Learning, Accreditation, and Continuous Quality Improvement

Learning, Accreditation, and Continuous Quality Improvement

Accreditation of healthcare organizations using generic healthcare standards and more recently  diving deeper  into the delivery of services  is considered  by many  as an initial  way towards excellence.  However, without a systemic and systematic approach  to organizational learning,  many opportunities can be lost and  necessary changes slowed down. Not so long ago I  read a story of people shouting for help when a wild river was draining them downstream.  Three rescuers happened to be nearby. The first one, a stout and courageous man, jumped into the river and helped  a drowning person. Comparing this to healthcare  it looked  like an urgent case needing immediate attention. The second rescuer thought that there were too many people in the water and that it would be more effective to have a boat thus  attending to more  people at once. The third one jumped into the water starting to swim upstream. “What are you doing? Why won’t you help us”? the second rescuer shouted at her.  “I am trying to find out what is happening upstream and  why these people are falling into the water.”

It  seems that both downstream and upstream approaches are the right things to do, at least at the present state of affairs in healthcare. Healthcare organizations are viewed as a complex system, as a live organism necessitating a constant change to survive and deliver high quality and safe care. Without a robust and integrated information-communication system, it is almost impossible to improve on a whole scale.  Improvement efforts are often short-lived  and therefore strong leadership is needed with the engagement of physicians, nurses and all other staff.

If you are an “upstreamist”  than the idea of organizational learning is not foreign to you. Organizational learning may be defined as  a process of increasing knowledge and innovation  of work routines with action and reflection going beyond individual-focused training  (Carroll and Edmondson , 2002). Organizational learning involves  continuous quality improvement (CQI) teams, improve collaboration, and healthcare reengineering works.   Organizational learning may have different names, nevertheless, the process is generic.

In the UK the term used is “Clinical Governance” The aim of organizational learning is to promote a culture of CQI  made of clinical performance, internal and external clinical audit, clinical risk management, complaints, health needs assessment, practice based on evidence, continuous education, leadership, culture of excellence and distinct  accountability.

Everyone working in healthcare has been  through specific training for his/her future profession. For quality improvement and patient safety, it is sometimes thought that no training and no competences are necessary as this is already  imprinted  in the human genome.  The third prerequisite for CQI is leadership skills to promote the integration of competences and stimulate working together.

Carroll JS and Edmondson AC. Leading organizational learning in health care. Qual Saf Health Care 2002;11:51-6.

 

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Sistematična analiza globljih vzrokov za napake

Sistematična analiza globljih vzrokov za napake

Človeške napake so simptom globljih problemov v sistemih in procesih!

Ko pride do analize nesreče (če napake namenoma ne pripišemo komplikaciji ali jo zamolčimo), se osredotočimo na tistega, ki je napravil aktivno napako. To je »lov na čarovnice« ali »odstranjevanje gnilih jabolk«.

Tak način je za varnost pacientov škodljiv, saj spodbuja skrivanje napak, defenzivno medicino in pripisovanje napak s škodo komplikacijam zdravstvene obravnave.

Živimo v kulturi obtoževanja. Nismo še uspeli vzpostaviti pravične kulture, kjer se vsakdo zaveda, da se napaka lahko zgodi vsakomur in jo lahko vsakdo sporoči pristojnim v zdravstveni ustanovi, ne da bi se bal neupravičenega obtoževanja, jemanja licenc ali kriminalističnega preganjanja. Pravična kultura pa nas ne razreši odgovornosti za lahkomiselne in/ali ponavljajoče se kršitve in nesprejemljivo profesionalno obnašanje.

Ali poznate koga, ki so mu začasno odvzeli licenco, ker se je zmotil, ali ga obtožili zločinstva?

Ali so vas že kdaj obdolževali, da ste krivi za napako, ker ste bili površni, nepazljivi, raztreseni, utrujeni… Ali ste že kdaj kaj pozabili, kar je pripeljalo do napake? Skoraj zagotovo se vam je to zgodilo, doma ali na delovnem mestu, saj imamo zdravniki in drugi zdravstveni strokovnjaki enake nepopolne možgane kot vsi drugi ljudje. Pristop k analizi napak se je na podlagi znanosti o varnosti v zadnjih dveh desetletjih temeljito spremenil. Sloni na sistemskem pristopu, ki omogoča najti globlje vzroke za napake in ugotavlja zakaj so ljudje v določeni situaciji ravnali tako kot so in zakaj je prišlo do napake (npr., zakaj so se zmotili, nekaj pozabili, spregledali bili površni...).

Lastne izkušnje avtorja na podlagi sodelovanja pri analizah napak s katastrofalnimi posledicami za pacienta kažejo na to, da v Sloveniji, še vedno raje vidimo, da se s prstom pokaže na »krivca«, ali obtoži sporočevalca napake.Vodstva so zelo nesrečna, če se odkrijejo sistemski vzroki za napako, saj težko priznavajo, kaj vse je v ustanovi ali na oddelku, ki jih vodijo narobe in koliko dela jih čaka, da bi vzpostavili sisteme, procese in varovala, ki bi se podobne napake v prihodnje preprečile.

Ko boste priročnik prebrali, se boste lahko ubranili neupravičenega obtoževanja, če se vam bo zgodila napaka.

Priročnik- sistematična anaiza globljih vzrokov za napake - ima 117 strani. Priloge so na spletu in obsegajo 76 strani ter vam bodo v pomoč pri analizi napak.

Za vodstvo, predstojnike, vodilne medicinske sestre:

  • Ne čakajte, da bo prišlo do katastrofalnih napak.
  • Ne čakajte, da vas bodo šele zunanji presojevalci opozorili na neskladnosti.
  • Ne čakajte na to, da se boste znašli v medijih zaradi napak.
  • Vzpostavite sistem varnosti pacientov v celotni ustanovi.
  • Vzpostavite infrastrukturo, procese in merite izide.
  • Preberite si priročnik in pri analizi napak upoštevajte sistematično analizo globljih vzrokov za napake.
  • Vzpostavite pravično kulturo.
  • Usposobite osebje za varno delo s pacienti.
  • Preoblikujete sisteme in procese z vgradnjo varoval za preprečevanje napak.

Sistematična analiza globljih vzrokov za napake

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