What are some examples of quality improvement in healthcare?
Over the last two decades, the desire for quality and safety improvement initiatives has prevailed in the healthcare industry. Quality health care refers to the extent to which the health services for populations and individuals increase the probability of desired health outcomes and are compatible with the existing professional knowledge. A recent Institute of Medicine (IOM) study reiterated the need for pressurized efforts to ensure patient safety. Studies have shown that faulty medical processes and systems rather than individuals cause the majority of medical errors (Hughes, 2008). These include inefficient and variable medical processes, the changeful mix of patients, variable provider experience and educational level, health insurance errors and several other factors contributing to the complexity of the healthcare. Additionally, to the present-day health care industry also functions at a much lower level than it is capacitated to provide effective, timely, efficient, equitable, patient-centred and most importantly safe health care (Hughes, 2008). Since errors result from the process and system failures, it is significant to adopt a range of process-improvement techniques that can identify ineffective and inefficient care and preventable errors and to influence changes related to the systems. Despite the existing errors, in the global health industry, developed nation such as Australia, United Kingdom and United States have made several advances over the last two decades. This paper examines the achievements that have been made towards improved patient safety in the last two decades. It also provides an analysis of the barriers to achieving 100% safe health services
Patient safety comprises the processes involved in protection of patients from injuries resulting from medical mismanagement. Ensuring patient safety called for operational processes and systems that increased the likelihood of deterring adverse events (Fletcher, 2001). Developed nations are in endless pursuit of ways to improve the quality of healthcare in order to make it safer. Accidents and medical errors happen either through omission or commission, through system and process failures, as well as through nosocomial infections and iatrogenic infections (Graves et al., 2009; Reed & Kemmerly, 2009).
While there is no assurance on the exact number of the adverse events, estimates indicate that some 10 percent of patients worldwide experience some form of adverse events in hospitals while about 2 percent experience serious consequences (Braithwaite, 2005). Despite the fact that it is not clear the number of events that are preventable, it appears that the deaths reported in hospitals, which result from preventable events, exceed the death toll. This however does not suggest that the medical errors happen strictly in hospitals (Agrawal, 2009). In any case, there are not reliable statistics from other health care areas, such as dentistry, to support the assumption.
Despite the large scale of medical errors, certainty on the numbers of the adverse incidents is non-existent in Australian hospitals and overseas. Indeed, most studies have extrapolated national figures from small sample populations. Based on analysis of 14,000 medical records, a study by the Quality in Australian Health Care of the Healthcare System in 1995 showed that 18,000 Australians died each year. In which case, some 16 percent of the hospital admissions could be related to adverse events (Emslie et al. 2002). Therefore, assuming that some 25 percent of the deaths resulted from adverse medical error events can be prevented, nearly 4,500 preventable deaths estimated from the 1995 study correspond to 13 Jumbo jet crashes each year. Although the figures are disputable, the medical error toll definitely overcomes that of road carnage toll of 1634 as of 2003 (Australian Transport Safety Bureau 2003). Studies done between 2000 and 2001 indicate that some 2 percent of the patients experienced severe effects while 10 percent of the patient experienced adverse events. This indicates large numbers given that an estimated 6.4 million hospital admissions were reported in Australia during the period (Roughead, 2008).
The healthcare systems have failed to guarantee safety of the patients because of the complexities in the healthcare system. Indeed, given the astonishing figures, the epidemiology of such silent epidemic has over the last one decade been examined with global figures indicating that some 10 percent of the patients will be harmed through preventable medical errors. Of these, 8 percent will die while 6 percent will suffer from permanent disabilities (Emslie et al. 2002).
Shift in regulations are among the most definite advances in promoting patient safety, specifically fuelled by the rise of private entrepreneurs in addition to the introduction of market mechanisms in the public sector. Among the developments include that of creation of regulatory bodies that seek conciliatory, devolved and participatory regulations, while at the same time sustaining traditional administrative methods such as inspections (Emslie et al. 2002).
Development of regulations over the last two decades has marked major advancements in the promotion of patient safety. In reaction to the mounting pressures on the need to address medical errors over the last two decades, recent years have witnessed proliferation of regulatory strategies and actors. For instance, Australia has the Australian Council for Safety and Quality in Health Care (2000), the US established the National Quality Forum, the UK has the Healthcare Commission, and Canada has the Canadian Patient Safety Institute.
A major shift has been noted in seeking the best way to ensure better and safer health care. While a larger bulk of the efforts has been channelled towards ensuring quality improvement, the patient safety issues still dominate the greater reform forum. At the same time, the control of abatement of risks to the communities as a key purpose has also emerged as the focus of these regulations. Advances have been seen in the approach to these regulations (Roughead, 2008). While the medical professional has traditionally been based on self-regulation, such a complacent approach is today being challenged by the growing regulatory bodies globally. Additionally, there is also interest in adopting external regulatory levers aimed at improving performance within the organisations, instead of assuming that such remedies should be left solely to voluntary behaviour change on the part of individual physicians, to ensure safe processes and systems.
Among the achievements in patient safety include networked governance of healthcare to promote patient safety. Government capacities have evolved in a range of directions. Today, the strategic planning performed by government departments takes consideration of the plans of various governmental and private sector players’ interests in order to ensure that their concerns on patient safety are considered (Roughead, 2008).
This however does not point to the idea of State Health Department or Commonwealth government aiming to wield power it is not mandated. Networked governance has achieved meaningful planning of healthcare provision by taking into consideration different other levels of the government, the hospital industry as well as pharmaceutical industry. This approach has been pursued by the Australian Council for Safety and Quality in Health Care, which the Australian Government Health Minister established in 2000 (Emslie et al. 2002). The Council functions through networked governance to gather different actors in healthcare provision to promote patient safety. The concept of networked governance is essentially suitable for pluralist health sector, such as that of Australia with multiple interest groups.
Several achievements have been made in reporting of errors. Reporting of events and standardised collection of data yields crucial data that is applied in medical practices to promote patient safety (Duguid, 2012). In Australia, this has been facilitated through federal efforts in creating patient safety organisations (PSOs) that are authorised to receive and review patient safety data, while at the same time engaging healthcare providers to improve healthcare delivery, without the fear of legal consequences (Clancy, 2009). Australian Council for Safety and Quality in Health Care also works to detect the safety and quality issues from the patient records. This has improved the ability of the government to monitor whether its objectives of ensuring safe healthcare is met.
Australian Council for Safety and Quality in Health Care has managed to reinforce a culture of safety among nursing homes, hospitals and medical offices in monitoring, evaluating and improving patient safety performance in Australia. In the United States, the AHRQ has reiterated the need for healthcare providers to use its suit of patient safety culture survey. The tool offers a baseline for organisations to monitor changes over time and to assess the patient safety intervention impacts. At present, some 6000 hospitals have established a mechanism that allows them to share culture survey data. This allows these hospitals to compare the efforts they make and to improve in consistency with the date, from the better performing hospitals. At the same time, peer-reviewed web-based journal, patient safety developed through the tool, helps organisations to espouse a blame-free culture and to assist the physicians to learn from each other’s mistakes (Clancy, 2009).
Australian Council for Safety and Quality in Health Care supports the development of patient-safety checklist that has been proved to deter, costly and deadly central line-associated bloodstream infections by some 66 percent (Clancy, 2009). Such promoted interventions include compulsory hand-washing along with other sanitary activities that aid in significant and sustained infection reductions (Graves et al., 2009). At the same time, increased use of intensive toolkit that contains the checklist among other tools has helped hospitals to reduce the infections by 75 percent (Clancy, 2009).
The creation of the Safe and Quality Use of Medicine in Australia in the 1990s triggered the review of traditionally-accepted practices that surround medication administration and reconfigured research-based safe use of medicines. This has indeed led to the origination of the term medication administration errors, which defines the deviation from the doctor’s medication orders as indicated by the patient charts. Other countries, such as New Zealand, followed a similar trend to that of Australia (Roughead, 2008). In 2003, the country’s healthcare providers started to adopt the Australian strategy to address the medication issues that hampered patient safety. Such strategies have presented nurses with opportunities to contribute to practical initiatives at the national policy level and to improve patient safety. It is critical to note that nurses engage actively in the debate, as well as donate enormous knowledge in this area.
Application of information technology systems in medication management has simplified the complex medical processes that are error-prone. This is particularly significant since clinical decision-making is a complex process that relies heavily on the ability of humans to concentrate and recall or process large amounts of date. The IT systems have improved access to patient information, such as medical history, which are vital for patient-care decision-making. For instance, the use of computerised physical order entry (CPOE) has been applauded for reducing errors in decision-making. Among the preventable errors that risk patient safety deterred by CPOE include wrong dosage form, wrong use of drugs, wrong dose calculation and instances where allergies are not checked while prescribing medication. Such systems make sure that orders are complete and legible (Henry & Fourer, 2009).
Further advances have been made in Australia. For instance, National Health Information Management Advisory Council (NHIMAC) was established to encourage collaboration between the States, Territories and Commonwealth to attain a national approach to the development, adoption and execution of online technologies in the health care, with the goal of improving patient safety (Emslie et al. 2002).
Several computer softwares have been developed to promote patient safety and quality healthcare, through teamwork, among them being TeamSTEPPS™. This evidence-based system has improved communication and teamwork among the healthcare practitioners through a complete set of training curricular. In the United States for instance, it has been distributed to over 14,000 organisations (Clancy, 2009). Several other programs, such as Team-oriented Medical Simulation (TOMS) and Anesthesia Crisis Resource Management (ACRM) are today used in Australia and the United States in training teamwork skills to the healthcare professionals, so as to promote patient safety.
To prepare healthcare practitioners for high-risk events, Australian Council for Safety and Quality in Health Care has supported numerous programs that make of simulation technology to improve communication, safety culture, teamwork, technical and diagnostic skills and other numerous features of safe healthcare (Baker et al., 2005). Among the projects include the Patient Safety Education Project (PSEP), which seeks to promote shift in patient care by promoting ‘train-the-trainer” curricular used in teaching the physicians to train patients on self-care. The program that was developed in 2007 is today widely used in Australian and the United States (Emanuel et al., 2008).
In Australia, the Australian Council for Safety and Quality in Health Care supports studies into medical resident fatigue and its correlation to medical errors. The researches have highlighted why resident fatigue is a key risk factor for medical errors. Progresses have achieved in the Australia leading to adjustment of hours per week that the medical residents should work (Agrawal, 2009).
A key challenge to promoting patient safety and healthcare quality is the lack of information on what should comprise ‘best practices’ or minimum satisfactory standards. Despite this, there is limited information on the degree of serious or adverse incidents. At the same time, error reporting systems have not been well established, in spite of the efforts to set up adverse events registers, as well as to document and review safety events. It should be observed that the lack of information has constrained the application of benchmarking, of the continual process of measuring the performance against standards (Roughead, 2008). These could have promoted the basis for continual quality improvement. Indeed, the issues that surround error-reporting include whether it should be made voluntary or compulsory. For instance, if physicians fail report errors based on fear of professional solidarity and litigation solidarity, then it follows that consumer complaints can become increasingly significant while a range of initiatives are ongoing to improve the capacity of patients to monitor the healthcare.
Failure in communication is also a major barrier to improved patient safety. Complex information systems require information systems that offer free-flow communication, in and among the medical professionals. Lack of communication may be caused by insufficient discussions of medical cases and oversight on the part of the medical staff in varied departments to coordinate patient safety.
Additionally, while improved reporting of events and standardised collection of data has promoted awareness of patient safety problems, documenting of improved performance is still challenging, since it can be difficult to interpret the increased rates of reporting the progress made in the actual events (Clancy, 2009).
Organisations in the health care sector also tend to prefer internal and not external regulatory strategies. Additionally, adoption of the safety-oriented practices is voluntary rather than obligatory, whether it concerns benchmarking, reporting of incidents caused by medical errors or lack of compliance clinical protocols. The main challenge at this stage is that the ‘voluntarist approach’ regards healthcare providers, such as hospitals, as if they are separate from its environment. In any case, the behaviour of the hospital and its staff is greatly susceptible to external pressures and organisational structure and culture interactions (Agrawal, 2009).
Failure to safeguard automation
Errors resulting from failure to safeguard automation have been a barrier to promotion of patient safety. A range of medical procedures are presently performed by automated systems through programmable machines. The significance of automating error-prone tasks through application of technology is broadly recognised. With automation having significant promise for improved patient safety, it should therefore be noted that technologies bring about the potential for novelty adverse events. Hence, any new automated system should be tested for operational settings. Examples of automation error include infusion pump free-flow causing overdose.
Staff shortage is also a major barrier to promotion of patient safety. Hospitals that are understaffed experience overworking of personnel, resulting to sleeplessness, stress and impaired thinking. This may cause lapse in performance. In the United States, many hospitals require nurses to work for more than 12 hours in a day. A national survey of medical residents hours of working revealed that some 50 percent of the first-year residents and another 30 percent of second-year residents worked for between 30 hours per shift. Unquestionably, this affects the performance of and quality of healthcare provision.
The prevalent complexity of the present-day modern medical care is among the factors barring promotion of patient safety. Modern-day hospitals are stocked with hazardous substances, which are operable by individuals with high stress levels performing intricate technical procedures. These define a risky environment. Studies have indicated that intensive care in complex clinical environments is more vulnerable to adverse events. At the same time, heavy workloads, insufficient staff and limited access to essential medical equipment also define factors in the work environment that bar patient safety.
Organisational cultures can also be unfavourable to the realisation of total patient safety. For instance, punitive organisational culture is a key barrier to promotion of patient safety, as workers tend to feel endangered by the ‘blame and shame’ cultures. This prevents the likelihood of identifying and addressing problems. Improved patient safety is dependent on review of and learning from the discovered adverse events. However, the ‘blame and shame’ culture may discourage the healthcare practitioners from reporting them. Hence, an organisational culture that is punitive is deterrent to the realisation of the flaws of the healthcare system and the efforts to improve patient safety.
Despite the existing errors, in the global health industry, developed nations, such as Australia, United Kingdom and United States have made several advances over the last two decades. Achievements made in patient safety include development of patient safety regulations, networked governance, advances in error reporting, creation of a culture of safety, reduced infections associated with healthcare, development of safety standards, use of IT systems, intensified teamwork in healthcare provision, advances in patient safety training and reduced medical resident fatigue. The barriers to achieving 100% safe health services barriers include lack of effective information-sharing, preference to internal regulatory strategies, failure to safeguard automation, shortage of staff, error-prone environment and organisational cultures
Agrawal, A. (2009). Medication errors: prevention using information technology systems. Br J Clin Pharmacol. 67(6), 681–686.
Australian Transport Safety Bureau. (2003). Road Fatalities, Australia: Monthly Bulletin. Canberra: Australian Transport Safety Bureau
Baker, D., Gustafson, S., Beaubien, M., Salas, E. & Barach, P. (2005). Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville: Agency for Healthcare Research and Quality (US)
Braithwaite, J., Healy, J., Dwan, K. (2005). The Governance of Health Safety and Quality. Commonwealth of Australia,
Clancy, C. (2009). Patient Safety: One Decade after To Err Is Human. Patient Safet and Quality Healthcare. Retrieved: <http://www.psqh.com/septemberoctober-2009/234-september-october-2009-ahrq.html>
Duguid, M. (2012). The importance of medication reconciliation for patients and practitioners. Aust Prescr 35, 15-9
Emanuel, L., Walton, M., Hatlie, M. & Lau, D. (2008). Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville: Agency for Healthcare Research and Quality (US)
Emslie, S, Knox, K & Pickstone, M 2002, Improving Patient Safety: Insights from American, Australian and British Healthcarse, ECRI Europe, Herts
Graves, N., Halton, K., Paterson, D. & Whitby, M. (2009). The economic rationale for infection control in Australian hospitals. Healthcare Infection, 14(3), 81-88
Henry, K & Fourer, M. (2009). Medication Administration Errors: Understanding The Issues. Australian Journal of Advanced Nursing 23(3). 34-41
Hughes, R. (2008). Tools and Strategies for Quality Improvement and Patient Safety. Rockville: Agency for Healthcare Research and Quality
Reed, D. & Kemmerly, S. (2009). Infection Control and Prevention: A Review of Hospital-Acquired Infections and the Economic Implications. Ochsner J. 9(1), 27–31.
Roughead, L. (2008). Literature review: medication safety in acute care in Australia. Adelaide: University of South Australia