Peter Spurgeon[1]

7/27/2019 Peter Spurgeon[1]

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A systems approach to improving service quality and safety.

Peter SpurgeonInstitute of Cinical Leadership, Medical School, University of Warwick



Sustaining and Implementing UniversalHealth 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-Andrés JM, 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

systems3. Variable

processes lead to

error

4. Errors

undetected;

not reported;

or investigated

without considering

system factors5. Lessons aboutsystems factors

not learned -

failure to change

the system and

prevent future

risks

6. No feedback

on action toaddress

systems factors

proactively

7. Organisationalacceptance 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 c linical pathway of care and the factors that inf luence 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 discussionbetween 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

Documents

Peter Spurgeon[1]