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Higher order goals

In this video Dr Mike Cooper explains the importance of feedback in improvement
I’m going to describe how we got our clinicians interested, in some cases passionate, about infection prevention and control. We were in a position where we had to reduce our health-care-associated infections. Although we knew it was other infections, mainly C. diff, that had the greatest effect on morbidity and mortality, most of the attention was aimed at MRSA, specifically MRSA bacteraemia, to the national level. In fact, the government even introduced MRSA bacteraemia targets for all hospitals in England. We took the view that our actions had to be aimed at reducing all health-care-associated infections. Because if this was successful, then the number of MRSA bacteraemias would reduce as part of this.
We’d been collecting our data for several years on a number of different infections, so we were able to use this to map our progress. The key thing though, was feedback. Feedback to the senior managers and all consultants being sent a monthly email showing the trends, the number of infections, and the attributions of these infections to individual wards and clinical areas. The staff were encouraged to share these results with all their colleagues, and to put them on display for the patients and the public. The feedback gave direct praise if there was good performance, but a sense of shared responsibilities if the performance was less good.
So if a ward did well, it was recognised as being due to their local actions and for taking ownership of the issue. But if a ward did badly, this was seen as the failure of everyone involved, including the infection prevention team, and also possibly the wider structures of the hospital. As the numbers improved, we had to come up with additional markers of health-care-associated infections, so we made sure that we were producing and feeding back meaningful data. When we compared our more recent data with the historical figures, we could demonstrate the difference in the mortality numbers and the mortality rates from before and after the improvements. So this was fed back to the medical staff.
Now they had always known that health-care-associated infections harmed patients, but because they thought that these infections were inevitable and unavoidable, it hadn’t really registered. So when they saw the direct effect of the actions they had taken, the number of deaths that had been avoided, the effect was startling. The infection prevention team were being stopped in the corridor and congratulated and quizzed about what more they could do. I remember one consultant said the day he first saw the mortality data, he had been due to teach the junior doctors about hypertension, but changed his plans and actually talked about infection prevention and control because he said he realised that this was more important.
We still send the monthly messages out to all the senior staff to maintain their interest and their enthusiasm. We now include other measures like lost bed days and the money wasted through patients being in the hospital just because of potentially avoidable infections. Now I readily admit that a lot of this data is not particularly scientifically robust. But the trends can be compelling, and they do continue to motivate staff and that in itself produces further improvements.

Higher order goals are outcomes that are expected to improve as a result of an intervention.

In this video Dr Mike Cooper explains how he successfully engaged clinicians in his intervention to improve infection control, encouraging a sense of shared responsibility through higher order goals and feedback.

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