The Art of Patient Safety E-Book

Veli-Matti Heinijoki

• Herausgeber: Books on Demand
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 264

Veröffentlichungsjahr: 2022

Beschreibung

Patient safety is first and foremost the key value of healthcare. Strengthening patient safety requires a proactive patient safety culture. Reacting to incidents is not enough. Accountable and proactive leadership based on risk management, combined with an up-to-date situational picture, is essential. Operational requirements and systemic development alone have not succeeded in bringing about sufficient change in the desired direction. A radical transformation that includes requirements for behaviour is manifestly necessary. The required change is based on a new way of thinking: the art of patient safety. By following and exploring the path presented in this book, you can develop your patient safety skills to complement your knowledge and expertise.

Leseprobe

‘To lead people towards a new goal, we must first find out where they are now. To really be able to help others, we must know more than they do; but above all, we must understand what they understand. If we fail to recognise this, we may only end up showcasing our own knowledge and seeking their admiration – to no avail. But instead, when we find them, we can walk towards the goal together.’

In this light, we have documented and given an insight on our observations about the current characteristics of healthcare and social welfare.

Those characteristics have a significant impact on management, employees’ performance, and consequently, on customer and patient safety. We will also present the means to encourage creating a new organisational culture.

Contents

Prologue

I Introduction

II Organisational and Safety Culture

What is Organisational Culture?

The Contents of Organisational Culture

How Does a Good Organisational Culture Show?

Effectiveness and Continuity Are Needed

Strengthening Mutual Understanding

Supervisors Lead the Way to the Right Direction

Patient Safety Culture

Culture of Accountability and Justness

Problems in Strengthening Organisational and Safety Culture

How to Find Solutions to Problems?

Behaviour Requirements

The Word Discipline Is Difficult to Understand

Positive Discipline

Backstop and Consequences

If Rules Cannot Help

Balance

Professionalism Needs Strengthening

Reliability Creates Confidence

III The Human Being

The Human Being Always Comes First

Organisational Culture from a Patient’s Perspective?

Client or Patient – Service or Care?

Failed Service Causes Harm

Time to Apologise

Human Error

Human Factors behind Errors

Systemic Chains and Control Processes behind Errors

Relation between Organisational Culture and Errors

In the Distorting Light of Hindsight

The Road from Errors to Learning

Taboos behind Errors

How Can Human Errors Be Prevented?

IV Cooperation

Together and in Unison

Team Resource Management (TRM)

Procedures and Checklists

Safe Communications (ISBAR)

Hot Wash-Up

V The Operating System of Patient Safety

The Contents of the Operating System

Patient Safety Plan

Managing Operational Risks

Zero Harm: Is It Possible?

Functional Risk Management in Practice

Risk-Taking

Assessing Functional Risks

The Bowtie Method

About Reporting Systems

What Could You Do?

Examining and Investigating Adverse Events

VI Learning

What Should You Learn about Patient Safety and How?

The Learning Organisation and Change

Knowledge Management

On the Relation between Success and Failure

Communication Is a Skill

How to Proceed?

Communication Needs to Change

VII Management and Leadership

Management Challenges

The Situational Picture in Patient Safety

Managing Safety Culture

Organisational Culture Eats Strategy for Breakfast

The Values of the Organisational and Safety Culture

Measuring the Organisational and Safety Culture

The Changing Operational Environment

The Excellency Trap and the Imperative of Success

The Need for Change Is Significant and Urgent

A Vision for Change

How to Make a Change?

Transformational Leadership

Changing the Organisational Culture of the Hope Hospital

VIII Foreword

APPENDIX The Patient Safety Diagnosis

Bibliography

Prologue

Finnish Author Väinö Linna once said that the truth must be faced directly. In this book, people take centre stage – patients and employees whose experiences and stories show the way as we examine patient safety as part of organisational culture. This book is based on the writers’ experiences in the field of patient safety. Information has also been gathered by questionnaires and interviews included in the FlyWell patient safety diagnosis tool. The method has been used both in public and in private organisations of different sizes. The diagnosis tool is annexed to this book.

Rather than making science, our aim has been to go through the information and the everyday experiences of people to create a picture you can relate to and make use of in your own work. We have written this book as a complement to scientific research, primarily for the hands-on healthcare and social welfare professionals. We have often pictured in our minds the immediate supervisors. They hold the key in building patient safety by setting a good example and by understanding the significance of organisational culture and safety culture. Whether the door to something new opens or closes hinges on the immediate supervisors, and our aim is to make it easier to open that door.

Healthcare research is faced with the problem that the prevailing perspective of the scientific community – how the reality of healthcare is studied and interpreted (the cultural paradigm) – guides the research and brings new information accordingly. Healthcare is firmly based on natural sciences and modern technical and economic systems thinking which do not direct enough research and interest to people and their behaviour. In practice, however, values, meanings, and attitudes often take precedence over systemic structures when decisions and choices are made.

Research findings show that organisational strategies focus on clientship and competitiveness. Human resources are rarely considered in strategic alignment. ‘This is reflected in the weak connection between strategy and human resource productivity management. Knowing this highlights the need for better analysis and processing of human resource productivity, human motivation, professional skills, and workingability as part of strategy work. Research results show that investing in people and skills benefits the organisation in the form of substantial savings and other advantages.’1 In light of this information, we want to encourage change in the organisational culture of healthcare by way of changing thinking and human behaviour. Accomplishing this means strengthening the parts of organisational culture most clearly visible to patients and their next of kin – service culture and patient safety culture.

By writing this book, we want to encourage you to think about the following question: what can I – by myself and together with others – do better? This book sheds light on patient safety procedures and looks for reasoned answers to the following questions: why do we succeed and why do we fail? What should we learn? How should we act? Where do we draw the line between the acceptable and the unacceptable way of acting? Which safety-related things are non-negotiable? Rather than being a methodological guide or a toolkit, this book aims at building a common understanding of patient safety.

Our gratitude goes to our families. Completing a book takes a lot of time and effort. Special thanks go to Lieutenant-Colonel (retired) Jarmo Ahonen, who has given high quality feedback and proofread the original Finnish text during the writing process. Warm thanks go to Niall O’Donoghue for proofreading the English translation.

When we have told people about writing this book, we have been inundated with stories from both patients and healthcare professionals. We would like to say a warm thank you to all those who have shared their experiences on both positive and negative events.

Tampere, December 2021

Veli-Matti Heinijoki and Petri Pommelin

1 Aura, Ahonen, Ilmarinen ja Hussi. Henkilöstötuottavuuden johtaminen [Human Productivity]. 2018. [English translation of excerpt by Sari Pommelin]

I Introduction

The idea of this book was born when a healthcare organisation chose improving its organisational culture as one of its strategic goals. We started contemplating on the characteristics and quality of a culture in need of improvement. Another incentive was a workplace survey result showing that many employees mistrusted the ability of their own unit to take care of them in case of illness. In addition, the survey showed that compared to the employees, the managers and administrators had a completely different view of that ability. Looking in from the outside, it seemed as though there were two different organisations. Moreover, we were puzzled as to how development work could be carried out in a way that would increase mutual trust within the organisation. Finally, the phrasing of the question went from being the contents of one training session to being a whole book.

As change agents, we want to shake the present organisational culture of healthcare. Our goal is to change the system-based approach into the patient-based approach, and consequently, to build safer practices. The human being – a patient or a client – should take precedence in healthcare and health services. In this book, we will be using the terms healthcare and patient. Most of the text is also compatible with the concepts of clientship and other social welfare and health services.

Our aim is to help create services that meet patients’ requirements, needs, and expectations. Requirements pertain to both patients’ rights and the general justification of the activity. Needs are related to the effectiveness of care. Moreover, every patient has the right to be treated with respect and to be heard. Services should be provided in accordance with commonly agreed procedures and through cooperation between all different occupational groups. The organisational culture, that is, the way people act, entails requirements for both activities and behaviour. Patients should be encouraged to participate in their own care to ensure the right situational picture and diagnosis. The service should be as transparent as possible; and to earn and ensure trust, the service provider should always be able to reliably produce the service repeatedly.

Proactive working methods should be used to prevent the inherent hazards of health services. Physical and non-physical harm should be minimised. An activeoperating system, and the situational picture it gives, help ensure and continuously improve patient safety. The operations should be managed in a way that allows adverse events to be processed in an open, responsible, and fair way. Service providers should be capable of learning from practical experience – good and bad – and to be able to assess and improve the quality of their operations. Patients, their next of kin, and employees should have a voice in their own unique situations, so that they can feel they are being fairly treated.

Without patient- and employee-oriented leadership, patient safety is in danger of remaining a support function lacking its role as an integral part of operational activities. The desired organisational culture requires that managers commit themselves to leading patient safety as an integral part of operational activities and by showing a good example. Through strong management and leadership, the focus for improvement needs to switch from a reactive to a proactive approach that emphasizes risk management.

We will approach the subject through stories because organisational culture and safety culture are formed and communicated to new generations of employees through stories and through everyday work. Employees become members of their social environment and learn their tasks through mutual interaction and through stories of ‘this is how we do it’. Shared knowhow and tacit knowledge mark the basis for everyday decisions – especially in situations beyond the scope of existing instructions.

Although the goal may be to revolutionise the basis of thinking, the most important foundation for high quality performance is continuous improvement. Better cooperation on all levels is also an important part of our vision. Shared knowledge and experiences of events in our work environment should serve as a resource, and they should increase the ability to promote safer and better-quality healthcare. We use questions and arguments to challenge you to reflect on the state of things in your own organisation and on your role and tasks in strengthening the organisational culture. We have created the imaginary Hope Hospital where our visions and development ideas can take wing.

A good organisational and safety culture is like the air in car tyres. It is free and invisible. It enables steering the car and helps both the driver and the passengers feelcomfortable. Without air, traveling becomes impossible before long, no matter how fine and efficient the motor or the equipment may be. In that case, even good driving skills are of no avail.

Healthcare Reform

Finnish healthcare and social welfare services will be reorganised, or they will reorganise themselves. There are several goals. Cost savings are one of them. We believe that the first billion can be saved through a better organisational culture and the benefits it brings. Additionally, besides achieving cost savings, healthcare clients and patients benefit directly in terms of higher-quality care and fewer adverse events. In healthcare, resource constraints are a constant topic of discussion. Seen from the outside, however, it is striking that at the same time significant costs caused by low quality are accepted.

Services of inadequate quality not only cause harm to patients but also consume scarce resources and affect employee well-being by causing friction. Addressing the situation would reduce costs and bring about a multiplier effect – and, therefore, would make sense also functionally and economically. Regrettably, though, the responsibility for keeping these things on the agenda all too often falls on support functions or separate associations that cannot easily make themselves heard in decision-making.

Focusing on costs may lead to the creation of colossal organisations. This, in turn, leads to long and complicated command chains in which the overall responsibility for patients and employees disappears behind increasingly fragmented specialisation. Leadership is at risk of becoming invisible, inaudible, and lost in the system. This feeds an organisational culture where bureaucratic protections are built to protect patients from medical errors.

The focus should be on anticipation, learning, and active leadership. Who will win the fight for the goals of patient safety? Who do we think will win: David or Goliath? The Finnish culture has always appreciated the agile David, but many decision makers seem to believe that the massive Goliath has a better chance of succeeding.

II Organisational and Safety Culture

What is Organisational Culture?

Organisational culture is difficult to detect and recognise, which makes the question interesting. Patient safety strategy and other documents guiding patient safety speak of transparent organisational culture, for example. Just what is meant by transparency has not been critically discussed. To achieve transparency, great hopes have been pinned on employees talking anonymously about their mistakes. Nobody has requested transparency on mismanagement. The traditional blame culture and the pressure from the surrounding society to find culprits hardly encourage transparency. Organisational culture is formed over a long period in the framework of the surrounding society and in the complex network of organisational and professional values and meanings.

A good organisational culture manifests itself in all those involved trusting the will, the skills, and the possibilities of the organisation to carry out its tasks successfully and to achieve its set objectives through the cooperation of all stakeholders. The key word is ‘will’.

Figure 1. The nature of organisational culture

How do work-related values translate into behaviour and communication? For instance, the appreciation of cooperation depends on which skills we value more: professional or teamwork skills? These valuations also dictate investments in education and resources. The social reality of meanings and networks can be depicted by a triangle whose angles represent the structural, social, and psychological dimensions. Within this framework, different communities, groups, and individuals make judgements and decisions; they also behave and communicate in it.

Organisational culture can provide answers to the difficult but essential question why wise and well-educated people too often take unjustified risks and behave as they see fit in various situations, regardless of instructions and the best interest of the patient. The triangle in Figure 2, which represents the dimensions of organisational culture, also provides the framework for the dimensions of learning and improvement.

Figure 2. Dimensions of organisational culture

The structural dimension describes how people and activities are organised. The psychological dimension describes an individual’s perceptions and motivations concerning choices and actions. The social dimension describes the effect that the intra-unit relations have on an organisation and the effect that the whole history of healthcare has on the functioning of an organisation.

Employees can adopt two different models when it comes to their role and attitude in each situation. They can either use their own personal model or let peer pressure affect their behaviour. Employees can have deep concerns about the safety of patients, but as group members, they may accept taking unjustified risks and prioritising the wrong things. This may happen in case of excessive haste, inadequate leadership, or outside pressure. Group members start to become cynical about their work and those around them. They may adopt the same cynical approach to patients and their next of kin. When we have had discussions during training sessions, especially in a neutral environment outside the workplace, I have noticed that people use their own personal model when taking a stand on things. Whereas at the workplace, donning a uniform also means donning the social reality of a group and behaving in tune with its values.

The same goes for a patient. Some years ago, I had hip surgery. I had decided to have an active role in my own care and at the same time, I wanted to monitor the process that I found myself in as a patient. I considered myself an expert in patient safety, and I wanted to learn more through my own experience. So, this was my attitude and starting point. The reality of it was that as soon as I put the hospital pyjamas on, I changed from an active participant and observer to a passive ‘object of care’. I melted away into the daily life of a hospital and regressed to the role of a patient.

The timespan of the organisational culture of healthcare is long. The Hippocratic Oath taken by medical doctors and the story of Florence Nightingale, the selfsacrificing nurse, are well known. In addition to the long timespan, there are other factors that set healthcare apart from other fields: it is emotionally charged and requires special knowledge; it also has an ethical and a moral aspect to it which justify its existence. When people are asked about the most valued professions, medical doctors and nurses are on the top of the list. Doctors with their skills and nurses with their care save and cure people.

Heroic tales in literature and entertainment also play a role in strengthening the mythical identities of health professionals. In practice, however, the lonely hero and the doctor-nurse duo’s key role are now history. The complex environment and the new significant processes – and the new professions and competences that go with them – require new professional skills. (Figure 3).

Figure 3. Elements of patient safety

The Contents of Organisational Culture

Organisational culture develops over a long period of time, and it is inherent in all activities and behaviours within an organisation. People adapt to their social and institutional environment, identify themselves with it and, ultimately, become used to the recurrent everyday behavioural patterns. These patterns form the organisational culture which can be divided into subcultures (Figure 4).

Figure 4. The composition of organisational culture

A uniform organisational culture makes work possible and enables it to proceed smoothly because there is no need to be constantly guessing what another person is going to do and how. Consequently, everyone can concentrate on the essentials. On the other hand, uniformity is also a disadvantage because it causes friction when an organisation is going through change, and it can even prevent the adoption of new approaches. The following story of a bacon pan serves an example of this.

A young couple were starting their life together in a new home. The newlywed husband decided to make his wife happy and made her breakfast. Whistling cheerfully, he prepared a fine brunch. His wife shuffled to the breakfast table and was happy to see the delicious meal before her.

‘Darling, why do you cut up the bacon into these small pieces? Long slices would feel better and crunchier.’

‘This is how we’ve always done it, and we’ve enjoyed it, but don’t ask me why. I’ve got to ask my mother when I see her.’

When the young couple visited the mother-in-law’s, they asked her why the bacon was cut into pieces.

‘I don’t know, but this is how I’ve always done it. Grandma taught me.’

Grandma was still going strong, and when she was asked about the reason for this dilemma rattling the whole family, the answer was clear:

‘When Aron and I got married, we got a frying pan that was too small for the big slices of lard we used to have back then, so we had to chop them.’

The pan no longer exists, and thin slices of crispy bacon have taken the place of lard, but the approach persists, and it has not been questioned until an outsider has paid attention to it. When a new employee, or a more seasoned one, asks you why something is done the way it is done, do not feel offended, but stop and think. It is not meant as negative criticism. You have simply run into a ‘frying pan’ and may find a better approach instead. If you are a supervisor or a senior expert in a leading role, the only way of effectively doing something about ‘inherited’ ways of acting is to be there and to show a good example. That is the only way you will be able to detect the bacon pans. If you have a supporting role and work, say, for patient safety, you will not achieve great results regarding bacon pans without having strong support from the operational management, because only they can create space for improvements by showing a good example.

The essence of organisational culture is also linked to status and organisational structures which are closely interdependent. Achieving or holding on to power – be it giving direct orders, giving expert guidance, or having an influential role – preserves the existing culture. In addition, it causes friction. It is not always about resisting change but rather about the difficulty of giving up old habits. Many organisational cultures stem from a certain social reality and form indiscernible ‘bacon pans’ that go unnoticed, and therefore, obstacles persist. Making way for a new way of thinking and doing is important, because the present culture, too, takes time and resources.Parts of the old culture must go, and you must trust better management and a better way of doing things to create space for something new.

How Does a Good Organisational Culture Show?

A mature organisational culture manifests itself as the will to perform tasks well and to complete them. In ordinary language, a job should be done properly. Managers, supervisors, and employees should take responsibility for the effects of an activity, regardless of the outcome. These responsibilities, together with those accountable, should be clearly determined in an organisation. In a good organisational culture, values are visible in day-to-day decision-making and activities. A good culture is marked by trust, collaboration, appreciation for each other’s knowhow, and being glad about joint success. These attributes should be evaluated in personnel surveys regularly.

The significance of organisational culture as a driver that guides all activities is emphasised in situations for which there are no norms or documented instructions. Even the best methods and tools fail to fully cover every situation or way of thinking that may arise in an organisation. If a work community’s values, essence and its employees’ attitudes support, for example, making a joint risk assessment before deciding to act, a reliable and safe outcome can be expected, and vice versa. The next two cases exemplify a less than perfect organisational culture that affects patient safety. They also show how many ways of thinking there can be.

I was discussing with the head nurse of an elective surgery hospital the alertness of operating theatre personnel. I mentioned the requirements for resting time and pre-flight alcohol use the Finnish Air Force have for their pilots. She replied: ‘Many of the people here are mothers with young children. If we started making demands about sleep and alertness, we couldn’t get anything done, because they are tired, the lot of them. It would be impossible to plan the shifts if you could simply call in tired.’

The head nurse and the hospital may certainly see it this way, but what do patients think when they find out that some of the people taking care of them are as alert as someone with one per mil alcohol in their systems? A surgeon in his sixties told me he had been trained by war veterans. They had told him that they had stayed awake for up to seventy-two hours with the help of medicines, so surely, he could stay awake and work for at least twenty-four hours. Might there be something wrong with the reasoning if a member of hospital staff feels like surrounded by war, even though neither of the above-mentioned cases was about a lifesaving procedure.

Effectiveness and Continuity Are Needed

Paying more attention to effects instead of results would allow an organisational culture to evolve. For example, by implementing a patient safety incident reporting system, healthcare organisations have been able to achieve results in the form of reports and statistics, and by means of that act, they have met the standard of reporting. However, if cultural commitment, transparent reporting, the importance of feedback, and the possibility of learning have not been fully embraced, or if there is no time or ability to complete the reporting process, then the desired effects on the quality of care and on patient safety are not achieved. The same problem applies to many other development projects as well. Results are achieved, but the operational effects do not materialise, nor are they assessed.

The importance of learning from mistakes has been used as an argument for incident reporting. This idea is being etched on people’s minds as an integral part of patient safety. When an incident is detected, you simply draw up a report and believe improvements will automatically follow. This leads to a wrong kind of approach, and the operational management and guidance remain weak. The situation is handled two weeks later – if at all. We – the writers of this book – must also confess to swearing by reporting. But the real effects remain few and far between. The only lesson learned from mistakes is that they can be brought out into the open, which, of course, is also important. However, effectiveness, in other words transparency, better situational awareness, and increased patient safety are not put into practice. Consequently, it is important to try out a parallel model, in other words, learning from best practices andsharing knowledge thereof. It would be interesting to learn what happens when people succeed in something.

Strengthening Mutual Understanding

Sounds nice, doesn’t it? This is a good starting point. It is easy to get on with people who agree with you. Some time ago, I commented on a patient safety incident and its consequences. I sent the comment to some of my friends. Most of them did not reply, but one sent a happy emoji and wrote: ‘I agree.’ Having read a few more sentences I realised he had not understood my message the way I had intended.

His reply made me think about the importance of ensuring mutual understanding. A comment is not enough as a response, at least not if you want to make a joint decision or an assessment of the situation. Even though the sender agreed, it would still be important to verbalise the thought more accurately to make sure that mutual understanding really has been achieved.

The hierarchical culture of healthcare does not encourage disagreeing. It is safer to agree or to say nothing. Nevertheless, even in this situation, patient-centeredness and patient safety require a certain kind of behaviour. This makes you think that ‘agreeing’ can be more dangerous than ‘disagreeing’. If I say I disagree on something, it usually calls for a reason, which in turn clarifies the situation by giving a new perspective. In addition to expressing your own opinion, do not hesitate to disagree. It helps build a more diverse picture of the situation. If you are a supervisor or an expert, do not be afraid of hearing this sentence: ‘I disagree.’ It only means that someone has really listened to you, started thinking, and trusts you as a supervisor because that someone has the courage to express his or her opinion.

In the future, employees from different countries and cultural backgrounds will challenge the cultural and linguistic conceptions of seeing different situations, and theways of acting in those situations. The next story describes how fundamentally different even national cultures can be, and how different interpretations and ways of acting they can lead to.

When I was Squadron Commander in the Finnish Air Force, a British squadron visited our base. The goal was to learn from each other’s best practices and to exchange information and experiences from day-to-day work. The goal was achieved. What I remember best is our cultural differences. We were sitting in my office, and I was showing my British colleague a report on aviation safety notifications and speaking about their content and our reporting system. He paid attention to how ‘many’ human errors the Finnish pilots made. He asked what happens to the pilot when an error comes to light? I replied that first, he is praised for his honest report and then, he is given guidance on the correct procedures and the data about the incident is shared with everyone, so that lessons can be learned. He, in return, told me that in Britain, such mistakes would be penalised by fines or by giving a warning. And because of these decisive actions, very few mistakes happen, which, in turn, means very few reports. When we were walking down the stairs, he said, in a friendly fashion, that we still seem to have a lot to learn about building a strict and safe culture for those serving in the air force.

I decided in my mind that on the contrary, we had reached a slightly more advanced level. It has been a while since that meeting, and I am sure that also in Britain, things are different now. I think the situation described above is a good example of the cultural differences between people’s perceptions of what is the right or the wrong thing to do.

I continued pondering the same matter in connection with another case. A commander of a squadron I value greatly was an expert in aeroplanes, tactics, and aerodynamics; they formed the basis of his thinking. I wanted to know how to become a good and skilled pilot and to find a working environment where it would be possible. I found the term airmanship interesting. Consequently, we had two different perspectives and two different cultural points of view – the scientific and the behavioural, which sometimes made it more difficult to see eye to eye. Understandingthis made me realise that it was also our mutual strength. Together we can be more and serve better our goals, employees, and students. We had always pulled together, but now more than ever, we were on the same page.

Supervisors Lead the Way to the Right Direction

Organisational culture is led by example and by presence in everyday situations. The key role is played by the ‘significant others’, in other words people who, owing to their status or some other reason, have authority over others. They can preserve or create a culture, for better and for worse. Employees find out what is important simply by watching where their supervisors and managers are headed, what they talk about, and what they take interest in. ‘Follow the leader’ is an important game to play also in working life.