Downloaded from http://heart.bmj.com/ on November 14, 2015 - Published by group.bmj.com

Editorial

The gift of failure: learning to provide better cardiac care Alexander M Clark To many, the 2-week ‘SNAPSHOT’ of patient care patterns across Australia and New Zealand1 will appear a picture of systems-wide failure. The results are likely to be of concern not only for the health professionals of these countries but also their general public, governments and media. Why, given the heavy weight of persuasive evidence supporting the best pharmacological and non-pharmacological interventions for acute coronary syndrome (ACS) patients, was suboptimal cardiac care so dominant in the 2 weeks studied? Across two wealthy countries with wellfinanced health systems, how can optimal cardiac care be provided to only three out of four patients—and be even worse for those patients who are more prone to heart disease, notably older adults? That large numbers of citizens may suffer unnecessarily due to poor and unequal cardiac care is not ethically or economically acceptable. Yet, whether and how the results reported by the research come to improve patient care will be determined less by the results themselves but by how people and their organisations choose to respond.

HARNESSING FAILURE BETTER Far from being associated with fear and incompetence, modern organisations increasingly see failure to achieve intended outcomes not only as being important to capture with data but also as being integral to subsequent learning and improvement.2 This is important because in spite of efforts and intentions to specifically avoid it, failure occurs often, in many different forms, and for all manner of reasons.2 3 Past successes and talent bring no guarantee future failure will be avoided and no one person or organisation—from Blackberry to Steve Jobs—is immune from its reach. Yet, despite its usefulness and dominance across biological, organisational and economic systems, failure remains mostly wasted.2 3 Predictable, yet unproductive responses to the inadequacies that SNAPSHOT describes are likely to arise from a myriad Correspondence to Dr Alexander M Clark, Faculty of Nursing, University of Alberta, Level 3 Clinical Sciences Building, Edmonton, Canada T6R 2R6; [email protected]

of minor technical objections that, taken together, could act to undermine its key messages. For example, concerns will be raised that the SNAPSHOT methodology adopted too lofty a bar for ‘optimal’ and ‘basic’ care, that most eligible patients do not attend centre-based cardiac rehabilitation or that large studies like SNAPSHOT ignore justified variations in clinicians’ prescribing practices for individual patients or the influence of contextual factors on care and outcomes. Such responses do not tally with other evidence. Moreover, the inequalities described in the study1 are echoed elsewhere4: marked variations in cardiovascular care exist across hospitals and jurisdictions in the same settings. These responses exemplify the folly of dismissing failure. Despite the seeming neutrality of science and scientists, being overly concerned with appearing successful is damaging.5 ‘For most of us, failure comes with baggage,’6 Ed Catmull, the President of Pixar Animation and Disney Animation concludes as he tells of a key ingredient of Pixar’s unprecedented levels of ongoing critical and commercial success: failure is confronted often, openly and constructively during, after and across its projects.6 How then can the patterns captured by SNAPSHOT be used to improve the future for people with heart disease from Australia and New Zealand?

TOWARDS GREATER SERVICE DIVERSITY There has never been a better case to support diversity in the provision of effective secondary prevention services. Persuasive evidence exists from meta-analysis that patients can benefit from both medicines and health services for secondary prevention (including cardiac rehabilitation and clinic-based counselling) irrespective of age, sex, disease status and location.7 Services need to be closer and more accessible to all eligible patients. A quicker and more widespread move is needed from funding less accessible centralised cardiac rehabilitation services towards supporting a wider range of online, remote and community-based programmes. To increase access, referral should be automated and patients should be able to access the specific type of cardiac rehabilitation service they want as soon as is safe and possible. Clark AM. Heart August 2014 Vol 100 No 16

TOWARDS HIGHER SERVICE INTEGRATION Fully acknowledging failure requires individuals and their organisations to not only recognise that problems exist but to do so head-on and with authentic and honest reflection on how they have each contributed to failures and can support better care.8 It is encouraging that in some parts of Australia, health professionals and services from across the disciplines providing cardiovascular care in acute hospitals are now working towards more fully integrated, linked and accessible secondary prevention services. This involves close collaboration between government and service providers in family medical settings and the community and government in constructing care pathways.9 Evidence is necessary but insufficient to motivate practice change—the relationships and pathways established by this network of collaborators provide an important driver for supporting the patient’s journey across health sectors and services. Similar ‘networking’ initiatives are needed across Australia and New Zealand and these should prioritise how healthcare providers can work more effectively in forming integrated secondary prevention care services to reverse the adverse trends identified by SNAPSHOT.9 Patient access to effective services must come first and eclipse parochial and self-interested concerns about financial remuneration, role expansion and clinical territory.

TOWARDS SYSTEMS THAT DO ‘SIMPLE’ THINGS WELL One of the most startling elements of SNAPSHOT1 is the contrast between the high-quality of evidence supporting its package of optimal care with the relative infrequency of how often this care was provided to patients. Ongoing misjudged paternalism and misplaced scepticism over whether patients who are referred will subsequently attend cardiac rehabilitation may account partially for why too few patients used cardiac rehabilitation services but cannot account for the inadequacies in prescribed pharmacological regimen. Clinicians involved in providing cardiac care may overly privilege ‘latest’ treatments and innovations in pharmacological management to the neglect of the less alluring but more established and supposedly ‘basic’ pharmacological care. The SNAPSHOT findings present a compelling case of the need for providers to do a smaller number of simple things much better: systems are needed to ensure that it is difficult for individual clinicians not 1221

Downloaded from http://heart.bmj.com/ on November 14, 2015 - Published by group.bmj.com

Editorial to prescribe key medicines for each patient and refer all eligible patients to cardiac rehabilitation. Local comparisons should be made between providers around key performance indicators constituting optimal care in SNAPSHOT—and these data should be made available for government and the general public. These indicators may be used in conjunction with fee for performance models of remuneration that have worked in the UK. The world’s most successful organisations fail and do so unpredictably but with surprisingly regularity.3 6 Yet, their ongoing and wider success is better guaranteed precisely because these organisations and their people are open to failure and the gifts that truly and authentically learning from failure can bring. These organisations build in time to openly reflect and discuss failure and in doing so, seek contributions from all involved irrespective of internal roles and supposed status.6 Far from being associated with weakness, inadequacy or incompetency, reflecting, discussing and acting on failure requires candour, courage and creativity

1222

from both individuals and their organisations.6 Learning the failures of SNAPSHOT must come first and will be integral to improvement and success.2 6

2

Competing interests None.

3

Provenance and peer review Commissioned; internally peer reviewed.

4

5

To cite Clark AM. Heart 2014;100:1221–1222. Published Online First 13 June 2014

6

7

8

▸ http://dx.doi.org/10.1136/heartjnl-2013-305296 9

Heart 2014;100:1221–1222. doi:10.1136/heartjnl-2014-306114

REFERENCES 1

referral to rehabilitation among acute coronary syndrome (ACS) inpatients: results from a large prospective audit in Australia and New Zealand. Heart 2014;100:1281–8. Clark AM, Thompson DR. Successful failure: good for the self and good for science. J Adv Nurs 2013;69:2145–7. Omerod P. Why most things fail….and how to avoid it. London: Faber and Faber, 2005. Chew DP, French D, Briffa TG, et al. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013;199:185–91. Clark AM, Thompson DR. Heart failure disease management programmes: a new paradigm for research. Heart 2012;98:1476–7. Catmull E. Creativity, Inc: overcoming the unseen forces that stand in the way of true inspiration. New York, NY: Random House, 2014. Clark AM, Hartling L, Vandermeer B, et al. The merits of shorter, generalist secondary prevention programs based in primary care: Results from a meta-regression. Eur J Cardiovasc Prev Rehabil 2007;14:538–46. Stone D, Patton B, Heen S, et al. Difficult conversations: how to discuss what matters most. New York, NY: Penguin, 2010. National Heart Foundation of Australia. Secondary prevention of cardiovascular disease: Nine key areas for action. A call to action to improve the health of Australians. Canberra: National Heart Foundation of Australia. http://www.heartfoundation.org.au/ SiteCollectionDocuments/Secondary-Prevention-ofcardiovascular-disease.pdf

Redfern J, Hyun K, Chow D, et al. Prescription of secondary prevention medications, lifestyle advice and

Clark AM. Heart August 2014 Vol 100 No 16

Downloaded from http://heart.bmj.com/ on November 14, 2015 - Published by group.bmj.com

The gift of failure: learning to provide better cardiac care Alexander M Clark Heart 2014 100: 1221-1222 originally published online June 13, 2014

doi: 10.1136/heartjnl-2014-306114 Updated information and services can be found at: http://heart.bmj.com/content/100/16/1221

These include:

References Email alerting service

Topic Collections

This article cites 4 articles, 1 of which you can access for free at: http://heart.bmj.com/content/100/16/1221#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.

Articles on similar topics can be found in the following collections Drugs: cardiovascular system (8469)

Notes

To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/

The gift of failure: learning to provide better cardiac care.

The gift of failure: learning to provide better cardiac care. - PDF Download Free
492KB Sizes 2 Downloads 3 Views