Carl Macrae is a senior research fellow with the University of Oxford and a respected advisor on patient safety to the National Health Service (NHS) and other healthcare organizations around the world. He has devoted much of his career to improving safety and reliability in organizations. Annemarie Taylor is Executive Director of the BC Patient Safety & Learning System (BC PSLS) and one of its original founders. She is an active contributor to patient safety initiatives across Canada and internationally.
Most healthcare providers would agree that patient safety has evolved over the past 15 years. We see evidence that patient safety is top of mind for healthcare organizations around the world, most of which have adopted new processes and systems to provide safe, high-quality, reliable healthcare. Yet, despite these improvements, we still struggle with improving patient safety on a broader system-wide level.
To understand more about why that is, BC PSLS Central Office spoke with two experts to hear their views about how a shift in our thinking will help us find the right path for the future.
Q: Let’s begin with the big picture…what’s changed with patient safety from where we began to where we are now?
Carl Macrae
CM: I think a lot has changed in terms of the sheer scale of activity and interest in patient safety and improvement across healthcare systems. We need to remind ourselves how rapidly these changes have been achieved. Fifteen years ago things like system-wide incident reporting systems didn’t exist. Human factors, systems analysis, and team training were rare and exotic ideas.
So, it’s important to congratulate how far healthcare systems have come, but also recognize that we have created new challenges, like the sheer volume of incident reports that are now routinely collected in many organizations.
AT: When we started we often had to explain what we meant to frontline staff when we talked about patient safety. Now, there’s a lot more awareness of patient safety and what it means and that’s reflected in reporting.
We’re trying to focus now more on supporting the learning from those reports, and we’re fortunate to have systems like the NRLS in Britain that are a few years older than us (BC PSLS), so we can see what they’re doing and learn from them.
Q: What has been most challenging about getting to this point, and are we still facing those same challenges?
CM: There are really impressive things happening, but often they’re in localized pockets where there are champions or dedicated resources for particular issues. The biggest challenges are still tied up in organizing and coordinating systematic improvements across an entire health service – tying things together into systematic programs that change the way healthcare is organized across organizations and systems.
Organizations need to move away from the traditional risk management approach that mostly focuses on adverse outcomes, and focus more on maximizing potential opportunities for learning – something I call the safety value of events. Rather than assessing an event in terms of how bad the consequences were, we should also be trying to understand events in terms of the safety value that might result from looking further into an issue.
Annemarie Taylor
AT: As a healthcare system, I don’t think we’ve fully made the transition to systematic, well-integrated processes that ensure the right people and perspectives are always brought to examine issues to maximixe learning. We need a more robust, systematic way of looking at reported events so we can learn what we need to change across the system, and ways to routinely communicate out to the people who need to know.
Organizations now have a significant volume of event reports and they have to figure out what to do with it. They tend to look at areas where there is high volume or serious harm, but I think that there are missed opportunities for learning and improvement that could be realized, perhaps, if a different lens or process was applied.
Q: How do we spread these improvements?
CM: That’s the key question.
Problems on the frontline are often hugely dependent on system-wide issues…how infusion pumps are designed, the way purchasing decisions are made, the equipment staff have to use, the way shifts are organized…all of these elements have an impact on frontline staff.
However, we know that safety investigations rarely expand beyond the local context, and that’s partly because we don’t have a well-developed structure or system to support a system-wide level of investigation. There needs to be greater recognition that localized safety issues usually have an array of different, system-level factors driving them—and we need better ways of understanding and addressing systemic issues.
AT: There is lots of great, collaborative work going on to review events and learn from them, but the investigation or analysis sometimes stops short of seeing how factors that are beyond the local level have contributed. Asking, “What happened further away from the event that needs to be addressed to make the system safer?” and adjusting our processes and teams to be able to answer that question could make the findings relevant to more than just the local setting, and more applicable across the system.
Q: Where does safety event reporting fit in? How can we more effectively apply what we learn through reporting and learning systems like BC PSLS?
CM: Event reporting and learning from incidents plays a key part in all of this, and there are huge opportunities that aren’t being exploited as much as they could be.
BC PSLS has fostered learning and improvement across the BC healthcare system since 2008.
There’s almost a trap in some organizations where incident reporting systems are seen as just that: events are reported into a database where they’re counted and anlaysis reports are generated.
But, in other industries and in the best places in healthcare, each incident is seen as an opportunity to start a conversation – to collaboratively explore how systems and practices are organized in a particular area of the system.
There’s too much focus on quantity and not as much focus on using each incident as an opportunity to reflect on and improve practice.
Incident reporting systems should operate as a platform for improvement and collaboration around surprising and unexpected events, rather than a database of unfortunate things that have happened in the past.
AT: There’s always been a big emphasis on report volume, but if there’s not enough attention on what happens to those reports, opportunities for learning are lost. Numbers are helpful if leaders want to see what’s top of mind for staff, but it’s important that they then take the next step and use those reports to generate discussions with their teams, to bring teams together to really talk with each other about the concerns they’re identifying, and to explore solutions. Frontline staff often have the answers!
The old school thinking about incident reporting was more about volume and risk management. Now, we are most interested in what we can learn from reported events to improve quality and safety – we are shifting our thinking to what Carl has described as an interactive process of learning, which I think is the whole point.
Q: How can we help to shift the thinking of both leaders and staff to that interactive process of learning?
CM: Reporting systems have grown out of an administrative data collection view of the world. Healthcare leaders are used to processes that quantify, collect, and measure different types of performance elements and provide relatively abstract analysis on trends and overall patterns. That’s important, but there’s an untapped potential for collaboration and learning that allows frontline staff to participate in improvement, which would give leaders a more detailed and granular view of the system they’re running.
So I think one way to shift thinking is to demonstrate how incident reporting systems can provide, to leaders in particular, a very rich, detailed stream of insights into the practical problems that frontline staff are experiencing—as well as demonstrating the innovations and improvements that can be developed on the frontline, when staff are properly supported to improve safety, as well as report on it.
AT: Safety event reporting tends to have a negative connotation.
One change we could make is to look more closely at how events are being prevented, or where we see evidence that teams have taken what they’ve learned from events and done something to achieve improvement. So, looking for those opportunities and focusing on the positive.
We also encourage staff to report and then produce an analysis with recommendations, but the in-between part – the review that is the participative and social learning component – is where we really need to spend more time so that both the process and the outcomes will help people improve safety in their day-to-day work.
Q: We’ve come a long way, but you both agree there’s work to be done. How do we move forward from here?
CM: In terms of learning from incidents, there’s a lot of potential to create new and exciting ways of using them and linking them to positive improvement processes.
New technologies are changing healthcare and may offer new ways to improve patient safety.
Incident reporting and adverse events are often seen as a completely separate realm to quality improvement, so I think one of the big opportunities is to integrate the parts more closely. Safety event reports and serious incidents should be triggers that start quality improvement work, for example.
If you have a system-wide reporting system like BC PSLS, you can develop a picture of the emerging risks and where the problems are, and also where learning is taking place most effectively.
There’s an opportunity not just to collect information on the ‘bad’ events, but making sure recommendations, changes, and improvements are also being captured.
Where are people really learning and solving problems, what sorts of ideas and improvements are being developed across the system?
Quality improvement comes from people actually changing what they’re doing and how they’re working. You hope that by the time an investigation into an event draws to a close that you don’t need to make any recommendations because processes and actions have already been changed. That should be part of what the investigation involves, discovering new ideas and coming up with solutions. Ideally, the investigation report includes a list of the improvements that have been made, not a list of actions for the future.
There are also analytical tools and techniques available now that weren’t some years ago. And there’s social media, this blog, and various other examples, and people can share information almost effortlessly.
There are real opportunities for healthcare and patient safety – incident reporting in particular – to leap ahead of what other industries are doing. We have the opportunity to see how social platforms and collaborative systems can allow people to work together across organizations, time, and distance in ways that were unimaginable 20 years ago.
AT: There are also opportunities that we didn’t have when we started, in the area of event classification, for example. We are doing a lot of work with specialized user groups in BC and Canada to expand on our initial set-up and ensure that data is as meaningful to our users as possible. We don’t want people to be frustrated or wasting their time.
There are also new technologies we are exploring, different ways that classification could be done without tying up people’s time, time they could use to talk to people and engage in interactive learning. If we can get to a point where we’re consistent with automated classification at a high level across the system, then I think we might approach things a little differently than we did at the beginning.
And, for reporters, there’s also an opportunity to provide them with some fairly tailored feedback on the kind of event they reported and facilitate learning, right in the moment, to impact their practice.
Advances in technology, and in thinking about patient safety, have been significant over the past decade, and we need to keep our minds open and leverage those changes wherever we can to benefit both patients and providers. That will be an interesting challenge for us in the years to come, but there are also exciting opportunities ahead!