Editorial
Authors:   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton, Roseveare Chris 
Published: June 2021

Quality in health care is difficult to measure. Detailed retrospective reviews of patients’ admission records often reveal areas where quality can be improved, but are time consuming and subjective. In our search for simple, reliable and reproducible measures, we end up using surrogate markers; things which we can collect easily, rather true markers of quality in what we achieve. The Society for Acute Medicine quality standards, which have formed the basis of the SAMBA audits over recent years, are no exception to this. The standards stipulate that patients should be assessed using an early warning score on arrival in the AMU, be seen by a clinical decision maker within 4 hours and a consultant within 14 hours, while quality indicators include the proportion of patients being discharged directly from the AMU and 7 day readmission rates. While these can provide a useful benchmark for comparison between units or evidence of improvement over time, they clearly cannot provide a complete picture of the quality of care delivered on the AMU. Timely assessment is important, but undertaking an early warning score does not necessarily mean that an abnormal score was acted upon promptly; rapid review by a ‘clinical decision maker’ is only valuable if an appropriate clinical decision is taken. Consideration for the patient’s experience on the AMU is also a key element in delivering a high quality service. This year’s SAMBA audit included a modified version of the ‘Friends and Family’ questionnaire in an attempt to provide a snapshot of patient experience of acute medical care. The results of this are presented here in the first instalment of the data analysis from SAMBA15. The usual ‘health warnings’ apply to these data – a single day in June is not necessarily representative of the remainder of the year, while not all participating organisations submitted patient experience data, introducing the possibility of selection bias. However some interesting themes emerge, many of which will be familiar to those who have worked (or been patients) on acute medical units. It is encouraging that positive comments outnumbered negative by 3:1, while positive comments about staff attitude were over 40 times more numerous than criticisms, despite recognition of the workload faced by staff on the AMU. Concerns about noise levels and catering were common themes, but the importance of timely assessment and care emerges in both categories; patients clearly appreciate being seen and treated rapidly and are frustrated by delays. Our pursuit of better measures of quality should not lose sight of the importance of measuring, and improving the speed with which we deliver care. The importance of honest feedback is a theme in this month’s ‘viewpoint’ article on ‘bad presentations’ by Ross Fisher; he asks why, when we wouldn’t accept poor quality clinical care, we appear to be so accepting of the poor quality Powerpoint. Apparently it is all our own fault – and of course he’s right. We need to challenge, and be prepared to be critical in our feedback. I am frequently guilty of opening a conference question with ‘I enjoyed your presentation….’, irrespective of the quality of what went before. Ross is an evangelist on this subject, and I am delighted that he has agreed to write a series of articles over coming editions outlining how our presentation practice could improve. How we measure this quality improvement is a challenge for another day.