardization of procedures may account for their finding. This accords with doctrine in manufacturing industry where reducing complex operations to a standard set of procedures is the first step in achieving ‘six sigma’ quality. Nothing is left to chance and nothing to the initiative of an employee. The key to success is everyone doing the same thing every time without fail. Marriott has a famous procedure for cleaning a hotel room—66 steps, takes 30 min, guarantees a clean room.5 This may seem excessive, but have you ever seen a dirty Marriott room?
All of which may seem to be a recipe for low job satisfaction: repeat endlessly and leave no scope for individuality—make it boring. But if this is the price of success, we should pay it.
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References |
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 TOP References |
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- Judge A, Chard J, Learmonth I et al. The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England. J Public Health [Advance access doi: 10.1093/pubmed/fdi003].
- Sheldon TA. The volume-quality relationship: insufficient evidence for use as a quality indicator. Qual Saf Health Care 2004;13:325–6.
[Free Full Text] - Sowden AJ, Sheldon TA. Does volume really affect outcome? Lessons from the evidence. J Health Serv Res Policy 1998;3:187–90.[Medline]
- National Institute for Clinical Excellence. Improving Outcomes in Breast Cancer. Manual Update. London: NICE, 2002.
- http://www.govleaders.org/reframing_the_conversation1.htm [19 April 2006, date last accessed].
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