How safe is the safety paradigm?

Exploring the role of managers in the development of a safety culture in seven French healthcare facilities: a qualitative study

BACKGROUND

Numerous studies have been conducted over the past 15 years to assess safety culture within healthcare facilities; in general, these studies have shown the pivotal role that managers play in its development. However, little is known about what healthcare managers actually do to support this development, and how caregivers and managers represent managers'role. Thus the objectives of this study were to explore: i) caregivers and managers' perceptions and representations of safety, ii) the role of managers in the development of safety culture as perceived by themselves and by caregivers, iii) managers' activities related to the development of safety culture.

METHODS

An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in France. Semi-structured interviews were conducted with managers (frontline, middle and top level) and caregivers (doctors, nurses and nurse assistants) and on-site observations of two managers were carried out in all facilities. A thematic analysis of semi-structured interviews was performed. Observed activities were categorised using Luthans' typology of managerial activities.

RESULTS

Participants in semi-structured interviews (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants. However, caregivers' expectations of their managers and managerial perceptions of these expectations only partially overlapped.

CONCLUSIONS

The present study highlights current categories of managerial activities that foster safety culture, and points out an important gap between caregivers' expectations of their managers, and managerial perceptions of these expectations. The findings underline the need to allow more time for managers and caregivers to talk about safety issues. The results could be used to develop training programs to help healthcare managers to understand their role in the development of safety culture.

Apparent Cause Analysis: A Safety Tool

Causal analysis is a core function of safety programs. Although established protocols exist for conducting root cause analysis for serious safety events, there is limited guidance for apparent cause analysis (ACA) in health care. At our institution, through a novel facilitated ACA approach, we aim to improve safety culture and provide a clear approach to address precursor safety events and near-miss safety events. We define facilitated ACA as limited investigation (scope and duration) of a safety event that resulted in little to no harm. These investigations require fewer resources and focus on preventive strategies. Our facilitated ACA model, with an operational algorithm and structured process, was developed and implemented at our tertiary-care, freestanding, urban pediatric hospital in 2018. Sixty-four ACAs were completed, and 83% were identified with the algorithm. Process measures, including time from event reporting to ACA launch (median 3 days; interquartile range 2-6 days), are tracked. Patient safety consultants averaged 5 hours to complete a facilitated ACA. A median of 3 disciplines or departments participated in each facilitated ACA. Through an iterative process, we implemented a structured process for facilitated ACA, and the model's strength includes (1) right event, (2) right team, (3) right analysis, and (4) right action plans. This novel facilitated ACA model may support organizational cause analysis and improve safety culture with higher-reliability processes.

Certainty and safe consequence responses provide additional information from multiple choice question assessments

BACKGROUND

Clinicians making decisions require the ability to self-monitor and evaluate their certainty of being correct while being mindful of the potential consequences of alternative actions. For clinical students, this ability could be inferred from their responses to multiple-choice questions (MCQ) by recording their certainty in correctness and avoidance of options that are potentially unsafe.

METHODS

Response certainty was assessed for fifth year medical students (n = 330) during a summative MCQ examination by having students indicate their certainty in each response they gave on the exam. Incorrect responses were classified as to their inherent level of safeness by an expert panel (response consequence). Analyses compared response certainty, response consequence across student performance groupings.

RESULTS

As students' certainty in responses increased, the odds they answered correctly increased and the odds of giving unsafe answers decreased. However, from some ability groups the odds of an incorrect response being unsafe increased with high certainty.

CONCLUSIONS

Certainty in, and safeness of, MCQ responses can provide additional information to the traditional measure of a number correct. In this sample, even students below standard demonstrated appropriate certainty. However, apart from those scoring lowest, student's incorrect responses were more likely to be unsafe when they expressed high certainty. These findings suggest that measures of certainty and consequence are somewhat independent of the number of correct responses to MCQs and could provide useful extra information particularly for those close to the pass-fail threshold.

Patient Experience Shows Little Relationship with Hospital Quality Management Strategies

OBJECTIVES

Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures.

MATERIALS AND METHODS

We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level.

RESULTS

Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture n = 1,503, deliveries n = 2,088, stroke n = 1,566). Patients admitted for hip fracture and stroke had the lowest scores across the four patient-reported experience measures throughout. Patients admitted after acute myocardial infarction reported highest scores on patient experience and hospital recommendation; women after delivery reported highest scores for patient involvement and health care transition. We found no substantial associations between hospital-wide quality management strategies, patient involvement in quality management, or patient-centered care strategies with any of the patient-reported experience measures.

CONCLUSION

This is the largest study so far to assess the complex relationship between quality management strategies and patient experience with care. Our findings suggest absence of and wide variations in the institutionalization of strategies to engage patients in quality management, or implement strategies to improve patient-centeredness of care. Seemingly counterintuitive inverse associations could be capturing a scenario where hospitals with poorer quality management were beginning to improve their patient experience. The former suggests that patient-centered care is not yet sufficiently integrated in quality management, while the latter warrants a nuanced assessment of the motivation and impact of involving patients in the design and assessment of services.

Quality management and patient safety: survey results from 102 Hungarian hospitals

OBJECTIVES

The aim of this study is to describe the development of quality management systems in Hungarian hospitals. It also aims to answer the policy question, whether a separate patient safety policy should be created additional to quality policies, on national as well as hospital level.

METHOD

In 2005, a questionnaire survey was conducted to evaluate the existing quality management systems in all Hungarian hospitals. The relationship between the level of the development of quality management systems, the certification status and the current level of patient safety activities was investigated using linear regression. Quality was measured with the quality management system development score (QMSDS), and patient safety by the number of patient safety activities.

RESULTS

102 of 134 (76%) of the hospitals have returned the questionnaire. The average hospital has 24.5 of 35 core quality activities, and 4 of 11 patient safety activities. There is a statistically significant but weak relationship between the QMSDS and the number of patient safety activities, explaining 12% of the latter's variance. Certification (International Standards Organisation (ISO) and professional standard based) is not significantly related to patient safety.

CONCLUSIONS

In our study quality by QMSDS is weakly related; however, certification is not significantly related to patient safety. We conclude that separate patient safety policies seem worthwhile to be created for the hospital sector in addition to the ongoing quality improvement efforts in Hungary.

Challenging patient safety culture: survey results

PURPOSE

The purpose of this paper is to measure patient safety culture in five Belgian general hospitals. Safety culture plays an important role in the approach towards greater patient safety in hospitals.

DESIGN/METHODOLOGY/APPROACH

The Patient Safety Culture Hospital questionnaire was distributed hospital-wide in five general hospitals. It evaluates ten patient safety culture dimensions and two outcomes. The scores were expressed as the percentage of positive answers towards patient safety for each dimension. The survey was conducted from March through November 2005. In total, 3,940 individuals responded (overall response rate = 77 per cent), including 2,813 nurses and assistants, 462 physicians, 397 physiotherapists, laboratory and radiology assistants, social workers and 64 pharmacists and pharmacy assistants.

FINDINGS

The dimensional positive scores were found to be low to average in all the hospitals. The lowest scores were "hospital management support for patient safety" (35 per cent), "non-punitive response to error" (36 per cent), "hospital transfers and transitions" (36 per cent), "staffing" (38 per cent), and "teamwork across hospital units" (40 per cent). The dimension "teamwork within hospital units" generated the highest score (70 per cent). Although the same dimensions were considered problematic in the different hospitals, important variations between the five hospitals were observed.

PRACTICAL IMPLICATIONS

A comprehensive and tailor-made plan to improve patient safety culture in these hospitals can now be developed.

ORIGINALITY/VALUE

Results indicate that important aspects of the patient safety culture in these hospitals need improvement. This is an important challenge to all stakeholders wishing to improve patient safety.

Assessment of patient safety research from an organizational ergonomics and structural perspective

The aim of this study is to review patient safety improvement initiatives within a conceptual framework that builds upon principles of organizational ergonomics and emphasizes structural factors that influence patient safety. The literature review included 131 English language published studies of patient safety improvement strategies extracted using Medline, Ovid Healthstar, PubMed and CINAHL searches. Keywords for the search included: 'patient safety'; 'medical errors'; 'adverse event'; 'iatrogenic'; and truncated options for 'improve'. The multilevel, hierarchical framework offered in this paper integrates quality management principles and organizational ergonomics theory and organizes patient safety initiatives according to sociotechnical system elements within three structural levels: health policies and associated health care organizations; health care delivery organizations; and health care microsystems. Utilizing the conceptual framework, this review of patient safety improvement initiatives highlights the need for consideration of the impact of all improvement proposals on each structural component within health care systems. The review also supports the need for patient safety research to evolve from exploratory, 1-D reporting to multi-level, integrated research.

Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system

Major reforms of the health insurance system and reimbursement systems for care providers are currently taking place in The Netherlands. These market-oriented health care reforms will transform the current central supply-driven system to a system of managed competition both among health care insurers and care providers. The reforms are not systematically linked to the discussions about quality of care and together with consumers who might be more interested in lower premiums; they offer almost no incentive for health care insurers and providers to steer on quality. Dutch policy makers should, therefore, be more explicit whether competition should take place on quality or price, and if the former is the case, additional incentives as part of the system reforms, are needed to create a business case for quality.

Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis

BACKGROUND

Few studies have tried to assess the combined cross-sectional and temporal contributions of a more comprehensive set of amenable factors to population health outcomes for wealthy countries during the last 30 years of the 20th century. We assessed the overall ecological associations between mortality and factors amenable to public health. These amenable factors included addictive and nutritional lifestyle, air quality, public health spending, healthcare coverage, and immunizations.

METHODS

We used a pooled cross-sectional, time series analysis with corrected fixed effects regression models in an ecological design involving eighteen member countries of the Organisation for Economic Cooperation and Development during the period 1970 to 1999.

RESULTS

Alcohol, tobacco, and fat consumption, and sometimes, air pollution were significantly associated with higher all-cause mortality and premature death. Immunizations, health care coverage, fruit/vegetable and protein consumption, and collective health expenditure had negative effects on mortality and premature death, even after controlling for the elderly, density of practicing physicians, doctor visits and per capita GDP. However, tobacco, air pollution, and fruit/vegetable intake were sometimes sensitive to adjustments.

CONCLUSION

Mortality and premature deaths could be improved by focusing on factors that are amenable to public health policies. Tackling these issues should be reflected in the ongoing assessments of health system performance.

Recognizing drug-induced liver injury: current problems, possible solutions

Currently there are three major problems in understanding drug-induced liver injury (DILI): (1) reliably establishing whether the liver disease was caused by the drug, or by another process; (2) determining the true incidence of and clinical risk factors for drug-induced hepatotoxicity; and(3) elaborating the mechanisms by which injury occurs to hepatocytes and other liver cells. We have focused here on the first two problems, as issues that may be amenable to actions in the near future, but the third may take substantially longer to work out. The first problem requires sufficient information for medical differential diagnosis. There are no pathognomonic indicators of DILI; even liver biopsy is not diagnostic. Making the correct attribution of causality requires analyzing the temporal relationship of drug exposure to illness and excluding all other possible causes. The second problem, determining incidence, cannot be done entirely adequately using currently available methods, whether by clinical trials, by spontaneous adverse event reports, or by retrospective epidemiologic studies. There is need for prospective safety studies to establish the true incidence of DILI caused by a drug, to identify risk factors for it, and to collect biologic materials for analytic studies toward better understanding mechanisms of DILI.