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Evidence based management

Although waiting to witness flamingos in flight is a great improvement on pigs, I believe Hadridge and Pow (JRSM 2008;101:7–11)1 understate some of the issues to be addressed before the NHS flock can take to the air. Their exhortation to have more confidence and curiosity, become more connected and show more compassion would seem worthy enough, but their strategy for inducing the cultural change required to ‘sort out’ the health system stops short of describing meaningful action below the layer of high level organizational leaders. This may be an unfortunate emphasis, as previous calls for studies to increase our improvement effectiveness have highlighted issues associated with the inverted power structure of healthcare organizations and the need to explore and understand this dynamic.2 
 
In contrast to Hadridge and Pow, though sharing similar objectives, Keroack and colleagues3 describe how they developed and used a composite index of quality and safety, based on patient-level data and the six attributes of an ideal health system articulated by the US Institute of Medicine: safe, effective, timely, efficient, equitable and patient-centred.4 Keroack et al. looked in depth at 79 US Academic Medical Centres and identified a distinctive set of behaviours and organizational practices which were uniquely associated with the top-performing hospitals. Although themes identified by this group have clear echoes with Hadridge and Pow's ‘four Cs’, the work of Keroack et al. might help further NHS organizational quality improvement in at least two important ways. First, by describing an approach that produces robust evidence supporting the value of specific operational practices it helps address the increasingly heard call for evidence-based management. Second, by encouraging the pursuit of improved healthcare through interventions at levels deeper than senior leadership, it brings a focus to the interface between those in service-line clinical leadership positions and front-line workers. Having experienced healthcare improvement efforts from the perspective of a Medical Director, Clinical Director and front-line clinician, I suspect that effective engagement at this interface may be a crucial factor if NHS improvement is to spread its wings.