Dr Jonathan Kirk
National Clinical Lead, Measurement and Monitoring of Safety Programme, Healthcare Improvement Scotland
'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.
Healthcare is a risky business and for the most part those working in healthcare have adapted to become expert in ‘recovery’. Most often, but not always, we cope surprisingly well. We get by despite system shortcomings. The danger familiar to all high risk organisations is that to a greater or lesser extent depending on the safety culture in which we work, we can come to accept those shortcomings such that ‘coping in adversity’ becomes the cultural, even celebrated norm (so called normalised deviance). It is possible to become blinded to the fact that a proportion of the crises we recover could have been prevented entirely by better planning. In other words we can become too accepting of variation in standards - our ‘tolerances’ can become too wide. From an operational and quality improvement perspective we can become too busy answering the wrong questions, to find the time ask the right ones.
The painful irony is that in such conditions significant amounts of finite operational capacity are lost to recovery of situations that might have been prevented by forward planning. Anticipation and preparedness are perhaps neither glamorous, nor heroic. In the same way fitting smoke alarms is perhaps perceived as less ‘exciting’ than putting out fires. Nonetheless they saves lives.
In reality therefore our challenge is how to move the conversation away from capacity to capability. To do this involves developing the cultural standards and operational efficiency to limit harmful and wasteful variation and deploy resources effectively to preventing system failures, rather than analysing them after the event.
The Framework serves as a helpful and effective tool with which to consider the questions we need to ask in order to develop the ‘operation wherewithal’ to overcome system frailty By giving us a Framework to help identify ‘what we don’t know we don't know’ ahead of time it can help us to become more ‘capable’ of preventing the conditions that give rise to harm.
In a following series of articles we will offer further insights from testing the Health Foundation’s Framework for Measurement and Monitoring of Safety and expand further on some of the observations from our time spent testing the Framework with two Scottish Health Boards.