Dr Azhar Alani, MBChB, MBA
Safety in healthcare is of paramount importance. I have already written about it in Arab Health magazine (1). This article is an extension with the aim to change healthcare culture by encouraging staff to raise their hands and report all medical events to prevent serious ones.
While patients are sometimes forgiving and always understanding, efforts to improve quality of care and patient safety still have a long way to go. Improving healthcare safety is still plagued by fear, gripped by reluctance and crippled by punishment. One reason why this is the case, surveys have shown that only 44% of hospital workers are sure they will not face punishment for their mistakes (2).
Empirical finding: non-harm events herald harm ones.
So, to learn from the empirical finding to address the above observation, one approach will be to encourage staff to be forthcoming and report back all events as and when they occur. If we capture and document all incidents, we will significantly improve safety and quality of care. The benefit of encouragement will be realised in the form of staff self-leadership. They will be empowered to take the initiative to deal with what’s error-prone to avoid mistakes in the first place, and prevent others from falling into similar traps.
Self-leadership is just the starting point, however. By acting as role models for others to follow, and through institutionalizing this forthcoming behaviour, culture change will be the foundation for future continuous. In other words, we need “Mea Culpa” to become the culture within healthcare. (Mea culpa / ˌmeɪə ˈkʊlpə / used when you are admitting that something is your fault. Oxford English Dictionary)
More often than not; however, change won’t happen by itself. We need to introduce methods, tools and even sometimes new technology and systems to embed change within the organization. Having a cross-functional multi-disciplinary team (MDT) will provide a holistic view when conducting root-cause analysis. Once required change is identified, we will need to expedite the implementation phase to avoid running into analysis paralysis. The implementation can be speeded up by starting with a small pilot to experiment in a carefully chosen department to create a fitting blueprint that can be rolled out to the rest of the organisation. Considering the anticipated large volume of data to be captured, and to ensure governance within the process, we may need to deploy an “event management system” to capture and report out on medical events.
Such systems are IT-based and may present challenges, in terms of financial investment, that need to be balanced with the realised benefits. Some hospitals are joining forces to have a common shared EMS where data is pooled in one place and insights and lessons learned, mined through analytics, are shared among all participating parties. Sensitive data is to be dealt with first before any such system is considered, of course.
There are various ways to address this situation, for example “management by walking around” and enhanced staff engagement. Both approaches are win-win methods as, not only will you avoid running into social loafing, you will also ensure all team members contribute. When it comes to patient safety, this cannot be over-emphasized.
• Preventable adverse event: an adverse event judged as unlikely to occur if the individual or system involved in delivery care had followed practices regarded at the time as accepted (that is, non-investigational) or “standard of care.”[NEJM 1991;324:370-6, Med J Aust. 1999;170;411-5, BMJ 2000;320:741-4]
• Error: an act of commission or omission that, based on currently available information, substantially increases the risk for an adverse event. [Eff. Clin. Pract. 2000;3:1-10]
• Quality of care: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. [Med Care. 1985;23:710-22]
• Root-cause analysis: systematic investigation technique that uses information gathered during an intense assessment of an accident to determine the underlying reasons for the deficiencies or failures that caused the accident. [Chigaco: Health Forum Inc, AHA Pr;2000: 155]
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(1) Arab Health article “A Patient Safety Revolution”Arab Health Magazine – July/August 2011 – page 42/43 http://content.yudu.com/A1tvqk/ISSUE4/resources/5.htm
(2) OpenSafety.org http://www.opensafety.org/2011/05/16/perceptions-of-hospital-safety-climate-incidence-of-readmission/
Safety in healthcare is of paramount importance. I have already written about it in Arab Health magazine (1). This article is an extension with the aim to change healthcare culture by encouraging staff to raise their hands and report all medical events to prevent serious ones.
While patients are sometimes forgiving and always understanding, efforts to improve quality of care and patient safety still have a long way to go. Improving healthcare safety is still plagued by fear, gripped by reluctance and crippled by punishment. One reason why this is the case, surveys have shown that only 44% of hospital workers are sure they will not face punishment for their mistakes (2).
What seems to be the problem?
Observation: fear of admitting and owning up to errors is manifest in healthcare delivery environment. Punishment is a hindrance if progress is to be made in patient safety and quality care.Empirical finding: non-harm events herald harm ones.
So, to learn from the empirical finding to address the above observation, one approach will be to encourage staff to be forthcoming and report back all events as and when they occur. If we capture and document all incidents, we will significantly improve safety and quality of care. The benefit of encouragement will be realised in the form of staff self-leadership. They will be empowered to take the initiative to deal with what’s error-prone to avoid mistakes in the first place, and prevent others from falling into similar traps.
Self-leadership is just the starting point, however. By acting as role models for others to follow, and through institutionalizing this forthcoming behaviour, culture change will be the foundation for future continuous. In other words, we need “Mea Culpa” to become the culture within healthcare. (Mea culpa / ˌmeɪə ˈkʊlpə / used when you are admitting that something is your fault. Oxford English Dictionary)
Frontiers of Patient Safety: Front-line Staff
Frontline staff team (FLS) are at the focal point of healthcare delivery and information flow. They are the single most important team to work with when it comes to improving patient safety. FLS team are in direct contact with patients and they spend the most time interacting and caring for them. This group includes all non-manager work-force who are working with patients day in, day out at the bedside, on the ward, in labs, pharmacies and ancillary services. By focusing on FLS and encouraging them to report near misses and unsafe conditions, we can take timely corrective actions to avoid serious injuries. Admittedly, it’s not an easy endeavour and would require perseverance and patience.The Power of Mea Culpa
The aim is to move from considering error reporting a task to help all involve to recognise it as a duty. That’s the cultural change we are trying to achieve. Mea Culpa takes a bottom-up approach and starts at grass-roots level to ensure ownership. It embodies self-leadership by encouraging taking the initiative, and demonstrates leading-by-example through becoming role models for others. Mea Culpa encourages learning by bridging the gap between knowledge and know-how, and it empowers staff to voice their concerns. There is nothing more hands-on than raising the hand. It’s not “Project of the Month,” though. This is change for good and for the betterment of all involved.More often than not; however, change won’t happen by itself. We need to introduce methods, tools and even sometimes new technology and systems to embed change within the organization. Having a cross-functional multi-disciplinary team (MDT) will provide a holistic view when conducting root-cause analysis. Once required change is identified, we will need to expedite the implementation phase to avoid running into analysis paralysis. The implementation can be speeded up by starting with a small pilot to experiment in a carefully chosen department to create a fitting blueprint that can be rolled out to the rest of the organisation. Considering the anticipated large volume of data to be captured, and to ensure governance within the process, we may need to deploy an “event management system” to capture and report out on medical events.
Such systems are IT-based and may present challenges, in terms of financial investment, that need to be balanced with the realised benefits. Some hospitals are joining forces to have a common shared EMS where data is pooled in one place and insights and lessons learned, mined through analytics, are shared among all participating parties. Sensitive data is to be dealt with first before any such system is considered, of course.
Social Loafing
Social loafing is the tendency of individuals to put forth less effort when they are part of a group. Because all members of the group are pooling their effort to achieve a common goal, each member of the group contributes less than they would if they were individually responsible. While we focus on team work, and we all understand that today healthcare delivery is a function or organization design and not the product of individual effort, we need to pay close attention to prevent social loafing from ensuing within work environment.There are various ways to address this situation, for example “management by walking around” and enhanced staff engagement. Both approaches are win-win methods as, not only will you avoid running into social loafing, you will also ensure all team members contribute. When it comes to patient safety, this cannot be over-emphasized.
Appendix - Medical Errors: Definitions
• Adverse event: an injury or complication caused by medical management that prolongs hospital stay or produces lasting disability or death.[NEJM 1991;324:370-6, Med J Aust. 1999;170;411-5, BMJ 2000;320:741-4]• Preventable adverse event: an adverse event judged as unlikely to occur if the individual or system involved in delivery care had followed practices regarded at the time as accepted (that is, non-investigational) or “standard of care.”[NEJM 1991;324:370-6, Med J Aust. 1999;170;411-5, BMJ 2000;320:741-4]
• Error: an act of commission or omission that, based on currently available information, substantially increases the risk for an adverse event. [Eff. Clin. Pract. 2000;3:1-10]
• Quality of care: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. [Med Care. 1985;23:710-22]
• Root-cause analysis: systematic investigation technique that uses information gathered during an intense assessment of an accident to determine the underlying reasons for the deficiencies or failures that caused the accident. [Chigaco: Health Forum Inc, AHA Pr;2000: 155]
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(1) Arab Health article “A Patient Safety Revolution”Arab Health Magazine – July/August 2011 – page 42/43 http://content.yudu.com/A1tvqk/ISSUE4/resources/5.htm
(2) OpenSafety.org http://www.opensafety.org/2011/05/16/perceptions-of-hospital-safety-climate-incidence-of-readmission/
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