high reliability healthcare 16 october 2009. patient safety events - a global problem: 10% of...
TRANSCRIPT
High Reliability Healthcare
16 October 2009
Patient Safety Events - a Global Problem:
10% of hospital patients suffer an adverse event each year (UK, New Zealand, Canada and Europe)16.6% of hospital patients suffer an adverse event (Australian study)1.4 million hospital patients worldwide acquire Healthcare Associated Infections (HAI) 100,000 cases of HAI lead to 5,000 deaths a year (UK)1 out of every 135 hospital patients acquires HAI (USA) 98,000 hospital deaths every year through medical error (USA)
High Reliability Healthcare
Systems
Safe, high quality care
Provider Market
Evidence Based
Practice
Governance
Regulatory
Framework Political Legislative
Commissioning for Quality
Insurers
Service
Users, Public
Key Levers and Drivers
Key Ingredients
Person-centred careOpen and transparent learning cultureStrong leadership, governance, accountability, management and team workingClinicians in executive management Fit for purpose workforceEffective information management and measurementInformed decision-makingRobust quality assurance – internal and external
“Systems and processes are only as good as the people
who work within them”
COMMUNICATIONS
LEADERSHIP
MULTI-DISCIPLINARY TEAM WORKING
BEHAVIOURS
CULTURE
RELATIONSHIPS
Open and Transparent Culture…
“…as soon as we knew we’d made the mistake we met with the family and told them”
“…telling relatives – well you see, we don’t do that here it’s not in our culture”
“…I thought I’d made myself clear, I don’t speak to patients, I have people who do that for me”
A culture and ethos of professionalism, courage,
openness, informed decision-making, effectiveness,
efficiency, learning, innovation and knowledge.
High Reliability Culture
Leadership
“Us, doing the right thing”
If we are ever in doubt about what to do, it is a good rule to ask ourselves what we shall wish on the morrow that we
had done.
John Lubbock