Dr Jonathan Kirk
National Clinical Lead, Measurement and Monitoring of Safety Programme, Healthcare Improvement Scotland
Vincent et al direct us to consider a different approach to help us to answer the question 'how safe is our care?' The difficulty, familiar to many healthcare professionals, is that we are conditioned to deal with risk and make good. For some, that ability to prevail in adversity will have defined their progression. It is culturally embedded in what we do. The problem in trying to improve safety is that it requires us to question that culture and re-consider our tolerance of risk. Doing so requires us to accept the hypothesis that sometimes, harm results from us operating with higher levels of risk than is good for our patients (so called normalised deviance).
In other words, restricting our view of safety by considering only reported episodes of harm, tells us less about the prevalence of unsafe conditions and perhaps more about how well we cope with them. If I were to walk across a road blindfolded, I might make it to the other side but clearly that does not mean it is a safe way to do it. Repeating it would probably end badly, sooner or later. The framework for the measurement and monitoring of safety directs us toward a broader view safety with a series of prompts to help us look beyond establishing the absence of harm towards ensuring the presence of safety.
Considering the five dimensions of safety prompted by the framework, leads us to a different understanding of 'what safe is'. It highlights unknown unknowns and surfaces gaps in understanding. That change in understanding leads to a new view of safety that naturally crosses the artificial divides we have ourselves created in our pursuit of different quality and performance ambitions.
Recent years have seen a rapid increase in quality and safety improvement initiatives. Significant gains have been made in the avoidance of certain specific harms. However, as more initiatives and programmes appear so proportionally does the volume and complexity of measurement and reporting. Therein, lies potential unintended consequence. As the measurement burden increases, it can outstrip the capacity or capability of individuals, teams or organisations to cope. Beyond that point lurks risk of paradoxical reduction in quality, perverse incentive, hollow assurance and low morale. The problem we have is that considering multiple facets of quality separately can actually limit progress by fragmenting conversations, diluting improvement efforts and turning off the workforce. There is a danger therefore that we tie ourselves in knots. The framework can help us in that regard by realigning some of the fragmentation. This helps return us to a more joined up way of thinking, which appears to resonate well with teams at the front line and to have several key benefits:
Identifying gaps in understanding and unknown unknowns helps teams to identify hitherto unconsidered barriers to improvement.
Broadening understanding of ‘what safe is’ helps them to bring together information and conversations about different aspects of safety, quality and performance. This helps make sense of and increase understand of their interdependency. Bringing the information together seems to make it both more meaningful and more manageable.
Building a common understanding of safety, both within teams and between different organizational levels helps teams to agree areas of focus and also to clarify common purpose. It appears to be a useful point of reference to help standardise what we mean when considering safety.
Teams find that relying mainly on past harm (so called ‘lagging’ indicators) tends to result in them being very reactive in their approach to improvement. Increasing focus on emerging and future safety concerns (so called ‘leading’ and ‘predicting’ indicators) helps them to be more proactive and has a front footing effect. It helps them to get ahead of the problem and to become wise before the event rather than after it.
To be able to detect when things are going wrong or becoming unsafe, we need the means for early recognition. This can come partly from conversations and alerts, but we can also use signals from data. Having a better understanding of the variation within key safety critical processes can help teams to distinguish natural ‘ups and downs’ from signals indicating the emergence of problems that need closer consideration. Developing effective use of time series data such as ‘statistical process control’ charts can help us to understand variation, understand which improvement techniques to use and when to intervene. This in turn allows them to target our efforts more effectively and avoid losses of misinterpretation.
Identifying the key interactions needed to gather accurate real time information and structuring those interactions helps teams to understand the questions they need to ask to get a clear picture of emerging hazards. It moves them from seeking assurance towards proactive inquiry.
Increasing understanding of gaps in information, inaccuracies of data and deficiencies in communication helps them to improve their decision making. It develops their collective wherewithal to learn.
The framework offers a reality check on how well data informs learning and cements the need to value more than that we can measure.
The framework helps teams to further appreciate the central importance of ‘what matters to patients’ when thinking about safety. It highlights that having a clear understanding of patient fears, concerns and expectations is key to delivering care in a way that helps them to feel safe. It helps them understand that in reality it is very often ‘the system’ that makes things complicated and that patients can make things simpler and help us to avoid unnecessary interventions.
The framework for measuring and monitoring safety can advance our approach to safety. Broadening our understanding provides us with useful insights to help shape the way forward. The apparent sense-making properties of the framework should not be underestimated and offers useful clues as to the possible benefits of a more joined-up approach to different quality and safety ambitions. This has been identified as Scotland’s primary focus in the forthcoming phase two of the safety measurement and monitoring programme.