19.05.2015
Patient safety (and quality) – Perspectives
and status in Norwegian Hospitals
Karina Aase
Professor “Quality and Safety in Health Care Systems”
Universitetet i Stavanger
uis.no
Research Seminar Patient Safety, University of Eastern Finland, 19 May 2015
Aim/agenda
“To develop new knowledge for
improved quality and safety in
health care services –
nationally and internationally”
Internationally
Nationally
Status in the hospital sector
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Quality and patient safety – what do we mean?
What is meant by safety in healthcare services? And for whom?
What is meant by quality in healthcare services? And for whom?
And what is the difference?
Any suggestions?
Quality in health services
1. Safe
avoiding injuries to patients
2. Effective
based on scientific knowledge
3. Patient-centered
responsive to individual patient preferences, needs, and values
4. Timely
reducing waits and harmful delays
5. Efficient
unavoiding waste of equipment, supplies, ideas, and energy
6. Equality
care that does not vary because of personal characteristics
(Institute of Medicine 2000, National strategy of quality in health & social services 2005-2015)
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Patient safety =
avoidance of adverse events (Norge)
Patient safety is protection of unnecessary harm as a result of
health services performance or lack of performance.
Including:
seasures to reduce risk
processes to monitor and analyse health services results
measures to identify new risk areas
(The Norwegian Knowledge Centre for the Health Services, 2010)
An old or new discipline?
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What/who sets the agenda?
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Different perspectives to patient safety
Clinical
(Quality) improvement
…
Sociological
Psychological
Technological
Juridical
…
(Esmail 2006, West 2006, Parker & Lawton 2006, Boaden 2006, Beatty 2006, Jones 2006)
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What characterises the discipline?
(clinical perspective)
Relevance/scope
Evidence
Finding and validating effective safety measures
Leadership programmes
Reporting systems
Communication methods (e.g. SBAR)
CRM programmes, checklists
Quasi-experimental designs:
”Significant reduction in mortality and
complications, significant improvement in team
behaviour and attitudes, reduction in adverse events,
improvement in organisational support”
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Super! What is the problem?
1. Patient safety measures can not be reduced to a ”medicine” that
either has effect or not
2. Time interval between pre- and post measurement (2-13 mnd)
”85% of the included operations used the checklist during the
research project while 45% continued using it afterwards”
(Vats et al 2010)
3. The gap between the measure (measureable effects) and the nonstandardised realities of practice
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What characterised the discipline?
(social science
perspective)
The nature of the «problem»
What affects what? (Fulop et al 2009)
Different contexts give different results
Identification/description of practice
Organisational/cultural factors
Leadership, models and systems
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Five and ten years after «To Err is Human»
(Wachter 2010)
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Research areas (Jha et al 2010)
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Who is good at what?
(Macchi et al 2011)
Dependant on perspective and research area
Certification/accreditation (Regulation/policy)
Measurement/tools (”7 steps”)
Creation of local roles (clinical risk management)
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Australia/Canada advanced in many areas (policy)
Norway?
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Norway: Status 2010/2012
2010
7819 patient admissions
16 % at least one harm
(min 3,5 %- max 38 %)
7 % at least one harm with
prolonged hospital stay
(min 2 %-max 18 %)
1 % harm with permant injury
0,66 % deaths
2012
11 728 patient admissions
14 % at least one harm
8 % at least one harm
with prolonged hospital
stay or more serious
consequences
0,7 % re-operation in
relation to harm
Norway: «New» White Paper!
”Good quality – safe services. Quality and
patient safety in health- and social services”
(Meld.St.10, 2012-2013)
”The governments overall objectives for quality and
patient safety work:
More user-oriented health- and social services
Increased focus on systematic quality improvement
Improved patient safety and reduction of adverse events”
(p.9)
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2014-2018:
A National Patient Safety Programme
”We can become world leading within patient safety” (p.3)
1. Vision
Patients, users, and next-of-kin receive and experience that
Norway has the world’s safest health- and social services
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How far from the ”world’s safest” are
Norwegian hospitals?
For example: Organisational and cultural factors
”Quality and Safety in European
Union Hospitals: A research-based
guide for implementing best
practice and a framework for
assessing performance” (2010 –
2013)
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Patient safety culture (Sorra & Nieva, 2004)
1) Department manager’s safety focus
2) Organisational learning and continuous improvement
3) Team work within departments
4) Communication and openness
5) Feedback and communication concerning adverse events
6) Non-punitive response to adverse events
7) Manning
8) Stop working if required
9) Hospital mangement support for patient safety
10)Collaboration across departments/wards
11)Transitions and experience transfer across the hospital
Patient safety culture (Stavanger University Hospital)
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Sykehusledelsen støtte til pasientsikkerhet
25
27
28
Rapportering av (nær)hendelser
29
31
Samarbeid på tvers av avdelinger
36
39
Avleveringer og erfaringsoverf. på sykehuset
42
40
Tilbakemelding og kommunikasjon om feil
46
49
Bemanning
SUS 2008
50
50
Org. læring og kontinuerlig forbedring
SUS 2006
67
64
Kommunikasjon og åpenhet
Teamarbeid innen avdelinger
72
69
Ikke straffe feil
72
Nærmeste leders vektlegging av sikkerhet
72
0
10
20
30
40
50
60
70
77
76
80
90
Prosent
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Bergen University Hospital,
2009/2010
Smaller selection (n=358)
Safety culture among operations
personnel
Close to identical results with Stavanger
2006/2008
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Aim:
To study how organisational and cultural
factors affects
1) clinical effectiveness
2) patient safety
3) patient experiences
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Organisational/cultural factors (Bate et al, 2008)
Structural - structuring, planning, coordinating
Political – power issues, conflicts, relations
Cultural - give “quality” a shared collective meaning
Educational – develop and foster learning processes
Emotional – inspire and mobilise
Physical – design, buildings, technological infrastructure
• Leadership – a clear strategic direction
• External demands – response to social, political, and
contextual factors outside the organisation
Two Norwegian hospitals (rural/city)
A structured approach to quality and safety:
Formal and rational ‘science’ approach (systems, tools, data)
dominates over the informal ‘art’ of improvement
Measures driven by external factors (macro level) over internal
factors (own initiative)
Differences between hospital A (rural) og B (city):
Cultural (shared vs clinical dominance)
Political (top-down vs bottom-up negotiations)
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Hospital A (rural) – ”high-performer”
Norway
Structural
External demands
Political
Leadership
Cultural
Physical
Score from:
1 (low) to 10 (high)
on 8A quality
Hospital
challenges
Educational
Emotional
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Hospital B (city) – ”medium-performer”
Eksterne krav
Ledelse
Struktur
10
8
6
4
2
0
Fysisk teknisk
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Politikk
Kultur
Score fra:
1 (lav)
til 110 (høy)
Serie
på Serie
alle studerte
2
kvalitetsdimensjoner
Læring
Entusiasme
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Hospital A versus hospital B
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Hospital A/B versus Europa
Structural
External demands
10
8
Political
6
4
2
Leadership
0
Physical Technical
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Cultural
Serie 1
Pink = Europa
Serie 2
Green = Hospital
Serie A3
Blue = Hospital B
Educational
Emotional
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Influencing factors?
Hospital size
Culture
Competence
Power issues
Physical/technical infrastructure
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Future:
Combining different perspectives!
”Understanding how and why patient safety measures have an
effect – not just whether they work or not”
(Dixon-Woods et al 2011)
This requires
a multi-disciplinary effort
research programmes and research financing that facilitates such
approaches
(
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How to become the ”worlds best”?
Learning from other sectors or other countries?
- that opens up for questions?
[email protected]
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