We welcome Singer and colleague’s contribution to developing the
concept of a safety culture.[1] Policy-makers, managers and clinicians
are slowly realising that patient safety will not be improved solely by
counting adverse events or by introducing technical innovations. History
tells us that when these initiatives are evaluated the results will
probably show a marginal impact on patient safety, and one...
We welcome Singer and colleague’s contribution to developing the
concept of a safety culture.[1] Policy-makers, managers and clinicians
are slowly realising that patient safety will not be improved solely by
counting adverse events or by introducing technical innovations. History
tells us that when these initiatives are evaluated the results will
probably show a marginal impact on patient safety, and one that is likely
to be poorly sustained. In order to maximise their impact we need to
understand the shared attitudes, beliefs, values and assumptions that
underlie how people perceive and act upon safety issues within their
organisations. This is what is commonly called the ‘safety culture’ of an
organisation.
The problem with the approach adopted in this paper is that it fails
to get to the heart of the hospital’s culture. What they have done is to
use a blunt survey instrument to assess the opinions of individual members
of staff to a series of statements about safety. The responses represent
the most superficial evaluation of the ‘climate’ of the organisations in
which they work. These opinions are likely to be influenced by a wide
range of factors that have little to do with the organisation’s culture.
Furthermore, the relationship between these opinions and the shared values
that underlie them is largely unknown.
If we really want to understand the safety culture of an organisation
we need to use more sophisticated approaches.[2] These should draw on a
wide range of methods – participant observation, in-depth and semi-
structured interviews and focus groups, alongside attitudinal surveys and
the use of new and established culture-measurement tools.[3]
Developmental or action research approaches might provide additional
insights into the complexity of the organisations. The aim should be not
only to understand and assess the concept of safety culture but also to
examine ways of improving it and integrating it with the broader field of
organisational culture. This presents a significant challenge to health
service researchers. Singer and colleagues have made a start but there is
a long way to go before we know how, or indeed whether it is possible, to
change the safety culture of our hospitals and primary care centres.
References
(1) Singer S et al. The culture of safety: results of an
organization-wide survey in 15 California hospitals. Quality and Safety in
Health Care, 2003. 12: p. 112-118.
(2) Mannion R, Davies H, Marshall M. Cultures for performance
in healthcare: evidence on the relationships between organisational
culture and organisational performance in the NHS. Centre for
Health Economics: York, 2003.
(3) Scott J et al. The quantitative measurement of organisational
culture in health care: A review of the available instruments. Health
Services Researcher, in press.
Buetow and Wellingham present a comprehensive overview of
accreditation of general practices in New Zealand, and elsewhere, in this
well-written article.[1] They make the very significant point about the
limitations of quality assurance as compared with the more important
performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the...
Buetow and Wellingham present a comprehensive overview of
accreditation of general practices in New Zealand, and elsewhere, in this
well-written article.[1] They make the very significant point about the
limitations of quality assurance as compared with the more important
performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the major
organisational changes which have occurred within general practice over
the last decade, now involving some 90% of GPs.[2-4] These have a strong
focus on continuous quality improvement. Nor do they make reference to
the major quality achievements in primary care through primary care
organisations,[3] now rapidly evolving into more broadly-based primary
health organisations. Accreditation is only part of this broader primary
health care strategy.[5]
Recent studies of these organisations have shown that visionary GP
leadership, driven to achieve the best possible quality outcomes for
patients, has been the critical factor in these achievements.[3] These have
included the better management of substantial resources associated with
service delivery, including improved pharmaceutical use and prescribing
behaviour.
Practice accreditation has a contribution to make to the quality
strategies of these organisations, which in turn will facilitate
accreditation amongst member practices. But accreditation is only one
part of a comprehensive package. Clinical leadership, within these new
organisational settings, will play a key part in promoting a broader
approach to quality improvement.
References
(1) Buetow S, Wellingham J. Accreditation of general practices:
challenges and lessons. Qual Saf Health Care 2003; 12:129-135.
(2) Malcolm L. Mays N. New Zealand’s independent practitioner
associations: a working model of clinical governance? BMJ 1999; 319:1340-1342.
(3) Malcolm L, Wright L, Barnett P, Hendry C. Clinical leadership and quality improvements in primary care organisations in New Zealand. Clinical Leaders Association of New Zealand, Auckland, 2002. http://www.clanz.org.nzhttp://www.moh.govt.nz/
(4) Malcolm L, Wright L, Barnett P, Hendry C. Building a successful partnership between management and clinical leadership: experience from New Zealand. BMJ 2003; 326:653-654.
At the Linnaeus Collaboration meeting in Canberra, Australia last week
(sponsored by the Australian Primary Health Care Research Institute and
the US Agency for Healthcare Research and Quality), primary care
researchers from Australia, Canada, England, Germany, New Zealand, and the
United States met to consider further research aimed at improving patient
safety in primary health care. We discussed the...
At the Linnaeus Collaboration meeting in Canberra, Australia last week
(sponsored by the Australian Primary Health Care Research Institute and
the US Agency for Healthcare Research and Quality), primary care
researchers from Australia, Canada, England, Germany, New Zealand, and the
United States met to consider further research aimed at improving patient
safety in primary health care. We discussed the issues raised in the
editorial by RM Wilson because we also think that improvements in medical
record-keeping are crucial to improving patient safety. From our
discussion, the following was clear:
1. Paper medical records are not a viable phenomenon for the 21st
century and beyond. This is a particularly challenging notion for the
countries in North America and Australia, where there has not yet been a
wholesale clinical and political commitment to electronic medical records.
2.. The medical record of the 21st century may well be patient held
and maintained. As researchers we found this idea worrying because medical
records are a rich and valuable research resource - we worry that they may
become so well disintegrated that they may no longer be available for
research.
But to answer Wilson's questions:
1. We agreed that the key functions of the medical record are to keep a
record of all encounters between patients and the formal health system.
This record may then be used: (1) to maintain patient safety by ensuring
that health information about a patient exists and is accessible to those
who need it - at any time and in any place, (2) to identify early signs of
catastrophic events (e.g. bioterrorism) through sentinel monitoring, (3)
to measure costs and benefits of healthcare in the real-world setting, and
therefore (4) in light of the above, to be a continuous healthcare quality
improvement tool.
2. What constitutes a "minimum" dataset for a patient record has
already been considered (e.g. [1]). To best fulfil all its functions,
medical records should hold full information about each healthcare
encounter, including setting and encounter method (face-to-face, phone,
email, video, etc), dates, both patient and provider views of reason for
encounters, and details of care provided (including information about
medications, investigations, referrals, immunisations, and other
preventive measures). There is disagreement between countries on the
extent of patient information that is necessary in a patient's medical
record. For instance, in New Zealand the government is concerned that
patients' ethnicity and residence location (for calculating deprivation
and measuring inequalities) are recorded - neither piece of information
having particular significance for gps' clinical decisions. No other
country represented at the meeting had to provide these particular items,
but in the US and Germany health insurance information is absolutely
required. There will obviously be international variation in "key"
elements.
3. How do we implement such requirements? Marshall and Smith write
persuasively in this issue of financial incentives [2]. While we agree
that financial incentives are necessary for systemwide adoption of medical
records standards, we also think political will, a rationale that is
credible to healthcare providers, and cultural change in practice are
crucial.
References
1. Tilyard MW, Munro N, Walker SA, Dovey SM. Creating a general practice
national minimum data set: present possibility or future plan? NZ Med J
1998; 111: 317-20.
2. Marshall M, Smith P. Rewarding results: using financial incentives
to improve quality. Qual Saf Health Care 2003; 12(6): 397-8.
Reed and Card's essay on the problem of valuing action over thought
could not have come at a better time. For years, quality and safety
mavens have been paraphrasing Goethe -- "Knowing is not enough ... we must
do". But the resulting culture of 'do, do, do' has brought us quite a lot
of doo-doo.
To counter this, consider the question, "What did Einstein ever do?"
He invented nothing, patented nothing, created n...
Reed and Card's essay on the problem of valuing action over thought
could not have come at a better time. For years, quality and safety
mavens have been paraphrasing Goethe -- "Knowing is not enough ... we must
do". But the resulting culture of 'do, do, do' has brought us quite a lot
of doo-doo.
To counter this, consider the question, "What did Einstein ever do?"
He invented nothing, patented nothing, created no research teams, built no
institutions, presided over nothing. He published a few academic papers,
but funding agencies today don't care about academic papers -- they want
action, and so they get -- doo-doo.
We fully agree with Hasenfeld and Shekelle that many published guidelines
fall short of the internationally consented quality criteria for their
production and use, although the principles for the development of sound
evidence–based guidelines are well established. In response several
national and international initiatives have been working on programmes for
the promotion of quality in guideline developm...
We fully agree with Hasenfeld and Shekelle that many published guidelines
fall short of the internationally consented quality criteria for their
production and use, although the principles for the development of sound
evidence–based guidelines are well established. In response several
national and international initiatives have been working on programmes for
the promotion of quality in guideline development.[1-3]
In order to promote sustainable international partnerships in the field of
guideline development, use and research activities, a network of non-for-
profit organisations dealing with development, implementation and
evaluation of EBGs was founded in November 2002, called Guidelines
International Network (G-I-N). To date 46 institutions from 24 European,
American, Asian and Oceanian countries including WHO have become members
of the network.
In November 2003, G-I-N's released the first international Electronic
Guideline Library (http://www.g-i-n.net) giving access to nearly 1400 guidelines
and related resources with special focus on the methodological quality of
clinical practice guidelines.
This initiative is meant as a contribution to the improvement of
guidelines' quality and to dissemination of best available practice
guidelines worldwide.
References
1) Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J, for the AGREE
Collaboration. Towards evidence-based clinical practice: an international
survey of 18 clinical guideline programs. Int J Qual Health Care 2003; 15:
31-45.
2) Council of Europe. Developing a methodology for drawing up guidelines
on best medical practice. Recommendation Rec(2001)13 and explanatory
memorandum. Strasbourg, Council of Europe Publishing 2002.
3) The AGREE Collaboration. Development and validation of an international
appraisal instrument for assessing the quality of clinical practice
guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23
The paper by Redelmeier and Shafir resonated strongly with me because
I have always believed that there are important factors that motivate some
physicians to wash their hands while others behave differently. I agree
completely that this is a more complex issue than has been previously
noted. I always wash my hands in front of patients and have done so for
over 40 years. This has very little to do with the risks of healthc...
The paper by Redelmeier and Shafir resonated strongly with me because
I have always believed that there are important factors that motivate some
physicians to wash their hands while others behave differently. I agree
completely that this is a more complex issue than has been previously
noted. I always wash my hands in front of patients and have done so for
over 40 years. This has very little to do with the risks of healthcare
associated infections and much more to do with respect for patients and a
commitment to patient-centered care.
I was a pediatric resident at Boston Children's Hospital in the mid-
1970's and as nonchalant about hand washing as everyone else. Fortunately,
I had a wonderful mentor whose example changed me. Professor Charles A.
Janeway was a renaissance figure in international pediatrics and an
excellent teacher. Though in the twilight of his career Prof Janeway would
make rounds once a week with one of the senior residents and ward team,
examining a patient or two and then discussing the diagnosis and
management of each child.
One day we presented the case of a toddler with chronic inflammatory
arthritis. As Prof Janeway entered the patient's room, he washed his
hands, introducing himself to the child's mother, and then sat and talked
calmly with her, once holding her hand when she became tearful. He asked
if he might examine her child who was sitting in her lap and clinging to
her. Before examining the child he washed his hands a second time. After
the exam and further discussions with the mother, he washed his hands
again, a third time, before leaving the room.
In a small conference room we began to discuss the case, and one of
the students asked Professor Janeway why he washed his hands three times.
He slowly looked around at all of us, and said something to the effect of
the following.
"I washed my hands on entering and leaving the room because I did not
want to bring any infectious agents into or out of the room. I washed my
hands again, the second time before examining this frightened child,
because there is something about washing hands that sends a message about
caring. It is an honor and privilege to practice medicine and hand washing
sends a message about respect. The sound of water flowing and the warmth
of hands after washing conveys sensitivity and compassion, and patients
find this comforting."
I never forgot this lesson and have always washed my hands in front
of patients, not so much because of my fears of infection transmission,
but because of the message it sends to them. It's not all that complicated
really.
Ref:
1. Redelmeier DA, Shafir E. Why even good physicians do not wash their
hands. BMJ Qual Saf 2015;24:744-747.
Firth-Cozens article explores the effect of trust and the ways in
which it can be developed in health care organizations to enhance patient
safety.[1] Leadership attributes of ability, benevolence and integrity
most certainly contribute to the establishment of trust in a leader
however, these attributes alone are not enough to overcome the barriers to
open disclosure of errors.
Firth-Cozens article explores the effect of trust and the ways in
which it can be developed in health care organizations to enhance patient
safety.[1] Leadership attributes of ability, benevolence and integrity
most certainly contribute to the establishment of trust in a leader
however, these attributes alone are not enough to overcome the barriers to
open disclosure of errors.
Organizational trust must first be earned by its leaders through
demonstrated commitment to a ‘no blame’ policy with respect to adverse
event investigations. The author acknowledges ‘the importance of
considering the multi-causal and sociotechnical nature of most
accidents’[1] however, I believe this aspect of the article requires more
explicit discussion as it is fundamental to the development of
organizational trust.
Quick judgments and routine assignment of blame obscure a more
complex truth, a series of events and departures from safe practice, each
influenced by the working environment and the wider organizational
context.[2] If analysis of adverse events focused less on individual error
and more on organizational or system factors, an environment of trust may
begin to prosper and strategies to enhance patient safety would become
visible. No amount of leadership ability, benevolence or integrity will
lead to organizational trust if fear of blame exists. A consistent and
transparent process for a root cause analysis of adverse events is
essential for health care leaders to demonstrate in order to achieve any
degree of organizational trust and subsequent open disclosure.
As Firth-Cozens states in a previous publication, ‘the main driver of
higher organizational trust is going to have to come from the actions and
attitudes of leaders and managers at every level’.[3] Actions undoubtedly
speak louder than words when it comes to investigation and assignment of
blame in the analysis of adverse events. A culture change is required and
it must begin with the leadership of each health care organization.
Leaders who consistently demonstrate and acknowledge the role of system
failures as the root cause of adverse events, will have greater success in
establishing the trust that health care organizations so desperately
require. Maybe then we will begin to impact on the quality and safety of
the health care which we deliver.
References
1. Firth-Cozens J. Organisational trust: the keystone to patient
safety. Qual Saf Health Care 2004;13:56-61
2. Vincent C, Taylor-Adams S, Jane Chapman E, Hewett D, Prior S,
Strange P, Tizzard A. How to investigate and analyze clinical incidents:
Clinical Risk Unit and Association of Litigation and Risk Management
protocol 2000;320:777-781
3. Firth-Cozens J. Learning from error. In: Harrison J, Innes R, Van
Zwanenberg T, eds. Regaining trust in health care. Albingdon: Radcliffe
Medical Press, 2003.
I read Fretheim and Tomic's article [1] with interest as I trained in
frequentist stastistics and now work primarily with Stastistical Process
Control (SPC) in quality improvement (QI) initiatives.
I concur that there are missed opportunities for using Interrupted
Time Series (ITS) in QI; however, I note cautions in doing so:
Regression models applied in ITS often have the assumption of
homoscedastici...
I read Fretheim and Tomic's article [1] with interest as I trained in
frequentist stastistics and now work primarily with Stastistical Process
Control (SPC) in quality improvement (QI) initiatives.
I concur that there are missed opportunities for using Interrupted
Time Series (ITS) in QI; however, I note cautions in doing so:
Regression models applied in ITS often have the assumption of
homoscedasticity - i.e. that the process is no more or less variable over
time. In evaluation of QI initiatives we are seeking to violate that
assumption in that we wish to change a variable and non-performing system
into a reliable and highly performing system. This means that the ordinary
least squares estimators would not be best linear unbiased, with a risk of
overestimating the goodness of fit. This can be addressed using
generalised least squares estimators. [2]
Applying an ITS break point immediately on "intervening" assumes that
the intervention is immediately and consistently applied from that point
on. This might be true for a total replacement of one drug with another,
but is less clear for behavioural change interventions, such as hand
hygiene in hospitals. A similar case can be made for care bundle
interventions - one may start bundle in all cases, yet all aspects of
the bundle may not be consistently conducted.
I suspect that, as with statistics in general, that care is required
in selecting one's test, which will depend on the purpose required.
Perhaps a mixed method of SPC and ITS could be preferred?
[1] A. Fretheim, O.Tomic. Statistical process control and interrupted
time series: a golden opportunity for impact evaluation in quality
improvement. BMJ Quality and Safety 2015;24:748-752
[2] A. H. Welsh, R. J. Carroll, D. Ruppert, Fitting Heteroscedastic
Regression Models. Journal of the American Statistical Association
1994;89:100-116
The article by Gollop et al.[1] raises an interesting question:
does labelling a programme of change an "improvement" programme mean that
such a programme will automatically deliver improvements?
I am disturbed
by the implication that simply because something is "a key component of
the government's strategy to modernise the NHS and make it more
accessible to patients" it is therefor...
The article by Gollop et al.[1] raises an interesting question:
does labelling a programme of change an "improvement" programme mean that
such a programme will automatically deliver improvements?
I am disturbed
by the implication that simply because something is "a key component of
the government's strategy to modernise the NHS and make it more
accessible to patients" it is therefore not legitimate for staff to be
sceptical. In fact, the inclusion of such a sentence in the article
provokes me to yet greater scepticism: what exactly does "modernise" mean
in this context, and when did it become synonymous with "improve?" This
Orwellian use of language and the presumption that it is not legitimate
for intelligent observers to be sceptical about unproven innovation are
two of the reasons that many of us are so disillusioned with life in the
NHS. Having worked in the NHS for nearly twenty years, I have experienced
many waves of change: some have brought improvements, some have been
disastrous; some I have embraced and some I have resisted. I reserve the
right to remain sceptical and questioning, and I hope that the
Modernisation Agency will, as it matures as an institution, lose some of
its evangelical fervour and learn to listen to the opinions of others.
Changing its name might be a start!
References
1. R Gollop, E Whitby, D Buchanan, and D Ketley. Influencing sceptical staff to become
supporters of service improvement: a qualitative study of doctors' and managers' views, QSHC 2004; 13:108-114.
We note Dr Checkland’s comments on our paper on scepticism with
interest.[1] In response, we do not believe that the paper argues that it is
not legitimate for staff to be sceptical; indeed, we acknowledge the fact
that scepticism can be useful in highlighting gaps and flaws in
improvement initiatives. Nevertheless, the study – based on interviews
that centred on listening to the opinions of others...
We note Dr Checkland’s comments on our paper on scepticism with
interest.[1] In response, we do not believe that the paper argues that it is
not legitimate for staff to be sceptical; indeed, we acknowledge the fact
that scepticism can be useful in highlighting gaps and flaws in
improvement initiatives. Nevertheless, the study – based on interviews
that centred on listening to the opinions of others – did identify the
negative impact that scepticism and resistance are having on the pace of
change in the NHS.
With regard to the use of terms such as modernisation and
improvement, we think that this is a semantic argument that ignores the
underlying spirit and intent of planned reform. It is surely legitimate to
make certain assumptions about meaning in this context. Changes designed
to make health care better for patients deserve to be described as
improvements until subsequent research evidence demonstrates otherwise.
The drive to involve frontline staff in leading service improvement
encompasses the notion that change that proves not to be beneficial in
practice can be reversed. If we implement only that which has been
scientifically proven to be effective, the pace of change will be very
slow.
Reference
1. Checkland KH. Sceptics or realists [electonic response to Gollop et al. Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors’ and managers’ views] qshc.com 2004http://qhc.bmjjournals.com/cgi/eletters/13/2/108#80
Dear Editor
We welcome Singer and colleague’s contribution to developing the concept of a safety culture.[1] Policy-makers, managers and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that when these initiatives are evaluated the results will probably show a marginal impact on patient safety, and one...
Dear Editor
Buetow and Wellingham present a comprehensive overview of accreditation of general practices in New Zealand, and elsewhere, in this well-written article.[1] They make the very significant point about the limitations of quality assurance as compared with the more important performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the...
Dear Editor
At the Linnaeus Collaboration meeting in Canberra, Australia last week (sponsored by the Australian Primary Health Care Research Institute and the US Agency for Healthcare Research and Quality), primary care researchers from Australia, Canada, England, Germany, New Zealand, and the United States met to consider further research aimed at improving patient safety in primary health care. We discussed the...
Reed and Card's essay on the problem of valuing action over thought could not have come at a better time. For years, quality and safety mavens have been paraphrasing Goethe -- "Knowing is not enough ... we must do". But the resulting culture of 'do, do, do' has brought us quite a lot of doo-doo.
To counter this, consider the question, "What did Einstein ever do?" He invented nothing, patented nothing, created n...
Dear Editor
We fully agree with Hasenfeld and Shekelle that many published guidelines fall short of the internationally consented quality criteria for their production and use, although the principles for the development of sound evidence–based guidelines are well established. In response several national and international initiatives have been working on programmes for the promotion of quality in guideline developm...
The paper by Redelmeier and Shafir resonated strongly with me because I have always believed that there are important factors that motivate some physicians to wash their hands while others behave differently. I agree completely that this is a more complex issue than has been previously noted. I always wash my hands in front of patients and have done so for over 40 years. This has very little to do with the risks of healthc...
Dear Editor
Firth-Cozens article explores the effect of trust and the ways in which it can be developed in health care organizations to enhance patient safety.[1] Leadership attributes of ability, benevolence and integrity most certainly contribute to the establishment of trust in a leader however, these attributes alone are not enough to overcome the barriers to open disclosure of errors.
Organizational...
I read Fretheim and Tomic's article [1] with interest as I trained in frequentist stastistics and now work primarily with Stastistical Process Control (SPC) in quality improvement (QI) initiatives.
I concur that there are missed opportunities for using Interrupted Time Series (ITS) in QI; however, I note cautions in doing so:
Regression models applied in ITS often have the assumption of homoscedastici...
Dear Editor
The article by Gollop et al.[1] raises an interesting question: does labelling a programme of change an "improvement" programme mean that such a programme will automatically deliver improvements?
I am disturbed by the implication that simply because something is "a key component of the government's strategy to modernise the NHS and make it more accessible to patients" it is therefor...
Dear Editor
We note Dr Checkland’s comments on our paper on scepticism with interest.[1] In response, we do not believe that the paper argues that it is not legitimate for staff to be sceptical; indeed, we acknowledge the fact that scepticism can be useful in highlighting gaps and flaws in improvement initiatives. Nevertheless, the study – based on interviews that centred on listening to the opinions of others...
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