Transcript Slide 1
TAKING THE TEMPERATURE OF PATIENT SAFETY IN MEDICATION MANAGAMENT!
Prof Dorothy Jones Department of Health WA
Today
• • •
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Introduction
• • Patient safety management systems comprise active surveillance, risk management, policy making, quality improvement, evaluation and feedback processes.
Improving patient safety requires health professionals and organisations to share and learn from errors and to close the loop on errors by ensuring the problem is fixed.
Aetiology of “Organisational” Accidents
Organisational and corporate culture Contributing factors influencing clinical practice Task Defence barriers Error producing conditions Errors Accident/ incident Management decisions and organisational processes Violation producing conditions Violations James Reason. Stages of Development of organisational accident. In Charles Vicent (2001), Clinical Risk Management (2nd Edition). BMJ Books, Pge 15.
Threats to safety in medicine
Patient
Primary illness Secondary illness Risk Factors Atypical response to treatment Ongoing management
Professional
Proficiency Fatigue Motivation Culture (Invulnerability)
Organizational
Organizational Culture Scheduling & Staffing Experience levels Work Load Error policy Equipment issues
System - level
National culture Health-care policy and regulation Payment modalities Medical coverage
Expected Events and Threats Unexpected Events and Threats
Sourced from Bob Helmreich. Threat and error model: University of Texas human factors research project. On error management: Lessons from aviation. BMJ 2000; 320:781-785
Problems with the traditional model
• • • • • • Quality improvement and risk management programs not linked There is no single source of information on the safety and quality of health care provided by an organisation Organisations are awash with data (Royal Commission into Bristol Royal Infirmary) Data sources not systematically exploited to: – identify analyse what is happening and – why things go wrong Both are necessary to improve patient care.
Solution = patient safety management system Runciman WB, Williamson JAH et al. An integrated framework for safety, quality and risk management… Qual Saf Health Care 2006; 15 (Suppl I): i82-i90 Human Factors and Patient Safety 591 (Unit code 312276) Faculty of Health Sciences, Curtin University Perth, Western Australia CRICOS Provider Code 00301J (WA), 02637B (NSW)
Definition – Safety management system
A safety management system is:
“a systematic approach to managing safety including the necessary organizational structures,
accountabilities, policies and procedures” and measurement and evaluation tools. Southern California Safety Institute (2009). Aviation Safety Management Systems – Essentials ( www.scsi-inc.con/SMS%20Essentials.html
)
Safety management system
• • • • Safety management systems have these functions: Identify safety hazards Ensure implementation of remedial action Continuous monitoring, measurement and evaluation of programs, governance processes and risk management systems Ensuring continuous improvement in the performance of the safety management system Identify safety hazards Implement remedial action to maintain safety performance Monitor and assess safety performance in organisation Southern California Safety Institute (2009). Aviation Safety Management Systems – Essentials ( www.scsi inc.con/SMS%20Essentials.html
) Ensure continuous improvement
Elements of a patient safety management system
• • • • • Identification of problems using surveillance systems Analysis of problems to identify hazards and risks Development of policies, guidelines or quality improvement programs to address problems Monitoring and evaluation of programs to ensure problem is fixed Dissemination of lessons learned.
Office of Safety and Quality in Healthcare (2007). Paving the way: Promoting safer health care in WA 2002-2007
Theoretical model of a patient safety system
Office of Safety and Quality in Healthcare (2009). Discussion Paper: Closing the Loop. Government of Western Australia: Department of Health
Desired attributes of a patient safety management system
• • • • • • Everyone in the organisation can report, including patients. Everyone in the organisation can access de-identified information and results Incident reports are confidential Incidents are investigated to identify contributory factors of errors and preventable factors Incident and investigation results are fed back to front line staff. Staff are informed of improvements and actions taken because of incident reports Multiple surveillance systems and data sources are integrated into a single risk management system, where ever possible.
Jones DA and Runciman WB (2009). Principles of Incident Reporting, in in Croskerry P, Cosby KS, Schenkel SM and Wears RL eds (2009). Patient Safety in Emergency Medicine; pp 70-74. Human Factors and Patient Safety 591 (Unit code 312276) Philadelphia: Lippincott Williams and Wilkins Perth, Western Australia CRICOS Provider Code 00301J (WA), 02637B (NSW)
BUT • WHEN THE ‘PATIENT’ IS FEBRILE…..WHAT IS THE KEY TREATMENT NEEDED?
There is a gap between the health care that research & evidence says we should have – and the care we actually get.
Why?
The Change Challenge
• • • • Fundamental & Central role of Leadership behaviours in leading and managing change Risky business (especially in isolation) One view of change… All change is loss – People do not resist change….
– People resist loss – Therefore a leadership role is to mourn & acknowledge grief (then envision the future)
Technical vs. Adaptive Change
• • • The single most common mistake leaders make is treating adaptive challenges like technical problems Leadership is the capacity to deliver adaptive change Adaptive problems – Beliefs – Values – Hearts Adapted from Heifitz & Linsky, Leadership on the Line, 2002
Technical vs. Adaptive Change
Technical change Adaptive change What is the work?
Who does the work?
Apply current know-how (single factor) Learn new ways (systemic) Authorities (benign) The people with the problem (arouses conflict) Adapted from Linsky & Heifitz
Why do people resist?
• • • • • Why do people resist the right thing, resist the good thing?
Why does adaptive change stimulates resistance?
The Tomato Effect or NIH evidence Natural chauvinism Cumbersome bureaucracy – yours, not theirs!
– Own your part of the problem, mess
Why resist the right thing…..
• • Adaptive change stimulates resistance because.. – Loss – Disloyalty – Feeling incompetent – No wonder people resist!
And so leading change is risky because there is loss, backlash, discontent, fear, blame
So system change needs Adaptive Leadership
• Challenges Habits, Beliefs, Values – Stimulates resistance – Asks people to take a loss – Creates uncertainty – Expresses disloyalty to people & culture – Challenges sense of competence
Adaptive Leadership is risky
• • Changes the status quo Creates new meaning – Creates or renews purpose – Purpose must be compelling
2 hallmarks of an adaptive challenge
• • A cycle of failure – Lets try again but work harder!!!
A persistent dependence on authority – Hardwired to hold authority figures resonsible – Its my manager; it’s the department; it’s the Area. It’s the CE – If only…
Adapted from Heifetz et al The Practice of Adaptive Leadership 2009
5 key characteristics of adaptive organisations 1. Elephants in the room are named 2. Responsibility for the organisation’s future is shared 3. Independent judgement is expected 4. Leadership capacity is developed 5. Reflection and continuous learning are institutionalised
Adapted from Heifetz et al The Practice of Adaptive Leadership 2009
Challenges
• • • • • • • Scaling up Every patient every time every where Sustainability Building resilience Structuring compassion and kindness Changing human behaviours Leadership
A safety management system
Set the policy Measure & review performance Organise & Implement Develop your processes
An afebrile safety management system….also includes
Set the policy Organise & Implement Measure & review performance Develop your processes