dr stephen gourley - central australia health service - nt government - national standards &...

National Standards

Are we on the right track?

Dr Stephen Gourley MBBS FACEM MHA Grad Dip Med EdACEM Quality CommitteeACHS ED Quality Working Group Member

Disclaimer

• I have no conflicts of interest to declare

• This is not going to be the usual S&Q management speak - promise

• It will challenge some of the stalwarts of the S&Q movement, but I ask you to keep an open mind

Overview

• A few concepts and definitions

• What is Safety and Quality?

• Brief history of the patient safety movement

• National Standards – how do they fit in

• Is it working?

• Safety II

• Complex adaptive system theory

• Resilience

Work as done vs. work as imagined

Work as done

Work as imagined

SAFETY

Work as done vs. work as imagined

Work as done

Work as imagined

SAFETY

Work as done vs. work as imagined

The Electronic medication storage story

Work as imagined……..

Work as done……….

Bad things happen to good people.

People are not machines

Balancing risk

Creativity

Innovation

Quality

• In HC, quality is usually defined by a lack of adverse events (safety) and a conforming to a set of rules (policy and procedure)

• It is said to be “good” when there has been standardised care provided and a good outcome

• Therefore, quality is pursued as a state of excellence (often unfortunately referred to as “best practices”) where there has been no deviation from a predetermined pathway

• It is assumed that by improving safety, you will inevitably improve quality

Quality definition - problems

• Is safe care quality care?

• Is quality care safe?

• Standardised care works well for the standardised patient and the standardisedhealthcare worker ……

• Does this exist?

• Do we really know what the “best practice” is?

Patient safety movement

• There is good evidence that patients come to harm from adverse events in health care

• The “To err is human” report was done in USA in 1999 by

• Showed a rate of iatrogenic harm to be about 1:1000 admissions

Patient safety movement

• Comprehensive strategy to reduce preventable errors

• Admirable goals such as eliminating wrong site surgery and identification mistakes

• Falls, transfusion errors, pressure areas

• The goal at the time: – “Concluding that the know-how

already exists to prevent many of these mistakes, the report sets as a minimum goal a 50 percent reduction in errors over the next five years.”

• Errors…are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals.

Patient safety movement

• Assumptions:

1. Safety must never be compromised

2. Safety is able to be achieved and maintained by removing error

3. Standardising care will reduce error and therefore improve safety

4. Safe care will always mean better quality care

Australian study

T Brennan (2000) The Institute Of Medicine Report On Medical Errors - Could It Do

Harm? NEJM 342:15. 1123-4.

Could the report cause harm?

• There were concerns raised as early as 2000• Definition and measurement of error• Safety was already an important concept and not

overlooked as suggested by the report• The estimate of error is based on extrapolation

and not statistically valid– We do not know the real background rate

• “Unless the epidemiologic science of error detection improves greatly, the effort to prevent errors may deteriorate into a marketing ploy”

T. Brennan (2000) The Institute of Medicine Report on Medical Errors - Could It Do

Harm? NEJM 342;15:1123-1125.

Wilson RM Van Der Weyden MB.(2005) The Safety of Australian Healthcare: 10 years

after QAHCS. MJA 182;6. 260-1.

The Australian Patient Safety Movement

National Standards

• The aim is to standardise care and processes with the aim to reduce error

• They are rapidly expanding – there were 7, then 10, now we are looking at15

• But who actually evaluates them and if they are working?

• What is the evidence?

National Standards

National Standards

• Each Standard is broken down into subsections and different items

• There are also many developmental ones which will likely become full ones in the future

• In the current10 National Standards, there are 209 core standards and 24 mandatory

• 256 different sections to complete

Patient Safety is a multi billion dollar industry

Patient Safety outcomes

• Safety and quality has become an industry in its own right

• Billions of dollars have been spent investing in the movement here and in the US

• In Australia, this industry employs thousands of people– Policy development, regulatory boards, federal and

state level,

– Individual hospitals invest in developing and maintaining accreditation

And yet ….

• In the 20 years since the release of the “To err is human” report, the rate of harm has remained essentially unchanged

• It is a far cry from the stated objective in the report to reduce errors by 50% in 5 years

N Engl J Med 2010;363:2124-34.

Linear process

IncidentReview

(Diagnose)

Prevention / policy

(Treatment)

Linear theories

• HC is deeply embedded in the Dx/ Rx paradigm

• Reactive, not proactive

• Useful to simplify complex ideas

• Root cause analysis is a good example

Gastric Lavage

Root Cause Analysis

Usual outcome of RCA

Incident

Incident

IncidentIncident

Policy

PolicyIncident

Policy

Policy

IncidentIncident

Policy

PolicyIncident

Policy

Usual outcome of RCA

Incident

Incident

IncidentIncident

Policy

PolicyIncident

Policy

Policy

IncidentIncident

Policy

PolicyIncident

Policy

Limitations to RCA as a linear process

• Usually conducted in retrospect– Observer bias

– Recall bias

– Reporter bias

• Examines an adverse event through the first story through a timeline

• Often omits the “second story” which is often more important

• They are usually done as the result of a rare event– The event often has a poor outcome with emotional

overlay e.g. death

Second story

• This looks at the unspoken or human element

• E.g. distractions, personal issues impacting on performance

• Has been demonstrated to be a much larger impact on adverse events than previously thought

• Very difficult to control in humans

Can you have too many guidelines?

Milgram student shock experiment

What has gone wrong?

• Clearly, it is much more complicated than what we think

• We need a more sophisticated model to help us understand the healthcare system and then use this model to improve it to reach our ultimate goal of providing safer healthcare

Is Health Care a rock or a bird?

Is Healthcare a Rock or a Bird?

Rock

Is Healthcare a Rock or a Bird?

Bird

Rock

Looking at what goes wrong, rather than what goes right

Carthey, de Leval and Reason (2001)

The imbalance between things that go right and things that go wrong

Concept Safety I vs Safety II

• Safety I

– Reduce harm to zero

– Based on the tradition of “do no harm”

• Safety II

– What is it that we are doing right and how do we maximise the conditions that foster this

“is the intrinsic ability of a

system to adjust its functioning prior to, during or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress”

Resilience

C. Nemeth, PhD, R.Wears, MD, D. Woods, PhD, E. Hollnagel, PhD, and R. Cook, MD. (2008) Minding the Gaps: Creating Resilience in Health Care - Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools)

“Every system

is perfectly

designed to

get exactly

the results it

gets”

What evidence do we have so far?

Standard 10 – Preventing Falls and Harm From Falls

Specific example - Falls

• Trying to stop falls to prevent morbidity and mortality sounds very logical

• Does it work?

• Maybe, falls are a sign of “total body failure” that occurs towards the end of your life

Injury Prevention 2011:17:e5. doi:10.1136/injuryprev-2011-040074

BMJ2016;352:h6781

BMJ2016;352:h6781

Summation

1. It is impossible to have a policy for everything

2. Safety is in our people – empowerment not constraint

3. Safety II – let’s focus on what goes right and re-create this

4. Safety is important – get involved

Thank you