Introduction to Quality and Safety Flashcards
Define harm, sentinel event and serious harm
- Adverse event – Institute for Healthcare Improvement (IHI)
Unintended physical injury resulting from, or contributed to by, medical care that requires
additional monitoring, treatment or hospitalisation, or that results in death (eg DVT/PE,
pressure sore, fall, infection) - Sentinel event – Australian Commission on Safety and Quality in Healthcare
Adverse patient safety events that are wholly preventable and result in serious harm to, or
death of, a patient – eg wrong side surgery (Never Event). - Serious harm –
- Requires life-saving surgical or medical intervention, or
- Has shortened life expectancy, or
- Has experienced permanent or long-term physical harm, or
- Has experienced permanent or long-term loss of function
Note: patients are often harmed by medical cate, often preventable (50%).
what is the biggest challenge in making the health system more safe?
”“…the biggest challenge to moving toward a safer health system is
changing the culture from one of blaming individuals for errors to one in
which errors are treated not as personal failures, but as opportunities to
improve the system and prevent harm”
Describe some stats related to adverse effects
- 5.4% of hospital admissions are associated with an adverse effect
- almost double in public settings
- 9.7% of emergency vs 3.9% in non-emergency
- the 14th leading cause of morbidity and mortality worldwide (As per WHO)
Provide some reasons for the lack of acknowledgement of harm in healthcare
- not dramatic i.e. no fiery wreck
- cognitive bias
- very low self-reporting
What is a narrative? How might tackling narratives improve healthcare?
Narratives are socio-culturally based mental models informing how we perceive, interpret and respond to events. There are several narratives surrounding harm in medicine that must be modified:
- fatalistic vs preventable
- problems and solutions are simple vs. complex
- individual autonomy vs. organisational or systemic accountability
- organisational responsibility vs collective or standardised
- one issue at a time vs integrated system improvement
- patients and carers are passive victims vs. participants or advocates
Distinguish between quality and safety
The aim of safety is to avoid catastrophe, and inspired by high-risk industries. Safety improvement is difficult and complex.
Based out of a philosophy of industrialisation. Triggered by international symposium on preventable anaesthesia mortality and morbidity.
Describe how the structure of health systems affects how we tackle errors
Most accidents and failures do not arise from a single cause, or the actions of a single individual, but instead small events link together and expand.
As a result, complex systems cannot be completely understood or controlled.
Additionally, errors are difficult to predict and prevent.
Note 2:
Healthcare is a complex adaptive system, not a production line. Thus:
- a complex adaptive system is comprised of multiple autonomous interdependent individuals
- thus emerging behaviour is unique and surprising
- adverse effects are due to a confluence of intersecting factors, rather than sequential domino effects
- Note: problem with RCA
- Normal accident theory - complexity theory
- Keep rules simple (principles) and trust adaptive behaviour
- In a complex, uncertain, ambiguous and dynamic environment, focus must shift from eliminating error to enhancing adaptive response capabilities
Describe how quality and safety is regulated in Au
Oversight of practitioners occur at 3 levels:
- specialist college standards
- healthcare organisation
- AHPRA or Boards
Note: distribution of complaints – small minority accounts for majority of complaints
Oversight of organisations:
- Australian commission on safety and quality n healthcate
- NSQHS
- ACHS
Define and describe culture and organisational culture
Culture can be thought of as the foundation of the social order that we live in and the
rules we abide by.
* A shared system of coercive influence that both enables and constrains our behaviour.
* Culture helps people work together cohesively by creating a sense of identity for a
shared understanding and commitment to purpose.
* Culture influences what we notice and pay attention to, how we respond to events, and
how we assess and manage risk.
* Culture evolves as a group solves problems together.
* Culture evolves both bottom-up and top-down.
* The attraction – selection – attrition model.
* Cultural strength = resistance to change.
Organisatonal culture can be divided into three levels:
- Visible artefacts: how we do things around here. Conscious, explicitly taught, objective, justifiable processes and procedures.
- Espoused values: statements of vision and purpose. Beware the hidden culture
- Basic assumptions: deeply held beliefs. They are unconscious and unchallenged. Implicitly learned ways of viewing and interpreting events
Artefacts are easy to observe but difficult to understand or explain without appreciation of deeper levels of culture. Culture exists as a coherent whole, incorporating all three levels.
Describeb the concept of safety culture
The concept of safety culture originated outside health care, in
studies of high reliability organisations (HROs) that consistently
minimise adverse events despite carrying out intrinsically complex
and hazardous work.
* acknowledgment of the high-risk nature of an organisation’s activities and the
determination to achieve consistently safe operations
* a blame-free environment where individuals are able to report errors or near
misses without fear of reprimand or punishment (just culture)
* encouragement of collaboration across ranks and disciplines to seek solutions
to patient safety problems
* organizational commitment of resources to address safety concerns
What are some example definitions of safety culture?
AHPRA - What is a true culture of safety? It engages the perspectives
of patients and families. When harm happens and it’s not disclosed,
my analogy is it’s like it’s a hit-and-run … you’re harmed, and people
don’t even look back: they pretend like it didn’t happen
* The Commission - A positive safety culture is one where barriers to
doing a good job are removed. It is characterised by a collective focus
on patient safety, mutual trust among staff, shared responsibility for
safe care delivery as well as confidence in leadership’s commitment to
patient safety.
Note:
organisational cultrue is crucial for patients safety
How can safety culture be improved?
Safety culture can be deliberately and meaningfully improved.
Key elements include:
* Leadership – continuous quality improvement
* Teamwork – safety 1 and safety 2
* Communication – formal standardised formats
* Just culture – adverse event investigation
* Psychological safety – flat hierarchy gradient
* Civility - professionalism
Describe professionalism
Professionalism
is an abstract concept and often defined by its absence. It can inclde intrisinc characteristsics, and can be reinforced with explicit and implicit learning.
It encompasses:
* Social contract
* Ethical behaviour principles
* Competency
* Identity - professionalism as culture (basic assumptions)
Professionalism can be taught
* Explicit Vs Implicit (the hidden curriculum)
* Formal instruction in professional values / rules
* The code of conduct
* describe what is expected of all doctors in Australia
* set out the principles that characterise good medical practice
* make explicit the standards of ethical and professional conduct expected by
doctors by their professional peers and the community
* Rationale for upholding professionalism
* Centralise to decentralize
* Control with culture (Perrow 3rd order control)
