Implementing Patient Safety

Addressing Culture, Conditions and Values to Help People Work Safely

Suzette Woodward

• Publisher: Productivity Press
• Year: 2019
• ISBN:
  9781351235365
• Edition: 1
• Topic: Business
• Subtopic: Operations
• Index: Business

Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached.

Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely.

Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years.

This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like.

This book builds on the author's first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the 'how'.

Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the author's personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.

Part One

Create a Balanced Approach to Safety

1.1 Part One Introduction

Part One describes the growing sense of unease about the way we do safety in healthcare together with some exciting ways in which we can do it differently. It describes the dominant approach to patient safety in healthcare we use today. It will propose that while the dialogue about patient safety has increased significantly we have become stuck. Stuck in a world of bureaucracy, negativity and blame. The tone and methods of patient safety have led to disengagement especially of clinicians. All of the evidence so far necessarily calls into question the prevailing ways in which patient safety has been framed and addressed to date. An important challenge we all have now is how do we engage, motivate and mobilise people to work safely within this negative workplace and culture.

Thankfully, the way we think about safety is changing (Hollnagel 2013. Vincent and Amalberti 2016, Mannion and Braithwaite 2017). Part One, therefore, considers how we should shift our approach to safety from focusing purely on failure to studying how things happen on a daily basis, how they typically go right (Safety II), and how this needs to be balanced with the learning from failure (Safety I). I propose that there are a number of safety myths that are getting in the way of progress and I go on to share the latest thinking, the new models of safety and the ideas born out of complexity science and complex adaptive systems.

1.2 Failure

1.2.1 Negativity

In life we pay more attention to the negative things; the negative headlines in a newspaper, the negative reviews of an article we have written, the poor feedback about a talk we may have delivered. We all remember the negative comments in an appraisal rather than the positive comments. Even if there is a balance of positive and negative findings we put more weight on the negative ones and feel that the priority is to address the negative rather than the positive. Even if we get one negative comment and nine positive comments, we feel we have to change ourselves to meet that one comment rather than accept that most people liked it so there is no need to change. This in turn may mean that we change it so that only one person likes it and nine people don’t. This attitude has ‘infected’ the world of safety. Consequently, negativity is considered more impactful that positivity. We constantly feel we have to change based on the negative things that happen rather than the positive.

This is the same in life as well as it is in safety. Pinker (2016) says that many people face the morning news with trepidation and dread. We are continually told that things are getting worse and that modern life is much more negative than our past. We pay attention to the stories of negativity and it leaves people longing for different times when it felt safer, kinder and more equitable. If we translate this to healthcare, what people do is pay attention to the bad news and pay attention to the stories which point to the feeling that the health service is getting worse. The media is particularly effective at pointing out where healthcare fails rather than where healthcare succeeds. And within healthcare safety we focus almost exclusively on the negative; what are the problems we need to address, what are the things we are doing that are going wrong, data collection systems, the number of incidents, accidents, never events, serious incidents, deaths, complaints and claims. The current methods used to study safety in healthcare are fixated on where we have failed in order to figure out how we can prevent those failures and improve the way we care for patients.

There is a desire to quantify the level of failure. Asking if healthcare is getting worse or better. Or whether it is less safe or safer. The following describes what the researchers and safety experts over the years have tried to do so far to find out the scale of the problem with the ultimate aim of being able to tell if we are getting safer or not.

1.2.2 Studies of Failure

Research in relation to failure can be tracked back to over a century and a half ago, since the time of Florence Nightingale and Ignaz Semmelweiss. Florence Nightingale wanted to study why some of her patients died and some didn’t and what the causes of these differences were when she cared for the army in the Crimean War. This was from April 1854 to March 1855 and she believed that most of the illness (or harm) which afflicted the army was caused by defects in the system. She estimated that one in seven of her patients died from preventable diseases rather than their battle wounds and that the things that would reduce the ‘harm’ or illnesses included good nutrition, warm clothing, good ventilation, cleanliness and hygiene (Huxley 1975). The work of Ignaz Semmelweiss published in 1857 is often quoted as one of the first patient safety research studies into maternal morbidity and mortality and infection control. His work concluded that increased hand-washing resulted in a reduction in mortality from infections for mothers and babies in his care. However, much of his findings were dismissed by his colleagues who refused to change their practice and Semmelweiss died well before his work would receive the recognition it deserved (Woodward 2017).

It is interesting to note that the contributory factors of both are similar to our knowledge today. The factors Nightingale found in relation to nutrition, clothing, ventilation, cleanliness and hygiene and the finding by Semmelweiss that washing hands made a significant difference to maternal morbidity and mortality have stood the test of time. So, there have been some clues and indicators for quite some time that we have yet to ‘fix’.

Also in the late 1800s, another pioneer Ernest Codman took the radical step of publishing not only his patients’ outcomes but also his judgements on whether the results could have been improved and the probable causes of failure to achieve ‘perfection’. Codman graduated from Harvard Medical School in 1895 and interned at Massachusetts General Hospital. He joined the surgical staff of Massachusetts General and became a member of the Harvard faculty. While there, he introduced the first morbidity and mortality conferences. However, in a similar way to Semmelweiss, staff were nervous about his work and in 1914 the hospital refused his plan for evaluating the competence of surgeons and he lost his staff privileges there. Codman eventually established his own hospital (which he called the End Result Hospital) to pursue the performance measurement and improvement objectives he believed in so fervently. To support his ‘end results theory’ Codman made public the results of his own hospital; in which for the 337 patients discharged between 1911 and 1916, Codman recorded and published 123 errors (Woodward 2017).

1.2.3 Retrospective Case Note Reviews

Move forward over a hundred years and we find research studies which have tried to understand the scale and nature of the problem by auditing patient case notes. There are very few documented early studies of the subject but an example published in 1974 conducted in California studied patient records and estimated that out of three million hospital admissions there were 140,000 injuries, 24,000 being considered due to ‘negligence’ (Woodward 2017).

Since the late 1990s, the main method of study has therefore been to audit patient case notes which is usually described as ‘retrospective case note review’. These case note review studies have been carried out across the world and have cited a range of incident rates ranging from 2.9% to 16.6% of all hospital admissions with preventable adverse event rates ranging from 1.0% to 8.6% (Woodward 2017). The first of these was undertaken in New York State (Brennan et al. 1991), the findings of which were extrapolated to suggest that as many as 98,000 patients in hospital settings in the US died each year as a result of problems related to their care. One of the following studies was undertaken in the UK in two acute hospitals by a team under the leadership of Vincent and colleagues (2001). This has led to the now often used 10% statistic in the UK (and possibly worldwide) which is used in a number of different ways such as ‘on average there is a 10% error rate in healthcare’ or simplified to things like ‘10% of patients in healthcare are harmed’.

Other examples include a study from New Zealand that concluded that 3.4% of 118 deaths were related to ­preventable errors in healthcare (Briant et al. 2006). A large retrospective case record review study of 21 of the 101 ­hospitals in the Netherlands reported a figure of 4.1% adverse events contributing to death among deceased patients (Zegers et al. 2009).

Hogan and a team of researchers conducted a retrospective case record review study in the UK in 2009 (Hogan et al. 2012). In this study of 1000 adults who died in 2009 in ten acute hospitals, reviewers judged 5.2% of deaths as having a 50% or greater chance of being preventable. Extrapolating from these figures the authors suggest there would have been 11,859 adult preventable deaths in hospitals in England in 2009. Hogan and her colleagues found that the problems associated with preventable deaths occurred in all phases of hospital care but were most likely in wards (44%) and involved poor clinical monitoring (31%), diagnostic errors (30%), or inadequate drug or fluid management (21%). Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities judged to have had less than one year of life left to live.

In a further study of deaths in England by Hogan and her colleagues the reviewers identified a preventable death rate of 3.6%, lower than the results in 2009 (5.2%), and no significant variation in the proportion of preventable deaths between hospitals (Hogan et al. 2016). This study was to determine the proportion of avoidable deaths in acute hospital trusts in England and to determine the association with the tools used to assess and compare hospitals on their mortality data; the hospital standardised mortality ratio (HSMR) and the summary hospital-level mortality indicator (SHMI). The reviewers studied 34 English acute hospital trusts (ten in 2009 and 24 in 2012/13) randomly selected from across the spectrum of HSMR. The difference between 2009 and 2015 is stated as:

• In the 2012/13 cohort, the patients were sicker with a higher prevalence of several key comorbid conditions. Whether or not this was a real difference or reflected greater propensity to record these comorbidities, the impact on reviewers is likely to mean they were less likely to judge a death as avoidable.
• Reviewers’ awareness of the use of ‘do not attempt resuscitation’ orders was probably greater as a result of the wider use of highly visible forms in the case records plus changes to the medical review form, which drew their attention to such orders.
• There was a minor difference in the wording of the question about attribution of avoidability.

There was a small but statistically non-significant association between HSMR and the proportion of avoidable deaths. The authors concluded that the small proportion of deaths judged to be avoidable meant that any metric based on mortality is unlikely to reflect the quality of a hospital. Therefore, the authors recommended that measuring mortality should be focused on identifying ways of improving the quality of care and not used as an indicator of safety in a hospital.

Assessing mortality using either retrospective record review or a hospital wide mortality ratio is not a helpful or informative indicator of the safety of a hospital. It is potentially misleading to the public, clinicians, managers, and commissioners to praise or condemn a trust on the basis of either measure.

Hogan 2015

1.2.4 Limitations in Measuring Safety

The measuring and monitoring of safety continues to be a challenge. As mentioned, retrospective case note review is a method based on experts‘ assessments of healthcare records, considering the quality and safety of care provided during an admission. Hogan and others have described the fallibility of even the most carefully structured case review (Lilford et al. 2010, Hogan 2016). Despite the provision of extensive training and support, experienced clinical reviewers often disagree on what constitutes an avoidable death and are influenced by a range of extraneous factors. Equally if used to assess whether a patient has been harmed it is highly subjective and requires significant experience in understanding the care being provided. It is also flawed as a methodology because patient case notes can never include every single thing that has happened to them. So the judgement is being made on incomplete data. The limitations and risks associated with retrospective case record review method include (Hogan 2016):

• The poor reliability of the reviewers‘ judgements. This includes that the estimates of life expectancy are dependent on reviewers’ judgement. Even using two reviewers has only moderate reliability, because of the subjective element in judgements of avoidability and the quality of care. There is often disagreement between reviewers.
• Outcome and hindsight bias influences the judgement of causation and preventability.
• Variations in the intensity of treatment delivered to the growing population of elderly, frail, multi-comorbid patients have the potential to impact on the number of errors and the small number of deaths occurring in...