A blog by Dr Simon Bailey and Adam Brisley, Research Fellows, NIHR CLAHRC Greater Manchester and Alliance Manchester Business School
It is not very often that you hear about the disappearance of a disease. Perhaps new diseases are discovered, or new names are given to old problems, but for one to just disappear overnight is a novel phenomenon.
Our story begins with the introduction of a national incentivisation scheme called Commissioning for Quality Improvement (CQUIN). CQUIN is a time-limited pay-for-performance programme designed to motivate improvement in particular priority areas. When individual NHS organisations like hospital trusts adopt CQUINs, they are given 12 months to reach an agreed standard and set targets for every quarter. If they hit all their targets, they receive the full ‘bonus payment’ offered by the scheme. In 2014, a CQUIN was launched to improve the documentation of acute kidney injury (AKI) in hospitals, particularly with regard to patient discharge summaries.
We are part of a research team that is currently working across several hospital trusts in England to evaluate different approaches to the improvement of care related to AKI. AKI is characterised by a sudden reduction in kidney function. It is identified through a blood test and scored on a scale of severity from 1 to 3. If low severity AKI is treated quickly then it may pose no great threat to the patient’s health. If left untreated however, AKI can progress and become fatal. The target message for those trying to improve AKI is that it is common, costly, harmful, and preventable.
Discharge summaries provide details on illness and treatment and give guidance for the ongoing care of patients outside of hospital. They are a kind of snap-shot, a ‘story-so-far’ document that pieces together a journey that may have taken place over many months. AKI presents particular difficulties when producing such stories. It is unlikely to be the primary reason for admission to hospital and is unlikely to exist in isolation from other problems. It can appear at any time in almost any hospital department. It does not have a dedicated ward, neither is it associated with one particular patient identity. And moreover, AKI does not appear as a set of observable features or characteristics – no lesions or tumours.
Instead, for a case of AKI to be identified, many disparate events, procedures, pieces of information, conversations, and decisions must be brought together from across different times and places and assembled in a co-ordinated manner. This is the key to the mystery of AKI and where the CQUIN enters the story.
The CQUIN for AKI is a way of using the final element in each hospital care pathway – the discharge summary – to retroactively engineer the care process, in effect setting in motion the series of events required to bring AKI into existence. In practice, financial incentives are discussed by managers as financial penalties to be imposed should the organisation fail to live up to its obligation to improve and are used as a potentially powerful means of convincing hospital staff of the importance of this or that intervention. The idea is that this carrot-cum-stick approach will cascade the problem of improvement through the organisation, from senior to middle management right through to the individual clinical staff responsible for making the various changes required. Ideally, the target is set, a deadline is agreed, resources are deployed, meetings are arranged, processes are mapped, risks are identified and mitigated, new systems and processes are designed, decision aids are introduced, and an entire apparatus is established to ensure that AKI is appropriately identified, treated, communicated, and documented.
In practice however, what this means is that the existence of AKI relies on argument, rhetoric, and innumerable small acts of convincing, persuading, and coercing others of the importance of AKI and the CQUIN. These acts and asks exist among many other acts and asks in the moment-to-moment experience of individual staff within hospitals. Staff develop habits and routines to help them order this complex and dynamic world. Any attempt to improve care is an attempt to intervene in this routine and change something. Routines evolve out of habits formed over time, often in response to specific demands or problems. Change is hard and the CQUIN is a very specific and time limited demand. It sets in motion intense activity on the part of staff, but when the time is up, and the target is achieved, what happens? Another target is adopted, and a different series of activities is set in motion. Perhaps these new activities mesh with the existing activities; perhaps, over time, routines change, or perhaps they do not. How are priorities set in such situations? Which targets do we try to hit first? When the incentive to change is based upon a time limited injection of financial resources, prioritisation becomes shaped towards this target. There is an opportunity cost to this prioritisation, as competing priorities are side-lined, targets become obsolete, and events and activities are diverted elsewhere. If objects such as AKI are formed out of such events, then what happens when these events no longer occur?