Pitcher Partners encourages healthcare decision makers to consider five key steps as a way to address and respond to the challenges articulated in ‘Targeting zero’, the recent Government review of hospital safety and quality assurance in Victoria.
1. Remove hazards wherever possible, or at least substitute for a lessor hazard
Even in the safest environment, patients are exposed to hazards throughout their care. This can include anything that has the potential to cause harm. When harm occurs, a root cause analysis will assist to identify the hazards involved. The key is then to ask:
- Can this hazard be removed entirely?
- If not, can a lesser hazard be substituted?
- Or can we constrain exposure to the hazard?
2. Ensure you understand the impact of human factors
Even the most experienced human beings can make mistakes. There are limits as to how much information one can process to make an effective decision. Time pressures, distractions, and poorly designed equipment can increase the risk of error. In fact, unfamiliar tasks increase the risk of error by 17 times (e.g. clinician on a new rotation) and time pressure increases the risk by 11 times (e.g. emergency situations).
3. Simplify and standardise
Reducing complexity and unnecessary steps will simplify a process. Standardising work instructions reduces ambiguity. Staff should not have to figure out what needs to be done in what sequence each time a standard task is performed.
4. Ensure education and training is appropriate for the situation
Education is regularly applied as a treatment for an adverse event, but alone this is sadly insufficient. Even education regarding a policy that was not followed may raise awareness in the short term, but this awareness will diminish over time. In this instance it is more important to understand why the policy was not followed.
5. Ensure quality and safety is everyone’s responsibility
Creating a strong culture of safety is the responsibility of all individuals in an organisation, but most importantly the role of leadership. Behavioural norms are shaped and reshaped over time. If left unchecked, unhealthy norms can grow and dominate. Sweeping safety issues under the carpet is an example of an unhealthy behaviour that will become a norm.
Imagine resting a bit easier at night, with the knowledge that every patient, every day, is in the safest possible environment to receive care.
Take these five steps, and get your quality and safety journey underway!
Michelle McDade is a Client Director at Pitcher Partners Consulting Melbourne. Michelle is a lead consultant in PPC Health & Care industry practice, with extensive experience in public and private health.