Summary of the lectures and mandatory literature of Quality and Safety

Quality and safety exam

Problem talk 1:

Learning goal: What are the roles and effects of formal structures in quality improvement
efforts?

Sub questions:
1. What are advantages and disadvantages of protocols for quality improvement work?
2. How can we know if a structure is effective in improving quality of work

Wrong-site errors:
Performing a procedure on the wrong side of the patient’s body, performing a whole
procedure, or performing the correct procedure on the wrong patient constitute some of the
worst medical errors that clinicians and patients experience. The term wrong-site
encompasses surgery on the wrong person, the wrong organ or limb, or wrong vertebral
level. Wrong-site surgery is unacceptable but rare.

Introducing quality and safety

Why is it important?
- Very relevant in times of crisis- but just as important in everyday work
 How can we think about this work in general?
 How can we intervene?
- Patient care can be standard, unsafe, fragmented, variable, costly
- Efforts to improve Q&S are marginally on agenda of healthcare organizations
- Existing power structure and hierarchies prevent quality improvement.

Quality and safety are not always the priorities of healthcare organizations.
- Tools for quality and safety are poorly understood.

How can we define it
- Institute of medicine: 6 dimensions of effectiveness
 Nonprofit organizations to provide information to American government and
private corporation.
 6 dimensions of quality
1. Effectiveness: provided care must improve health
2. Efficiency; you do so in the most sufficient way -> maximizing the quality of
care.
3. Equity: Everyone should get the same level of care, based on their individual
meets.
4. Patient centeredness: meet the needs and preferences and provide education
and support.
5. Safety: Care should be safe, and not lead to harm.
6. Timeliness
 These dimensions could sometimes conflict with each other -> efficient
care is probably not the most effective care.

, - 2001: the IoM defined care as living up to its standards and expectations. Good care
is defined in terms of what did we expect from it, both from a biomedical point of
view and from a patient perspective.
- The degree to which service for individuals and populations increased the likelihood
of desired health outcomes and are consistent with our current professional
knowledge.
 What one person desires is different from the next person .
- WHO
 Shares the same criteria
 Same criteria as IoM
- Dutch quality, complaints & disputes act (Wkkgz)
 Same criteria as IoM, but replaces equity with transparency.
- Dimensions become part of practices as well

Quality and safety in practice; what is out here
- Many instruments for quality and safety available, think of
 Clinical guidelines
 Accreditation bodies
 Performance indicators
 Technologies
 Patient participation tools
- However, Q&S are human accomplishments
- We need to take into account the work that people do

Quality and safety in practice; what problems do we encounter
- Explanations that are often given for lacking quality and safety
 Instruments are badly implemented
 Evidence of how instruments work is lacking
 Interactions between instruments and contexts of use are unclear
 Interaction between instruments is unclear

What makes it hard to research?
- Practical limitations
 Research is often focused on simple interventions in complex environments.
 Local insights are rarely universally applicable
 There’s still a lot we don’t know
- Different views on what is importance
 Healthcare professionals, managers, policy makers tend to focus on instruments,
tools, structures
 They often ignore practices of quality and safety

,What characteristics can we discern.
- Q&S are multi-layered
 Interactions between macro, meso, micro levels of care.
- Q&S are dynamic
 Changes at each level have consequences for quality instruments.
 Interactions between instruments, organizations, laws, and protocols
- Q&S are emergent.
 Q&S emerge form care practices, they are not inherent properties of care.
 Consequences of interventions are unpredictable.

Q&S practice
- What should we do
 Reflexive and contextual approach
 Less top-down focus on implementing interventions -> could be bottom-up as
well
 Move focus on making healthcare resilient.

In short
- Huge and complex challenge
- Dynamic definitions
- Many different instruments
- Effects are poorly understood.
- Multi-layered, dynamic, emergent

Organizing for quality framework
- Six challenges in quality and safety work
 Structural: structuring, planning, and coordinating quality efforts
 Cultural: giving quality a shared, collective meaning, value and significance within
the organization.
 Educational: creating and nurturing a learning process to support continual
improvement.
 Political: Addressing the politics and negotiating the buy-in, conflict and
relationships of change.
 Technological & physical: designing physical infrastructure, and technological
systems supporting the quality efforts.
 Emotional: Inspiring, energizing, and mobilizing people by linking QI to inner
sentiments and deeper commitments. -> about inspiring and motive people; how
do you get people on board.
->They form a basis of a conceptual framework that we use in this course

Framework
- Tells u not how quality and safety should be done -> we use it as a new way of looking
at quality and safety -> analytical framework.
- The six challenges lie at the core of the book -> based on qualitative research
conducted in several hospitals that made successful quality improvements.
- They identified 6 challenges that all healthcare organizations face to improve quality
and safety of health care delivery.

,  Outer context: macro context in which quality and safety should take place ->
regulations, markets.
 Outer context: market & resource environment, technological
environment, political and regulatory environments, social and cultural
environments.
 Inner context: meso level of organization -> In terms of structure.
 Organization size, organization structure, organization performance.

Six challenges (Hans Vermaak) -> learning to change.
The challenges are focused on work you need to do in quality improvement -> things to think
about to improve the quality and safety of healthcare.
- Structural challenges: challenge around structuring, planning, and coordinating
quality efforts. What kind of structures are present -> how can we change these
structures (Bate et al)
 Good structures are essential for organizing quality effort (strategies, information
sharing, coordination, dedicated teams).
 Too much focus on structure can be a bad thing -> can lead to fragmentation, and
decoupling.
 We need good structures in organizations -> on meso and macro level.
 Not always that more structures lead to better quality and safety -> where do
they get these ideas from: they conducted research -> how they did their quality
work -> the framework we use is based on ethnography research: what do they
do.
 Inspector about guidelines, rules, and structures: did you adhere to the protocol -
> if there was a protocol -> improvement: better adherer to the protocol.
 You need to understand why the nurse did not follow the protocol ->
follow what they should have done.
 What you need to research when someone doesn’t follow the protocol:
why didn’t he follow the protocol. For example, cultural. Or you think the
protocol is not right for this situation -> you should discuss this with
colleagues and patients to know this is the right choice.
 Which protocols are useful and which situation -> in this choice, many
aspects should have been weighted.
 Decoupling: you have protocols -> but you look one week before the
evaluation to the protocols to determine whether you adhere to the
protocols-> you don’t actually follow it during the whole period.
 We are going to look to the practices that people do when focusing on quality and
safety.

- Cultural challenge; giving quality a shared, collective meaning, value and significance
(within organization).
 Culture is crucial for sustaining change and for process of sensemaking -> culture
of reflexivity, culture of innovation, culture of openness and sharing.
 However, there are also dysfunctional cultures (think of clan culture, a toxic
culture on the work floor).
 What is culture of your organization -> how can you change it, it is crucial for
sustaining.