PATI ENT SAFE T Y
Following NHS reforms to create a culture of openness and transparency, research found that open culture was indeed associated with lower mortality rates in hospitals. This approach is encapsulated by ‘Communication and Optimal Resolution’ (CANDOR) processes. Generally, the CANDOR process begins with identification of an event that involves harm and proceeds through response and disclosure, through investigation and analysis, to final resolution.7
To support safe outcomes the
gathering and analysis of data needs to be targeted at the correct areas and measures. Research8
has shown that the three major components in encouraging a safety culture are: l A just culture. l A reporting culture. l A learning culture.
What makes a just culture? NHS England and NHS Improvement have published a guide that advocates a ‘just culture’. A just culture is fair treatment of staff that supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented. With the five
principles of FREDA (Fairness, Respect, Equality, Dignity and Autonomy on which all international human rights treaties are based) being used by the CQC to regulate health and social care services, staff should feel confident to report incidents and give open and honest feedback when responding to staff surveys. Analysis of mortality and high harm events should investigate details such as whether an event was reported earlier, communications with staff and patient or relatives was prompt, leading to an outcomes assessment. None of this is possible, if staff do not feel confident to report in full when something does go wrong.
Reporting culture in high reliability organisations
High reliability healthcare organisations that have succeeded in reducing patient harm take a positive approach to reporting. By gathering information diligently, deferring to expert opinion (specialists, safety scientists and frontline staff), and with intelligent analysis of all the data gathered, trends and causal effects can be identified. These can lead to identifying likely harm scenarios before they happen. An example of this (referred to earlier) is the reduction of pressure sores in ICU patients. Reporting systems need to be sufficiently
sophisticated that as well as reporting volumes and sensitivity, they support investigation team structure, investigation quality and provide actionable risk centric control suggestions.
The same connected system should also provide control implementations and tracking. An example of this in action – in 2018, a project was initiated by the Joint Commission Center for Transforming Healthcare in the US, where they worked with three hospitals to find root causes and solutions to pressure injuries. From May 2018 to December 2019, the hospitals saw an average 55% reduction in pressure injuries in the intensive-care unit. From January to April 2020, the hospitals reported an average 62% reduction.
Creating a learning culture When introducing any new system, team engagement in the development of changes in organisation process and policy is a key to success. Involving frontline staff, listening to their views, encouraging staff advocates for new systems all help to increase engagement with new systems. Positive executive engagement in reviewing new processes and rewarding engagement further reinforces the value of new processes.
One of the key points noted early on in the Joint Commission Center for
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