PATI ENT SAFE T Y


Transforming Healthcare study was that the hospitals had made improvements in the past, but were unable to sustain them. Since the project began, there has been a culture shift and a focus on education where frontline staff are now doing everything in their power to prevent pressure injuries. Kaiser Permanente South Sacramento Medical Center,9


a 200-bed community


hospital that is taking part in the programme, has sustained its nearly 60% reduction in pressure injuries even through the COVID-19 pandemic when patients in the ICU are typically hooked up to devices for weeks.10


Systemisation of the process The CQC document states: “We’ll expect to see proper processes and frameworks to show how people are being involved, and evidence to prove this is happening.” It also states that the CQC will intervene much sooner to assure itself that that services are focusing on protecting people before they experience poor care and avoidable harm. Care organisations need to have the systems in place to support staff in safe processes. They can achieve this by: l Adopting systems that are designed for the purpose of collecting data on risks, incidents, investigations, claims and feedback. Such a solution provides an audit trail, showing compliance as well as providing the means for staff to report safety concerns in a blame-free setting. Relying on spreadsheets provides no audit trail of information and no central repository for reliable data.


l Choose a best-in-class solution from an experienced and trusted source, that has the breadth and depth to manage all information, and ensure that it is stored centrally, making it easily accessible for analysis of trends and causal effects.


l Join a community for sharing best practice in patient safety, risk and quality management. Build connections across the health sector that will enable you to share experience and to learn from other organisations.


If healthcare organisations can step back, review patient safety and in so doing, ask their frontline staff what they think, they may find that providing them with a voice is a meaningful move towards better patient safety and all the benefits that that entails – for everyone.


Not just lives saved


One of the key points in the CQC document is that stronger safety cultures should result in a vision where there is zero avoidable harm. There are other similarly compelling benefits including: l Reducing staff burnout – Having a process that enables people to report incidents truthfully without blame or fear


High reliability culture has been proven to have significant and tangible benefits. Following NHS reforms to create a culture of openness and transparency, research found that open culture was associated with lower mortality rates in hospitals.


of recrimination not only reduces stress on staff, already heightened by COVID-19 and a key factor in staff burnout, it enables the organisation to learn from mistakes. Reducing staff burnout also means fewer staff leaving the profession and taking with them many years of valuable experience.


l Cost and resource savings – The cost of additional treatments and care for patients that have suffered avoidable harm goes into many £millions per year, and so too does the cost of legal action from victims.


Just a small improvement in patient safety for procedures that are performed thousands of times per year means the risk is reduced and lives will undoubtedly be saved. The change in approach to pressure sores in ICU is just one such example, and one that is likely to be quite pertinent as hospitals deal with increased patients in ICU due to COVID-19.


CSJ


References 1 Department of Health & Social Care, Busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in the health and care system in England, Updated 24 November 2020, accessed at: https://www.gov.uk/government/consultations/ reducing-bureaucracy-in-the-health-and- social-care-system-call-for-evidence/outcome/ busting-bureaucracy-empowering-frontline-staff- by-reducing-excess-bureaucracy-in-the-health- and-care-system-in-england


2 KaiNexus Blog, Five Principles of a High Reliability Organization (HRO), 18 March 2019, accesed at: https://blog.kainexus.com/improvement- disciplines/hro/5-principles


3 CQC’s draft strategy for discussion, accessed at: https://cqc.citizenlab.co/en-GB/projects/cqc-s- draft-strategy-for-discussion.


4 King’s Fund, Tackling variations in clinical care: assessing the Getting It Right First Time (GIRFT) programme, 28 June 2017, accessed at: https:// www.kingsfund.org.uk/publications/tackling- variations-clinical-care?gclid=EAIaIQobChMIg7_ Mkbey3QIVqrDtCh35ewn1EAAYASAAEgLv4PD_BwE


5 Survey of UK doctors highlights blame culture within the NHS,


6 BMJ, 20 September 2018, accessed at: https:// www.bmj.com/content/362/bmj.k4001.full


7 KaiNexus Blog, Five Principles of a High Reliability Organization (HRO), 18 March 2019, accesed at: https://blog.kainexus.com/improvement- disciplines/hro/5-principles


58 l WWW.CLINICALSERVICESJOURNAL.COM


8 Communication and Optimal Resolution (CANDOR) Toolkit, accessed at: https://www.ahrq.gov/patient- safety/capacity/candor/modules.html


9 Fadi El-Jardali et al, Predictors and outcomes of patient safety culture in hospitals, BMC Health Serv Res. 2011; 11: 45. Published online 2011 Feb 24. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3053221/


10 Joint Commission Centre for Transforming Healthcare, Hospital Acquired Pressure Ulcers/ Injuries Prevention, accessed at: https://www. centerfortransforminghealthcare.org/improvement- topics/hospital-acquired-pressure-ulcers- prevention/


About the Author


Chief Digital Officer of RLDatix, Phil Taylor oversees the RLDatix’s product and development strategy. For the past 14 years, he has held a number of positions within the legacy Datix organisation and has a deep knowledge of the patient safety industry. Phil holds a BA from Manchester Metropolitan University and is a Chartered Accountant. RLDatix helps organisations drive safer, more efficient care by providing governance, risk and compliance tools that drive overall improvement and safety. Its suite of cloud-based software helps organisations reduce healthcare-acquired infections, report on adverse events, and ensure patient safety learnings are deployed effectively and immediately through dynamic policy and procedure management.


FEBRUARY 2021


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