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    Focus on the process to achieve structural quality improvement

    Jens Hooiveld
    Last modified: 21 January 2021

    A healthcare professional who makes a mistake or is involved in an accident often feels personally responsible, or even guilty about the event. The reality is that incidents most often arise due to a weak link in a process or a malfunctioning system. Although the root cause is outside the individual care worker’s sphere of influence, and despite efforts by quality managers to connect errors and events to system failures, attributing incidents to people still occurs. Focus on processes to help alleviate the blame game and staff reproach.

    Use PRI to find weak links in your process

    Encourage staff and others to report incidents, and gain direct insight into the weak links in a given process—all with the help of a comprehensive reporting module.

    Start by truly understanding your processes, converting them into flowcharts to immediately clarify what functions are responsible for the parts of a process, and at what stage. An analysis method called prospective risk inventory (PRI) clearly identifies in advance where the weak links in a process may be, so that you can eliminate any risk factors. Ideally, a PRI can prevent accidents or incidents. With every change in processes or with every change in an organizational unit, it is advisable, or sometimes even mandatory, to perform a PRI analysis.

    Conducted after an incident has taken place, the PRI can show retrospectively where the system has failed. For safety’s sake, start with the most risky processes.

    Read more about organizing Incident Management on our topic page, containing important points for preventing, reporting, and attending to incidents and events.

    Case study: Putting process analysis into practice

    The following case reflects the events in one hospital, where multiple incidents were reported about the care process of the endoscopy department within a week:

    • The day before a scheduled gastroscopy and an endoscopy procedure, a patient was instructed to prepare by drinking a barium meal. However, on the day the patient arrived for the procedure, the doctor was not available. The procedure was canceled and the patient was sent home.
    • Another patient’s examination was canceled due to a lack of patient preparation.
    • An unexpected lack of beds occurred when a patient required admission following an examination.

    Upon initial review, the root causes of these incidents could easily have been dismissed as miscommunication. However, using structured analysis methods, true breakdowns in the process or system can be identified:

    A PRI reveals the true root cause of the incidents

    The hospitals’ Incident Review Committee decided to nominate the care process of the endoscopy department for a PRI, and conducted the analysis with all care providers involved in the recent events. The analysis results in new insights into the actual root cause of the incidents:

    • Unclear agreements were made in the process with regard to an ultrasound or endoscopy.
    • There was a lack of knowledge and clarity among staff as to whether the doctor was on duty and whether he happened to find the registration in his mailbox.
    • No one, ultimately, maintained responsibility for shepherding the patient through the existing care process.

    As a result of the PRI, a process coordinator was made responsible as the care process “point person.” Together with the relevant care professionals, the process coordinator rewrote the care protocol and the improvement measures were immediately implemented, optimizing and standardizing the process.

    Lessons learned

    Incidents and near misses can and should be triggers for the analysis of an entire process, if necessary. In the case above, if the root cause of the incidents had been assumed to be miscommunication among the participants—patient, physician, and staff—the true root cause would have been overlooked. Worse, the weak links in the care process would not have been identified and remedied, thereby jeopardizing patient safety.

    Consider the patient who prepared for their procedure but went home without any action being taken. The next time that patient requires a procedure, they’ll likely feel less safe. In that same incident, the hospital incurred unnecessary costs, as a team was ready to carry out the procedure but could not for lack of a provider.

    Reporting and analyzing incidents in healthcare requires transparency and disclosure in a non-punitive environment. By making everyone aware of the risks, healthcare ultimately becomes safer for patients, providers, staff, and the institution .

    Process analysis

    A PRI analysis isn’t the only method for analyzing a process to achieve structural quality and safety improvements. Failure Mode and Effects Analysis (FMEA) is a systematic and proactive analysis for finding possible weak spots in a process. This prospective risk analysis consists of different variants, aimed at different types of processes.

    FMEA focuses on the “how and why” of a failure—not whether a system will fail. By performing an FMEA:

    • the impacts of potential failure can be estimated;
    • measures can be devised to reduce the likelihood of the occurrence of failures; and
    • the potential effects of a failure can be limited.

    Read more about analyzing incidents and risks on our Data Analysis topic page, or download our eBook on Incident Management for more background on how to register incidents.

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