PATI ENT SAFE T Y
connecting the expert insights stored in incident reporting solutions with other healthcare data systems (like EHRs), will enable healthcare organisations to track insightful and actionable patient safety data. A case in point is the example we discuss in more detail later, where increased admissions in ICU can lead to a corresponding increase in the instance of pressure sores. Monitoring the instance of one, alerts us to prepare for the other. This jump forward in technology, combined with a high reliability culture, will allow organisations to systematically review and analyse their implementation and iterative adjustment of medicines, healthcare tools, procedures and practices to support improved care. The good news is that this is not a new idea.
Getting it Right First Time The Getting It Right First Time (GIRFT) programme aims to bring about higher- quality care in hospitals, at lower cost. It uses national data to identify variations and outcomes. It shares that data with all those concerned with a service – not only clinicians, but also clinical and medical directors, managers and chief executives – and monitors the changes that are implemented.4
A core and essential
element of the programme, according to GIRFT, is that it should be led by frontline clinicians who are expert in the areas they are reviewing. This means the data that underpins the GIRFT methodology is being reviewed by people who understand those disciplines and manage those services on a daily basis. We have learned from the high reliability movement that this type of approach is essential to success when looking to improve organisational procedural governance and an organisation’s risk profile – something that Governance, Risk and Compliance (GRC) programmes in most organisations look to achieve.
In fact, for an organisation to properly
support high reliability principles, the GIRFT programme should be viewed as an expert support team to be used with safety scientists and in-house expert teams. We believe that each participating organisation
Organisations that have systems in place to monitor safety performance are better placed to respond to problems as they emerge.
should have processes embedded in systems that support the effective and consistent investigation of any area of interest. However, these are identified, prioritised and sponsored. In considering this strategy we need to remember Peter Drucker’s words “Culture eats strategy for breakfast”.
Why organisations need to be better at listening A major survey of UK doctors published in late 20185
revealed that most feel they work in a dangerous and toxic environment with a blame culture that jeopardises patient safety and discourages learning and reflection. Previous research indicates that high levels of under-reported patient safety incidents is a clear indicator of poor culture where a system designed to be one of listening and learning is seen as a system of blame, fault identification and regulatory burden. Two of the key attributes of high reliability organisations is that they are sensitive to operations and defer to expertise. Incident reporting is a key tool in listening to the experts, ie. the clinicians and people on the frontline who may not have the most seniority, but have the most in-depth knowledge of the processes involved in the care being provided.
In a high reliability healthcare organisation, everyone is constantly aware of how processes and systems affect patient
Previous research indicates that high levels of under-reported patient safety incidents is a clear indicator of poor culture where a system designed to be one of listening and learning is seen as a system of blame, fault identification and regulatory burden.
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care and, what is, and what isn’t working. This focused attention on processes leads to accurate information to support decision making and to introduce or amend processes where required. Very few patient safety incidents are caused solely by acts or omissions of individual staff. High quality investigations often reveal system issues that need be addressed to prevent similar incidents recurring in the future. However, if staff fear the response to reporting a patient safety incident could be reprimand or blame, this can lead to incidents going unreported. This results in difficulties in analysing and rectifying issues, ultimately increasing the likelihood of similar incidents occurring in the future. Safety reporting systems connect expert carers and specialists with organisational leadership, delivering the insights required to develop a detailed understanding of organisational behaviour and its impact on safety outcomes for patients and operational efficiencies.
‘An organisation with a memory’ Learning from the past is the holy grail of patient safety. A key to achieving this goal is to banish information silos, ensuring that opportunities for developing insights into improving patient care are clearly identified, centralised and triaged, thereby supporting the flow of information through the entire learning cycle. By taking a platform approach, whereby best of breed solutions are connected to provide a gateway to multiple systems that all feed each other, this information can create a transparent learning information system, providing not just the memory, but also the nervous system to help the organisation to learn, develop and apply intelligence as a single high reliability focused entity.
Adopting high reliability theory High reliability culture has been proven to have significant and tangible benefits.
FEBRUARY 2021
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