A systems approach to improving service quality and safety.

Peter Spurgeon
Institute of Cinical Leadership, Medical School, University of Warwick
Sustaining and Implementing Universal
Health Coverage
Universal Health Coverage
- societal commitment (?)
- policy target
- ignore concepts of core content and level of provision

Implementation
- separate challenges
- dependent on context

Sustainability
- full cycle back to policies and resources
Managing organisations - for what?
Argue that we have not focussed managerial effort appropriately

Why has patient safety movement only emerged in last 20 years?

Ultimate goal of health organisations must be best quality (within resource)
and safety of care provided

If quality and patient safety are assumed they wont happen

Health service represents an integrated system- all elements must be
involved in delivering the care specified

Systems approach essential (not Fire Fighting)

Poor quality, unsafe care cannot be the basis of sustainability
Safer Clinical Systems
A systems approach to building safe and reliable patient care through:

proactively searching for and managing risk


ensuring feedback to create continuous
learning, engagement and sustainable solutions

Prevalence of Adverse Events:
An International Problem
Hospital:
Systematic Review 9.2% (De Viries 2008)
Latin America 10.5% (Aranaz-Andrs J M, 2011)
Canada after discharge 23% (Forster 2004)
New Zealand 11.2% (Davis, 2002)
Sweden 12.3% (Soop 2009)
USA Harvard 3.5% (Brennon 2004)
Denmark 9% (Scioler, 2001)
England 10.8% (Vincent 2000)

Ambulatory care: 9.65% (Tache, Systematic Review 2011)

We continue to harm patients
Raised awareness

Several large scale initiatives
Some impressive results in micro systems
Rare organisational changes (e.g. Intermountain, Cincinnati)
Challenges with spread and sustainability
Variable evidence of impact

Evaluation of Safer Patients Initiative February 2011

Patient Safety First Campaign report March 2011

Current initiatives have had
limited impact
The Safer Patients Initiative generated considerable learning and new
insights; in particular, that a wider set of methods and approaches are
needed to impact on patient safety at an organisational level.

It also highlighted the scale of the resources needed to make organisation-
wide change, the need to make changes at every level of the system from
policy to deep engagement with professionals, and the time needed to
deliver and embed improvements.

Our research shows poor reliability
Failures in reliability pose real risk to patient safety
15% of outpatient appointments affected by missing clinical
information

Important clinical systems and processes are unreliable
Four clinical systems measured had failure rate of 13%-19%

Wide variations in reliability between organisations

Unreliability is the result of common factors
Lack of feedback mechanisms and poor communication.

It is possible to create highly reliable systems

The Health
Foundation May
2010
The Current Problem
1. Reactive
safety culture
2. Lack of
understanding of
influencing factors,
leading to unreliable
systems
3. Variable
processes lead to
error
4. Errors
undetected;
not reported;
or investigated
without considering
system factors
5. Lessons about
systems factors
not learned -
failure to change
the system and
prevent future
risks
6. No feedback
on action to
address
systems factors
proactively
7. Organisational
acceptance of the
inevitability of risk &
harm
We need to think about systems
When things go wrong for a patient, the fault rarely lies with individual practitioners, but
with either the design of the process or the context in which practitioners work.

We require an approach that:

Proactively identifies risk and learns from error
Considers the wider system and influencing factors
Identifies poor design and variation

Our definition of a system is:
A clinical pathway of care and the factors that influence that pathway,
both within and without the organisation

What is a safe clinical system?
Our working definition of a safe clinical system is:

A clinical system that delivers value to the patient, is demonstrably free
from unacceptable levels of risk and has the resilience to withstand
normal and unexpected variations and fluctuations


Value is what matters to the patients but is often characterised in the NHS
by good clinical outcomes and good experience, delivered in a timely manner.

Timeline of the Programme

Measuring Safety
Measurement will be carried out to demonstrate:
A structured narrative argument supported by evidence - use of Systems
Safety Appraisals at key steps that describe and collate the evidence of
improvement and how the objectives of Safer Clinical Systems are being or
going to be achieved
Improved reliability - measurement against standards appropriate to the
pathway using Statistical Process Control
Minimised risk through ranked risk analysis of key stages or tasks in the
pathway and how it changes
Reduced harm through quantitative analysis of incident reports and case
note review, when possible
Sustainability by demonstration of continued improvement and of achieving
factors associated with sustainability

Understanding Context
Systems and contextual metrics will be gathered to measure:

Leadership and engagement
Safety culture
Team working

Addressed through proven measurement instruments, interviews and discussion
between senior management, clinical leadership and support team.

Our Philosophy
Safe delivery of care is the key priority for productive, efficient
organisations

Valid and reliable care delivery systems underpin all other aspects

Whole systems thinking is crucial to sustainable high quality provision