Summary Health & Safety of Healthcare

Quality & Safety
of Healthcare




GW4007MV

S537735 - Thomas van Waesberge

14th October 2022 – December 2022

,Lecture 1
1.1 Introducing Quality & Safety
Why is it important?

- Very relevant in times of crisis – but just as important in everyday work
o Politics, unprecedented, facemask, social distancing, new difficulties
o When restrictions are not followed new restrictions are made  corona pass
o How can we think about this work in general?
o How we can intervene?
- Meanwhile …
o Patient care may be substandard, unsafe, fragmented, variable, costly
o Efforts to improve Q&S are marginally on the agenda of healthcare organizations
o Existing power structures and hierarchies prevent quality improvement (QI) 
heroism among medical specialists
o Instruments for QI are poorly understood
o Demographic changes, aging population, rise of co-morbidities…

How can we define it?

- Institute of Medicine:
o Six dimensions:
 Effectiveness  Provided care must improve health
 Efficiency  Provided care must improve health in the most efficient way,
maximizing the quality of care wherever possible
 Equity  Everyone should receive the same level of care based on their
individual needs
 Patient centeredness  Meet the needs of patients and their preferences,
but also about education and support for patients
 Safety  It should do no harm
 Timeliness
 (IoM, 2001)
 The dimensions can conflict with each other
o Definition: “the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge” (IoM, 2013)
 Relative and dynamic definition of quality
 Different people desire different things
 Current professional knowledge  shows that this definition is
dynamic
- World Health Organization (WHO)
o Same criteria as IoM
- Dutch Quality, Complaints & Disputes Act (Wkkgz):
o Same criteria as IoM, but replaces ‘Equity’ with ‘Transparency’

Q&S in practice

- What is out there?
o Many instruments for Q&S available, think of:
 Clinical guidelines – evidence based interventions of which intervention is
effective for which diagnosis

,  Accreditation bodies – external committees that assess the care in
organizations
 Performance indicators – like waiting times or turnover rates
 (Information) technologies – patient portals, medication dispensers etc.
 Patient participation tools
 Etc.
o However, Q&S are human accomplishments:
 We need to take into account the work that people do!
- What problems do we encounter?
o 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?
o Practical limitations:
 Research is often focused on ‘simple’ interventions in ‘complex’ environments
 Local insights rarely universally applicable
 There’s still a lot we don’t know about the environment of health care
o Different views on what is important:
 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?
o Q&S are multi-layered:
 Interactions between macro, meso and micro levels of care
o Q&S are dynamic:
 Changes at each level have consequences for quality instruments (ex.:
changing use of guidelines through time)
 Interactions between instruments, organizations, laws and protocols, etc.
o Q&S are emergent:
 Q&S emerge from care practices; they are not inherent properties of care
 Consequences of interventions are unpredictable
- What should we do?
o Reflexive and contextual approaches
 Look at processes instead of a static picture of healthcare
o Less top-down focus on implementing interventions
 More opportunities for bottom-up
o More focus on making healthcare resilient
 About preventive

In short

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

, 1.2 ‘Organizing for Quality’ framework
Six challenges




- Analytical framework
- New view of how to look at quality & safety in healthcare
- Outer context  macro level
- Inner context  meso level of an organization

Structural challenge

- Challenge around structuring, planning and coordinating quality efforts (Bate et al.)
o Structuring, planning and coordinating are written in an active way, instead of
structure, plan and coordination
o Good structures are essential for organizing quality effort; e.g. strategies, information
sharing, coordination, dedicated teams
o However, too much focus on structure can lead to bureaucratization, fragmentation
and decoupling

Cultural challenge

- Challenge of giving quality a shared, collective meaning, value and significance within the
organization (Bate et al.)
o Collective meaning: are we talking the same about culture in the organization
o Culture is crucial for sustaining change and for processes of sense-making.
Examples: culture of reflexivity, culture of innovation, culture of openness and sharing
o However, there are also dysfunctional cultures (think of clan-culture, bullying, etc.)