Influencing the Quality, Risk and Safety Movement in Healthcare

In Conversation with International Leaders

Kim Sears, Denise Stockley

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781317116912
• Edition: 1
• Topic: Technology & Engineering
• Subtopic: Industrial Health & Safety
• Index: Technology & Engineering

Influencing the Quality, Risk and Safety Movement in Healthcare explores the inner workings of some of the most influential minds in healthcare quality, risk and safety. The book was created in cooperation with the Master of Science in Healthcare Quality graduate program, developed and delivered by Queen's University, Canada. This is the only standalone interdisciplinary Master of Science graduate degree in Healthcare Quality in North America that focuses on creating tomorrow's healthcare leaders. Following a one-to-one collaboration between each leader in healthcare with a dedicated learner of the MSc(HQ), readers are presented with a synopsis of the leader's work followed by an in-depth interview with him or her. Interviews center around the leaders' contributions to and thoughts on quality, risk and safety in healthcare, dealing with topics such as the development of their body of work, their greatest achievements, what they wish they could change, and future direction of quality, risk and safety, etc. The book provides a unique and highly accessible view into how and why the science of healthcare quality has developed, as well as giving a first-hand account of the founders and key players in the movement. It will offer valuable insights to any undergraduate/graduate class with an interest in healthcare, as well as professionals working within any of the many disciplines that can influence the healthcare system.

Chapter 1
International Leaders Influencing the Quality, Risk, and Safety Movement in Healthcare

Briana Broderick, Kim Sears, and Denise Stockley

Introduction

Issues surrounding quality, risk, and safety in healthcare are not localized issues and are of global concern. Based on this premise, we felt it was important to revisit the state of quality through the lens of international leaders and their perspectives on these issues in order to better understand how the field has evolved and future directions for quality advancement. Quality, risk, and safety are becoming more integrated across healthcare. It is the vision of this book that quality is the overarching concept and under this main concept, risk and safety are embedded. Some have envisioned that quality is an umbrella, which has safety and risk under it while others have conceptualized quality as the foundation upon which safety and risk are built.

Quality is a concept that has gained recognition in the last thirty-five years, but in reality has been around since Hippocrates (de Jonge, Nicolaas, van Leerdam, and Kuipers, 2011). Although there are various definitions of what quality means, it is agreed upon that quality in healthcare is essential to the well-being of patients and healthcare providers, and for the financial survival and growth of an organization (Buttell, Hendler, and Daley, 2007). Although the discipline of quality has a long-standing history in both healthcare and business (Boaden, 2009), the history of the quality movement in healthcare in North America really began in the 1980s as part of the National Demonstration Project on Quality Improvement in Health Care, which developed into the Institute of Healthcare Improvement (who gained it’s official title in 1991). This movement was advanced with the release of the Harvard study entitled Incidence of adverse events and negligence in hospitalized patients, which identified some of the issues that diminish quality within the healthcare system such as the identification that 98,000 adverse events are caused by medical mismanagement (Brennan et al., 1991).

Further to this study, in 2000 the Institute of Medicine released their book entitled To Err is Human: Building a Safer Health System. This book built on the findings of the Harvard study but kept the language accessible for non-clinicians by using real examples, such as, more people die of medical errors then motor vehicle accidents, breast cancer, and AIDS (Kohn, Corrigan, and Donaldson, 2000). Further, this book put a monetary cost to adverse events and noted that these errors cost the healthcare system in the United States (US) between 17 billion and 29 billion per year (Kohn et al., 2000). In 2001 the book Crossing the Quality Chasm: A New Health System for the 21st Century was released and once again identified that we are not advancing the quality of healthcare even though the need has been identified (Institute of Medicine [IOM], 2001).

Similarly in Canada, the quality movement has been advancing at a steady pace. The Canadian Patient Safety Institute was developed in 2003 with a focus to raise awareness of the quality and safety agendas in Canada. In 2004, the Baker and colleagues study entitled The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada, was released demonstrating that the rate of adverse events among patients in Canadian acute care hospitals was 7.5 percent. Of the 2.5 million annual hospital admissions in Canada, this equates to approximately 185,000 patients who experienced adverse events with close to 70,000 of these being preventable (Baker et al., 2004). Furthermore, Canadian data from 2001 revealed that preventable drug related adverse events was estimated to have cost the Canadian tax payers $11 billion (Kidney and MacKinnon, 2001).

Collaborating evidence from Europe demonstrates the global nature of quality, risk, and safety in healthcare. A 2000 report, An organization with a memory, from the United Kingdom Department of Health, revealed that 10 percent of patients experienced an adverse event, resulting in 850,000 adverse events a year (Donaldson, 2002). Data available from the European Union suggests that adverse events occur in 8–12 percent of all hospitalizations (Conklin, 2009). In a 2009 report, it was determined that reducing adverse events in the European Union would decrease medical errors by 750,000 per year, resulting in a reduction of permanent disabilities by 260,000 and 95,000 fewer deaths (Conklin, Vilamovska, de Vries, and Hatziandreu, 2009). For a comprehensive history on the development of the quality, risk, and safety movement throughout Europe, please see A brief synopsis on patient safety, 2010 by the World Health Organization (WHO). In 2012 the European Commission published a report on the results of recommendations made to member states in 2009. It was determined that most member states had made patient safety a priority through public policy, created an office responsible for patient safety, encouraged safety training in healthcare settings, made patient reporting of adverse events possible, and moved towards a blame free culture (Bangemann, 1994). These are just a few examples from around the western hemisphere where quality, safety, and risk have been addressed in the literature and provide the foundation for our work.

Broad Definitions of Quality, Risk, and Safety

Quality

The discussion of quality in healthcare spans more than two decades. A revolutionary thinker on the subject, Donabedian, recognized the fluid nature of quality saying that “several formulations [of quality] are both possible and legitimate, depending on where we are located in the system of care and on what the nature and extent of our possibilities are” (Donabedian, 1988). W. Edward Deming, a quality leader in both Japan and the US, defined quality by addressing its value as related to is marketability: “a product or service possesses quality if it helps somebody and enjoys a good and sustainable market” (Deming, 1994). In 2001, the IOM defined healthcare quality as “the extent to which health services provided to individuals and patient populations improve desired health outcomes.” They identify that care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision-making. In Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM identify that quality has six domains including: safety, effectiveness, patient centeredness, efficiency, timeliness, and equity.

Risk

The concept of risk has a much longer history and in 1661 the concept of risk primarily focused on risky hazardous behaviors. In 1798, risk was primarily alluded to within law literature. In more recent times, it can be seen as more of a neutral term referring to the probability of something adverse or dangerous (Shattell, 2004). According to Shattell, risk is seen to refer to the possibility of suffering harm or loss. It is perceived to be a factor involving uncertain danger. Over the last 15–20 years, there has been a shift from narrow perspectives on probabilities to events, consequences, and uncertainties. An antecedent to risk is the cognitive ability to distinguish between two or more choices (Shattell, 2004). The various types of risk noted by Jacobs (2000) are: epidemiological risk, absolute risk, relative risk, attributable risk, clinical risk, individual risk, and political focus and values and culture (Jacobs, 2000).

Over the last 15–20 years there has been a shift from narrow perspectives on probabilities to events, consequences, and uncertainties. The concept is that risk is inherent in healthcare as no procedure is void of risk. Risk has been defined as a chance or potential for loss or harm, a cognitive recognition involving thought and perception about self and/or others, and a decision-making process based on the probability or a weighing of the possibilities which includes decision-making processes as well as a chance of harm or loss (Shattell, 2004). The lesson learned from high-risk industries such as aviation and nuclear power, have often been applied to healthcare.

Safety

Since the beginning of the quality, risk, and safety movement in the 1970s, the concept of safety has been conflated with the concept of quality. Although safety fulfills an important role in quality, the two concepts are inherently different. Patient safety is a subset of the larger, much more complex and multidimensional concept of quality (Buttell et al., 2007). Quality should be thought of as the overarching concept under which safety and risk are supporting factors. Patient safety was defined by the IOM as the prevention of harm to patients (Aspden, Corrigan, Wolcott, and Erickson, 2004) and the freedom from accidental or preventable injuries produced by medical error (Wachter, 2008). Patient safety differs from quality improvement in that patient safety is envisioned to be more about preventing harm, and quality is seen to be about advancing the current level of care. In 2006, in his book, Patient Safety, Charles Vincent (2006), defined patient safety as “the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.” This definition is perhaps the most comprehensive since it acknowledges the inherently risky and unpredictable nature of healthcare. Therefore, Vincent argues that, “the reduction of harm should be the primary aim of patient safety, not the elimination of error.”

For the purposes of this book, our definitions of quality, risk, and safety are as follows:

Quality

The IOM defines healthcare quality as the extent to which health services provided to individuals and patient populations improve desired health outcomes (IOM, 2001). The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making.

Risk

A chance or potential for loss or harm, a cognitive recognition involving thought and perception about self and/or others, and a decision-making process based on the probability or a weighing of the possibilities which includes decision-making processes as well as a chance of harm or loss (Shattell, 2004).

Safety

Patient safety was defined by the IOM as the prevention of harm to patients (IOM, 2004). We have included the concept as freedom from accidental or preventable injuries produced by medical error (Wachter, 2008).

The Case for Quality, Safety, and Risk

It is relatively easy to make a business case for advancing quality. From a practical point of view, the IOM estimates that as many as 98,000 people die each year in US hospitals due to medical injuries (Kohn et al., 2000). Further, the Centers for Disease Control and Prevention estimate that two million patients suffer hospital-acquired infections each year in the US (Reed and Kemmerly, 2009). In 2007, Lucian Leape identified that the healthcare system is fragmented and prone to errors, and it is in desperate need of restructuring to improve patient safety and patient outcomes. He identified that the rate of error occurrence in healthcare has been identified as 10–100 times higher than in other customer-focused industries, such as aviation. Further, Leape noted that a systemic change is urgently required (Leape, 2007).

Although community health suffers from a lack of research generally, it has been clearly identified that the quality of care within the community setting is less than optimal. For instance, up to 28 percent of all emergency visits occur because of a drug related problem, defined as an “inappropriate prescription” an adverse drug reaction and/or a drug to drug interaction that occurred within the community setting, with 24 percent of these events resulting in a hospital admission once again in the adult population (Patel and Zed, 2002). Further, a recent secondary analysis of the Commonwealth Fund data gathered from a sample of 9,944 adults demonstrated that approximately 4 out of every 5 self-reported medication errors occurred in the community setting (Sears, Scobie, and MacKinnon, 2012).

Communication breakdown has been identified as a factor that is responsible for at least 70 percent of errors in hospital (JCAHO, 2005). Within three children’s hospitals, ineffective communication was cited as one of the top three factors for the occurrence of medication errors and near misses (Sears, 2009). Communication issues are amplified when the key players are not within the same building or do not have adequate systems to communicate. Further, the consistent factor that travels through both the hospital and community settings is the patient and their caregivers. The patient and their family value the healthcare that they receive and there is an expectation and a trust that this care is of high quality.

Linking Quality, Risk, and Safety

Healthcare quality is a global concern with consequences far beyond the confines of a hospital setting. The implication is that everyone within the healthcare system—healthcare professionals, government agencies, policy specialists, lawyers, architects and engineers, financial officers, patients, and others—all have a role to play in both the failures of the current system and future solutions. An interdisciplinary and collaborative approach, both within and outside of the clinical setting is required to overhaul the system. There has been recognition within healthcare that individual professions working in isolation cannot provide optimal care. Multiple studies have recognized the importance of interdisciplinary teams and/or cross-cultural competencies in the care of patients (Andreatta and Marzano, 2012; Oelke, Thurston, and Arthur, 2013; Nandan, 2013; Tracy and Chlan, 2014; Nancarrow, Booth, Ariss, Smith, Enderby, and Roots, 2013). Interprofessional teams are certainly a step in the right direction; but if doctors and nurses could have fixed the problem of healthcare quality, risk, and safety themselves, this would have been accomplished years ago.

Recognizing the major role of government, particularly policies governing access, resources, and finances, must be recognized and integrated into the solution. Government decisions reflecting policy and fiscal management have a significant influence over the operation of both public and private systems all over the world. Whether it is from restricting who can access the system through citizenship (Hanefeld, Lunt, and Smith, 2013), or tiered healthcare (Holst and Gericke, 2012), financing public systems (Bem, 2013; Nordgren, 2012) or the development of a public healthcare system (Dodwad, 2013) the role of government policy is key. For example, the United Kingdom and European Union’s current struggle with reimbursements, correct billing charges, and “health tourists” serve to highlight the direct connection between government intervention and health policy (Hanefeld et al., 2013).

Furthermore, in developing nations such as Yemen, lax government controls have resulted in an unequal healthcare system which serves only the top of the socioeconomic scale, leaving those unable to pay with limited to no access to healthcare (Holst and Gericke, 2012). Similarly, without proper government oversight and policy development/enforcement, India struggles to designate appropriate resources and serve rural areas (Dodwad, 2013).

Health literacy is another area in which government policy can affect healthcare outcomes. Healthcare literacy, as defined by the IOM in a 2004 report is “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions” (Nielsen-Bohlman, Panzer, and Kindig, 2004). In the United States of America several key policies, including the Affordable Care Act of 2010, the Department of Health and Human Services’ National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010, strive to bring healthcare literacy to the forefront of the quality, risk, and safety movement (Koh et al., 2012). This is especially pressing when one considers that, despite competent general literacy skills, approximately 50 percent of adults in the US have difficulty processing and following health information (Regenstein et al., 2012). The interconnected nature of healthcare makes it clear that there is no one simple solution. Instead we need a multi-faceted approach that encompasses interprofessional and interdisciplinary players from diverse backgrounds.

Healthcare Quality Education

With a goal to advance the healthcare quality agenda and in response to an identified need within both the educational and healthcare sector, Queen’s University (Canada) established a Master’s degree in Healthcare Quality. The Master of Science in Healthcare Quality [MSc(HQ)] program was developed in 2011. Faced with quality concerns and increasing cost in their institutions/practices, healthcare professionals realized that they lacked both the theoretical and practical knowledge needed to make changes. Searching for a way to improve their education, professionals were forced to select insular, discipline specific programs that divided focus between either theoretical foundations or practice based implementation strategies. We found no programs that crossed professions, disciplines, communities, subjects, and bridged the applied world to its theoretical roots. Healthcare, as a system, is a complex, dynamic, evolving entity, composed of a huge amount of players. Doctors, nurses, and other traditional healthcare professionals clearly play a role, but then so do policy makers, architects, data managers, lawyers, engineers, government agents, academics, and of course, patients. Traditional educational programs that place emphasis on creating silos between these players do nothing to contribute to a cohesive, efficient, safe, and reliable healthcare system. With systems beginning to show strain and with no comprehensive programs available to create a new brand of leaders who could guide healthcare into the twenty-first century, the system was stalled. It was from this climate that the MSc(HQ) was born. The MSc(HQ) is a two year, part-time, mostly distance graduate program. It is the only graduate program in the world to combine quality, risk, and safety in healthcare with an interdisciplinary and interprofessional curriculum that delivers both a theoretical background and real world, practical application. Open to applications from all disciplines, and taught by professors from Business, Law, Human Factors, Policy, Nursing, Medicine and in additional partnership with the Faculty of Engineering and the Faculty of Education, the MSc(HQ) strives to create a unique atmosphere of cooperation and communication. It is not until all the healthcare players speak the same language and play on an equal field that any headway will be made in improving healthcare.

Additionally, the MSc(HQ) offers an international perspective on quality, risk, and safety in he...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Notes on Contributors
• Foreword
• Preface
• 1 International Leaders Influencing the Quality, Risk, and Safety Movement in Healthcare
• Part I Quality
• Part II Risk
• Part III Safety
• Part IV Taking Stock
• Index