05 août 2022

Comment gérer les buts contradictoires que nous rencontrons en tentant d’améliorer la qualité et la sécurité des soins ?

Background. Healthcare and other industries have to manage and coordinate a number of different aims and longer-term ambitions. They must maintain quality, manage costs, support and retain the workforce, manage regulatory demands and consider wider societal objectives. These aims are all legitimate, but they are not necessarily aligned, neither in their time frame nor in their nature. Conflicts between aims have a profound influence on the implementation of safety and quality improvement and wider innovation system change. Healthcare leaders understand that these aims may conflict, but the extent and nature of such conflicts have been underestimated. Objective. This paper aims to support medical and nursing leadership and executives in the complex task of managing multiple aims in relation to improvement and innovation. Methods. We drew on our experience and the wider industrial and healthcare literature to find examples of studies and improvement projects with multiple aims and examples of innovation and change in which conflicting aims were apparent. We sought to identify principles that would enable the management of parallel aims and practical strategies that might facilitate implementation. Results. We argue that almost all improvement and innovation in healthcare should address parallel aims, actively seek to articulate these aims and manage potential conflicts between them. We propose four underlying principles to support a more productive approach to the identification and management of parallel aims: embrace multiple aims, consider both short- and long-term aims and ambitions, consider the wider societal context and appreciate that all changes take place within an evolving, dynamic context. In terms of practical actions, we identified five key strategies: (i) identify and monitor the parallel aims and accept that some will conflict; (ii) slow down to accommodate the natural flexibility of the system; (iii) think both the short term and the long term; (iv) expect and endeavour to anticipate some unintended consequences and (v) resist downgrading the project to partial implementation. Conclusions. We have argued that most improvement and innovation, unlike controlled trials, should consider multiple aims. We set out some broad principles and practices to reduce conflict and suggest avenues to manage conflicts and support positive synergies. We suggest that if this is not done, conflicts are much more likely to arise, which will be detrimental to the change process. Articulating the multiple aims and actively seeking to manage them in parallel will promote a more flexible and productive approach to innovation and change.

Commentaire du Dr Marius Laurent (PAQS)

  • Amalberti nous rappelle que la qualité et la sécurité nous conduisent à affronter des buts divers, parfois contradictoires. Les compromis entre les impératifs de qualité et de sécurité, les ressources disponibles, le bien-être ou la sécurité psychologique des travailleurs sont nombreux et parfois inextricables. La médecine basée sur des preuves devrait pouvoir nous aider, pensons-nous, mais le paradigme sur lequel elle s’appuie (identifier et surtout isoler les facteurs contributifs pour pouvoir tirer des conclusions causales) s’avère peu compatible avec l’évaluation de ces compromis. L’EBM s’avère être un outil peu adapté à l’analyse d’un monde complexe : ses conclusions nous laissent trop souvent dans une incertitude qui inhibe les décisions, Berwick le souligne (Berwick DM. The science of improvement. JAMA 2008;299(10):1182-1184). Les auteurs explorent des pistes pour progresser malgré ou grâce à ces buts multiples.
  • Voir lecture critique page 119.

Amalberti R, Staines A, Vincent C. Embracing multiple aims in healthcare improvement and innovation. Int J Qual Health Care 2022;34(1). Doi : 10.1093/intqhc/mzac006.