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Within the healthcare sector there is a strong focus on improving patient safety. Whether you are a patient/client, family member, caregiver, doctor, quality officer or director of a healthcare institution, everyone is looking for greater patient safety. But, how can you achieve safe care that focuses on the patient? By using a practical roadmap, we will walk you through the framework conditions that need to be met.
Roadmap to improve patient safety:
In order to learn from incidents, it is important that all incidents and near incidents are reported. Unfortunately, reporting an incident is still often considered an administrative burden that is difficult and redundant. When incidents are reported digitally you get a clear overview of the root causes and the different types of incidents.
From the quality management system, trends can be identified that can then be used for an in-depth incident analysis, which can contribute to the improvement of care. For a quality officer it is interesting to keep a database with root causes that occur regularly. These can be used for targeted improvement actions. New analyses will then reveal if such incidents occur less frequently.
Are quality and safety part of your daily activities in the organization? Do you use tools such as incident management, complaints registration and audits? But do you also face challenges managing the subsequent improvement actions? Experience shows that improvement actions are being identified, but not managed systematically. A missed opportunity because improvement is required in order to achieve strategic objectives.
A digital quality management system usually includes an improvement tracking system that supports completion of improvement projects. Improvement projects may be initiated in response to a specific incident, a trend or a certain issue.
TPSC's quality management system monitors tasks, actions and processing times to ensure that improvement plans are actually implemented. The PDCA cycle is also guaranteed, as this cycle can be repeated continuously. The quality management system shows that the organization has completed the process.
Dashboards are a powerful tool for internal communication about improvements. They not only allow better understanding of the number of reports, but can also be used to share improvement actions, thus allowing departments to adopt each other’s improvement actions. This promotes the learning capacity of the organization. Find out more about managing improvement actions and how they contribute to patient safety.
There is growing recognition that actively listening to experiences of patients/clients and their relatives, can substantially improve the quality and safety of care, without major change processes being necessary. This is called patient/client participation. Patient participation is not an aim in itself, but a means to implement quality improvements in healthcare. Follow-up on the results obtained is crucial for successful patient and client participation.
Patients/clients are the only ones to go through the entire care process. They can provide insight into any hidden imperfections in processes. Patient/client participation provides care institutions with essential information to further improve internal processes. What do they think works well in the organization? And where do they see opportunities for improvement of care and services?
When implementing patient participation, there are a few things to consider:
From a black-and-white perspective, we can distinguish two cultures that address ‘human errors’ within an organization: On the one hand the retributive culture, based on rules, violation of those rules and penalties. On the other hand, the restorative culture, a Just Culture. A corporate culture centered on trust, learning capacity and accountability.
In a Just Culture the focus is not on ‘the offender’ but on ‘the victim’ and how this person can be best assisted. Subsequently, it is important to look at the factors that led to the error, in order to bring about change and improve patient safety.
A manager or team leader shows leadership by sharing his or her vision of safety with the team. Through a dialogue with employees, but also by displaying exemplary behavior. A true leader is interested and curious, and asks his/her employees what makes it difficult for them to display the safety imperative at work.
In order to create a safety culture, it is important that employees become aware of unconscious behavior. The following interventions contribute to awareness:
Find out more about our software solutions for recording and analyzing incidents or to use, for example, when making safety rounds.
Quality and risk management also aims at creating a safe working environment for nurses, doctors and other aid workers. Safety for the healthcare professional covers various aspects:
There is growing awareness of the importance of organizing assistance for second victims. Research in the United states has shown that the vast majority of caregivers that has been involved in an emergency, require support. Experience of a hospital in the Netherlands showed that it is important that this support is provided proactively by peer caregivers.
When the organization is committed to a safe working environment, this also contributes to improving employee satisfaction. This is a key precondition for creating support to report incidents and, ultimately, improve quality of care.
Our peer support application facilitates the complete process of identifying and approaching the second victim and putting him/her in contact with a peer, up to the documentation and assessment of the aftercare provided.
When it comes to improving patient safety, care institutions tend to only look within their own department or organization. Safety in the care chain is considered, but this does not always go beyond the boundaries of the own institution. When multiple organizations (chain parties) are involved in providing care, we speak of transmural chain care.
Unfortunately, responsibility for patient safety is not always properly secured in this transmural chain care. Different patient safety policies and the autonomous position of organizations are some of the reasons for this. Many incidents result from miscommunication in the hand-over between organizations. To further improve patient safety, it is important to gain insight into the risks within the entire care chain. Transmural incident reporting visualizes the risks within the transmural care chain and this results in important information for management. Incident reports may be different in nature and provide insight into the weak links within the care chain.
The TPSC CloudTM platform facilitates transmural incident reporting. Incoming reports are easily shared with the different committee members through integrated email functionality. The progress of resulting improvement actions is communicated in the same way, not only to the employees involved, but also to the notifying person .
A digital quality management system allows healthcare institutions to combine all activities aimed at improving quality in one place. The organization thus knows what actions are taken, by whom and when. This immediately provides tools to identify the risks within the institution and address them in a holistic manner.
When incidents are reported digitally you get a clear overview of the root causes and the different types of incidents. Without any additional actions, the nature and type of the reports are recorded. By reporting as many (near) incidents as possible, a valuable database is created over time. From this database, trends can be identified that can then be used for an in-depth incident analysis, which can contribute to the improvement of safety. However, even one specific incident may be the reason to immediately initiate an improvement action, which can then be monitored and assessed within the same system.
Our services are used around the world by many leading care providers, ranging from mental health care institutions to pharmacists, hospitals and civil society organizations. Do you also want to improve patient safety? We will be happy to assist you ! Let us know by using this contact form.
Good communication is the foundation for patient safety as many incidents in healthcare are the result of miscommunication. How can we reduce the risk of this miscommunication?
Open communication that results in a ‘learning’ and therefore safe organization is not a matter of course. It is important that people recognize that successes and failures arise from a complex system of many interactions, and to what extent this can be discussed. In mutual communication it is therefore also important to keep looking at what works well, as otherwise nobody understands why things can go wrong.
In the event of a (near) incident, all those involved need to be heard for proper judgement on any follow-up action. By discussing an incident with all stakeholders, people ‘learn’ that incidents can happen to anyone and that by discussing these matters openly, it contributes to improving the quality of care. By pooling insights and experience of several healthcare professionals it is possible to gain an understanding of what caused the incident and possible improvement areas.
Incidents and improvement actions should not only be discussed within the department but also with other departments. Otherwise you end up with silo solutions whereby colleagues in a different department keep causing the same incidents. A ‘learning’ organization can prevent this and effectively guarantee quality improvement in their processes .
We have various ready-made applications for the management of your patient safety. You can quickly start using these applications and adapt them to the specific situation in your organization.
Is your organization about to make the transition from a paper-based to a digital workplace? Or does the organization already have a digital quality management system to improve patient safety, but wants to replace it? In both cases it is advisable to develop a business case. Download our eBook and use it as guidance for writing your internal business case.