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.
‘Integration and learning’ is fundamental to our pursuit of quality improvement and patient safety. If we are to improve we must develop our wherewithal to learn. No easy task when preoccupied with extinguishing fires!
The purpose of any framework I guess is to help in some way to order thinking. A helping hand to make it more likely we achieve what we are striving for. The Health Foundation’s framework for the measurement and monitoring of safety offers just that. A guide to nurture our understanding of patient safety and to help us consider the broader range of information we need to establish not only whether care has been safe in the past but also if care will be safe today and in the future.
Data, or rather ‘information’ is needed to enable intelligent decision making. To intervene or not?, to change or stick?, to escalate or not? Used appropriately it is our unit of learning. Measuring is the process of accumulating information. Monitoring is keeping a check on those measurements over time looking for deviation or variation that might require deeper understanding, and learning.
I wrote last time about the importance of developing ‘capability’ and how the Health Foundation’s Framework for Measurement and Monitoring of Safety can help us with that. Making care safer involves making decisions. Improvement results from making more good decisions and less bad ones. That can happen either deliberately or by chance. Sustaining improvement is harder and requires us to understand which were good decisions and which were bad. To do that we need to understand some of the basic statistical concepts that allow us to correctly interpret variation.
A lack of understanding of variation is harmful to individuals, teams and organisations on a number of levels. In essence if we don’t understand variation we don’t know whether we are getting better or worse. If we don’t know that, then we don’t know what to start or stop doing, what to do more of and what to do less of. We don’t know how and where to deploy finite resources. We risk making variation worse by changing the wrong things at the wrong time. We cause waste and harm by intervening when it would have been better to do nothing, or not intervening when it would have been timely to do so. We create perverse incentives by rewarding people for the wrong things. We demoralise staff by blaming them for things beyond their control. We waste time looking to explain perceived trends when nothing has changed.
Achieving meaningful improvement in the hullabaloo of frontline services is tough. Change is hard. Accumulating the theoretical knowledge and motivation is one thing. Having the tenacity to engage, challenge, overcome and sustain is a different and altogether more daunting (yet rewarding) challenge.
One of the more common phrases you will hear when seeking to engage others in change is ‘I haven’t got capacity’. ‘What would you like me to stop doing to allow me to focus on the change you wish me to make?’ To the early adopter or enthusiast it may come as a disappointment that your primary concern is trumped by multiple confounding or competing priorities.
The problem is that this philosophy presupposes that existing ‘capacity’ is entirely value adding and being used to maximum effect. Sadly we know that for a complex array of internal and external reasons, that is seldom the case. I would contend therefore that capability rather than capacity is the real issue.
'Do you know what you don't know?'
The Framework for Measurement and Monitoring of Safety can help us to broaden our perspective of patient safety beyond looking primarily at past harm, by directing us to consider the conditions that give rise to harm, or allow harm to prevail. It can help us to move from being ‘wise after the event’ to being ‘wise before the event’.
The challenge in the melee of frontline operations is how to develop the ‘capability’ to plan ahead. The conundrum familiar to many is how to get past dealing with today’s crisis in order that we prevent tomorrow’s.