What is Good Quality Care?

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Presentation transcript:

What is Good Quality Care? Safe Timely Effective Efficient Equitable Patient-Centred

Comparative Risks of Healthcare

Health Care Systems are Dangerous! Examples BBC investigation through FOI Act, May 2013 Cases of foreign objects left inside patients during operations – 322 Cases of surgery on the wrong body part – 214 BMJ July 2012; NPSA report methotrexate Deaths - 26 Serious harm - 25

Reducing Risk Some industries have dramatically reduced their risks. Which industries? How? By changing their ‘Safety Culture’

Manchester Patient Safety Framework Describes 5 safety cultures (in detail!) Generative Proactive Bureaucratic Reactive Pathological Group 1 – look at “01. Overall commitment to quality” Group 2 - look at “03. Perceptions…” Discuss & make a note of examples of attitudes A-E That you have come across at work That you have read about in the media

The Francis Report http://www.youtube.com/watch?v=CY-P9n_7atU

How Can We Change Our Safety Culture? Understand why accidents happen Find out what mistakes are happening Change our systems to make it… …harder to do the wrong thing …easier to do the right thing

Understand why accidents happen System Failures Poor design Latent factors Human Factors Focus Fitness Filters

Focus http://www.youtube.com/watch?v=ubNF9QNEQLA

Fitness

Filters http://www.youtube.com/watch?v=oaGpaj2nHIo

Find out What mistakes are happening From… Staff - event reporting, walk rounds, briefings Patients - complaints, comments, surveys External Staff - pharmacist, coroner, DNs Metrics - trigger tools, audit

NHS Reporting & Learning System – incidents reported from England 03 to 09

Proportion of incidents in GP setting - Jul 2010 - Jun 2011

Change our systems but how? What are we trying to achieve? How will we know if the change is an improvement? What changes can we make that will result in an improvement? Set clear and focused goals Focus on problems that cause concern Have clear, measurable targets

Application! Think of a significant event at work What happened? Who was involved? Why did things go wrong? human factors? system weaknesses? How can the system be changed to make it harder for this error to recur? easier to do the right thing?

Conclusions Understand, Find Out, Change Accept that making mistakes is normal Talk about your mistakes and ask… How can we make it harder to do the wrong thing? How can we make it easier to do the right thing? Care for patients - look out for potential problems Understand, Find Out, Change

The End

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