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

2. Comparative Risks of Healthcare

3. 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

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

6. 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

7. The Francis Report

8. 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

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

11. Focus

12. Fitness

13. Filters

14. 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

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

16. Proportion of incidents in GP setting
- Jul Jun 2011

17. 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

18. 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?

19. 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

20. The End