Week 2 Flashcards
Improving the quality and safety of care setting the scene
Evolving evidence on the scale and nature of the problem
Changing thinking about the sources or causes of the problem
Developing interventions to tackle the problem
Evidence of harm
1 in 10 10% hospital in patients of which 10-13% experience death (1-1.3%)
Estimated fourth leading source of death after heart disease and cancers
These are all estimates extrapolated from data with variable sample size and using retrospective reviews
Growing consensus suggests that around 10% of patients admitted to hospital experience some type of adverse events that would prolong their care result in disability or even cause death
‘Bad apples’- bad people
Individuals who are malevolent and intent are causing harm
Individuals who are poorly trained or skilled
Individuals who are past their best
‘Bad barrels’- problem systems
Bad behaviour can flourish because of ‘bad barrels’ or systems
Fail to detect and exclude bad apples
Provide conditions for good apples to turn bad
The old way of thinking
Errors and risk are inevitable feature of medicine- there but for the grace of god
Individuals and teams can have bad days
Individual skills will depreciate over time
There will always be bad apples need for regulation
A new way of thinking
Mistakes and safety issues are rarely the fault of individuals or teams alone
A range of factors enable or exacerbate the potential for things to go wrong
Refocus attention away from bad apples to bad barrels -the system factors
Human error
Deliberate- non compliant violations
Unintentional:
-execution error: attention based, memory based
-thinking error: rule based mistake, knowledge based mistake
Understanding the roots of safety
Active errors: are the sharp end of individual performance, decision making or cognition
Latent errors: are located upstream in the environment or work organisation and influence how individuals perform
Swiss cheese model
Active errors: patient safety incident
Latent conditions: poor design, procedures, management decisions etc
Root causes in healthcare
Institutional context factors
Vincent’s framework
Patient characteristics: complexity of condition, language etc
Task factors: design, clarity, availability of rules, accuracy of task
Individual factors: knowledge, skills, motivation etc
Team factors: communications, decision making, supervision, clarity of roles
Work environment: staff levels, skills mix, shift patterns, equipment management
Organisational and management factors: finance and resources, structures and process, cultures, policies and procedures
Institutional contexts: economic, regulatory context
Towards systems thinking
Quality and safety breaches often associated with poor and erroneous performance in the clinical micro system
-Incompetent, underskilled, outdated or malevolent professionals
-Poor team work
Individual blame and discipline has two immediate problems;
-discourages openness and conceals evidence
-neglects systems factors and reinforces individual factors
Bristol royal infirmary
29 babies died during cardiac procedures between 1980s and 1990s
Focus on the culture and regulation of medicine, re: substandard performance
-old boys network
-culture of secrecy
-lack of external monitoring
-lack of transparency with families
Key recommendations:
-patients should be more involved in decisions
-more systematic and external forms of appraisal and performance review
-more explicit concern with patient safety
Harold shipman
Estimated to have killed over 200 patients over 20 years
Wide ranging inquiry- 5 reports
-regulation primary care
-regulations of controlled drugs
-the role of other agencies such as coroner
Fifth report:
-GMC prioritised the profession over patients
-need for culture change
-more robust, external and transparent forms of regulation
-sharing of information between agencies
Mid Staffordshire
Substandard performance and unsafe care esp in A&E between 2005-08
Key findings:
-27-45% higher mortality rates
-patients neglected poor assessed and poorly treated especially elderly
-staffing-overstretched and poorly trained
-priorities-meetings targets and resources constraints at the expense of safety
-trust was rated as excellent by healthcare commission
Hitting target missing the point
What do inquiries do
Determine the significance and causes of an event
Allocate responsibility and blame
Make recommendations for change
Expression of public outcry and cathartic outlet
Ritual of re legitimation (or whitewash) be seen to do something
What do inquiries show
Regulatory failure- why did no one stop it happening
Organisational ‘goal displacement’ -why was care not valued
Dysfunctional cultures- why is safety not valued
Unsafe or unchecked behaviours- why did they act like that
Continuing problems (Berwick 2013)
NHS staff not to blame- it is the systems and constraints they face that lead to patient safety problems
Reassert the primacy of working with patients and carers
Use quantitative targets with caution not displacing better care
Ensure responsibility for safety and improvement are vested clearly
Give the people of the NHS career long term help to learn, master and apply modern methods for quality control, improvement and planning
Make sure pride and joy in work, not fear, infuse the NHS
Recommendations include Berwick
To improve training and education
Mastery of quality and safety sciences for all staff
The NHS should become a learning organisation
Supervisory and regulatory systems should be clear
All incentives should point in the same direction
Impact of Berwick report
One year after the report a survey found that training and support for staff to improve the processes of care was the area where least progress had been made (health foundation et al 2014)
Much remains to be done to support the ambition that the NHS should become a learning organisation committed to continuous improvement
Reliance on regulation and inspection as the mainstays to promote safety and quality has increased
The cycle of fear described in the Berwick report stronger than ever and hinder the development of the learning culture it advocated
National reporting and learning system
Incident reporting: staff document and communicate experience, foster reporting culture
Stratify and analyse incident data: determine the significance of events, determine the underlying causes
Learning and improvement: develop local and system wide recommendations, action and audit change
Reporting safety events
Reporting systems common in other sectors
Standardised documentation and sharing of frontline events
Enables greater understanding of individual events from which to develop aggregate understanding of common safety issues
Barriers to reporting
Practical barriers to incident reporting: access to computer/paperwork, time and resources
Prgamatic barriers: purpose and role of reporting, why do it, who does it benefit
Classification barriers: what to report and in what ways
Feedback and communication barriers: lack of positive reinforcement
Cultural barriers: fear of punishment
Cultural barriers: beyond blame
Emphasis on creating a safety or reporting culture- move away from blame culture
Blame and fear still big factors
Inevitability and normalisation of harm
Taboos and codes of conduct
Protecting reputation
Concerns about bureaucracy
Concerns about management control
The problem of culture change
Cultures not easily managed (nor are they genetic)
Cultures are not acquired through conditioning
Rewards and incentives are a very basic (poorly aligned) way of shaping culture (lack of meaning)
Meaning in the reward not in the behaviour it aims to produce
This is important for patient safety
