Essays

Essays February 2014

Over the past five months, the balcony of “personal reflection” has been alive with patient, family, care provider, manager and researcher voices. The Ghost of Healthcare Consciousness has posed questions to challenge current assumptions. A common theme throughout all of the conversations is this...listening to hear and with that a new conversation.

The Ghost of Healthcare Consciousness swoops in and says:

‘Healthcare will not be transformed until the patient has been made the centre of the healthcare system.  Not until the balance of power is centralized with the patient, will systems succeed in providing quality care.  You know what is required: a system that is wholesome, one that is cohesive, flexible, interconnected, cost effective, and one that magnifies the patient voice to a position of power. The largest obstacle in the way of improving care is the fractured and divisive nature of the system itself.

The problem is this: a healthcare system that stifles communication and creates tension between workers is ineffective and inefficient. This is is a healthcare system focused on internal fissures. The current system is not set up to prevent adverse events and neither the healthcare system, nor the judiciary system, are structured to help grieving patients, families and practitioners cope with the consequences. The common practice of focusing on silos - insulating one profession from another - compounds these problems further.”

In theory, it is such a simple concept: understand how to deliver quality care by focusing on reducing risk and promoting safety, both within the institutional setting and the community.  However the implementation needed to achieve quality, patient-centric care shakes the very foundation of our current model.  Only when nurses, doctors, architects, engineers, lawyers, managers, administrative professionals, etcetera, speak the same language will we begin to make a difference.   

The idea behind the empowerment is that anyone has the right and responsibility to speak up in the name of patient safety.  The experience of Virginia Mason, under the leadership of Dr. Gary Kaplan, and based on the Toyota production system, has proven that healthcare workers at all levels are capable of contributing to a quality healthcare environment.

As a first step these points should be considered:

  • A reporting tool should be available to all workers in non-urgent situations. Reports should be reviewed by administration and responses posted in an easily accessible area in a timely manner.
  • In urgent situations, workers need to be empowered to stop the line (bring an end to all activity surrounding the patient until the patient safety issue is resolved). Workers need to feel supported, protected and should be rewarded for stopping the line in the name of patient safety.  Any worker, from nurses, to maintenance workers, surgeons to administration should be empowered to stand up for patient safety at any time.  When a worker stops the line, an independent review of the situation should be undertaken by a member of the administration (such as the Quality Assurance Department).
  • Workers should not be faced with punitive measures, blame or administrative action, for either committing a patient safety error or the reporting of such errors.  Making all workers responsible for patient safety decentralizes power from the hierarchy of institutional politics and centralizes the power within the patient. Promoting and supporting a just culture is paramount in supporting a patient-centered healthcare system.

Recognizing that adverse events are, for the majority, not the result of lazy, bad or incompetent workers, but rather systems failure, is key to promoting a culture of patient safety.  For the purposes of this paper, systems failure refers to a ‘gap’ or oversight in an organization’s policies and procedures that negatively affects patient safety. As Sidney Dekker explains in his books, Just Culture: Balancing Safety and Accountability, and Second Victim: Error, Guilt, Trauma, and Resilience, individual people cannot be held accountable for failures of an organization, nor can we forget that healthcare professional are often traumatized by adverse events, making them the second victims.  In order to effectively empower healthcare workers to stop the line and report unsafe conditions, they must feel that neither they, nor their colleagues, will be blamed for the incident. In the blame, shame, and retrain culture that current exists in most of our healthcare system, the emphasis is on the individual worker, not the system.

This focus puts the patients in a perilous state: not only is the system which caused the adverse event untouched, but the healthcare workers are left with a hostile and disapproving environment. This suffocating environment does not promote the reporting of near misses, unsafe conditions or adverse events due to the fear of retribution from administration and colleagues. Moreover, healthcare workers who have experienced an adverse event in a blame and shame culture are traumatized a second time by their treatment after the incident.  In a culture where workers are unsupported in their grief, there is a greater potential there for lasting negative effects in the worker.  In some cases this can lead to an abandonment of the profession, or in extreme circumstances, self-harm.  A recognition of second victimhood, and a promotion of just culture, does not support negligent or incompetent practitioners.  Rather, it promotes a safe space for owning errors, and allows workers to openly grieve in a supportive and understanding environment. Also it provides reassurance that the system failure that led to the error will not be allowed to harm another patient. This kind of environment centralizes power in the patient because it takes focus away from punishing ‘bad’ workers and eliminates the risk to patients from system error or neglect from suffering workers. These concepts of just culture and second victimhood are fairly recent developments in quality, risk and safety.  Translating knowledge from the realm of academia to practice is also a key component in a patient central approach.

Knowledge translation is a set of actions that bring concepts, conclusions and research done in academia to institutions or organizations that can put new knowledge into practice (https://www.cihr-irsc.gc.ca/e/29418.html, retrieved Dec 4, 2013). Knowledge translation is critical to improving healthcare because it allows knowledge created at the highest levels to be implemented in the most beneficial ways on the ground.  A key element in improving care is being willing to evaluate current practices and accepting innovative and progressive changes.  In their 2012 paper, “Roadmap for a Participatory Research – Practice Partnership to Implement Evidence,” Drs. Margaret Harrison and Ian D. Graham, outline the Queen’s University Research Roadmap for Knowledge (QuRKI) strategy for knowledge translation. Developed for use in a wide variety of environments (hospital, community, and long-term care) it provides a guide for institutions/organizations looking to begin a knowledge translation implementation program. The development of a reliable knowledge translation research program concentrates power within the patient because it eliminates out-dated or stale practices. Putting the patient’s care at the forefront of hospital policies and procedures, based on best practices as devised by new research, confirms leaderships’ commitment to patient centered care. Knowledge translation, a just culture and empowering healthcare workers are all integral parts of centralizing power within the patient and creating a truly patient centered environment.

Empowering workers, creating a just culture and implementing a strong knowledge translation research program are some of the core tenants of the new face of patient centered care.  Once these key factors are subsumed, addressing issues of efficiency, connectedness and flexibility will be easier.  Rebuilding our healthcare system requires a top down as well as a bottom up approach that emphasises strong communication, respect and inter-professional education.  Focusing on the patient as the centre of the healthcare system and concentrating power within them is the ultimate goal. The time for little fixes and subtle changes has passed.  So fundamentally damaged is our healthcare system that nothing but an overhaul will bring order to a havocked system.  The time for wishing and hoping has passed; the time for action is now.

We end with a passage from the essay “The Patient Voice a Value Changer

“You should read a 2009 Discussion Paper by Steven Lewis titled “Patient Centre Care – A Introduction To What It Is and How To Achieve It”. The discussion paper talks about a number of specific challenges like:

  1. On many levels the nature of the relationship is inherently unequal – patients are by definition dependent on their provider.
  2. Much of the time, patients are in some degree of pain, discomfort, or anxiety. They are not at their peak, they are vulnerable and therefore reduced capacity to assert themselves and take control of their care.
  3. Status and other hierarchies come into play. Providers are not inculcated with a culture of service, they see patients as fundamentally different from customers.
  4. They view their time as a precious commodity (which it is) and organize their practice around its most efficient deployment –what do I need to do to cope with the demands.
  5. Huge risks (real or perceived in trying to change traditional power relationships and modes of communication and behaviour.”

 

About the Author

Kim Sears, RN, PhD – Dr. Sears is an Assistant Professor in the School of Nursing and Co-Director of the Master of Science program at Queen’s University.
Briana Broderick, HBA, BEd, MA – Mrs. Broderick is a Graduate Program Assistant in the Master of Science in Healthcare Quality program at Queen’s University.
David Goldstein, MSc. (Health Education), MB, BCh, BAO, FRCPC, MSc (Human Factors and System Safety), EXTRA – Associate Professor in the Department of Anesthesiology and Perioperative Medicine and Surgery and Co-Director of the Master of Science in Healthcare Quality at Queen’s University.
Denise Stockley, PhD – Interim Director, Centre for Teaching and Learning and Professor, Faculty of Education at Queen’s University.
Hugh Macleod, CEO Canadian Patient Safety Institute...Patient, Husband, Father, Brother, Grandfather and concerned citizen.

References

Canadian Institutes of Health Research, About knowledge translation & commercialization, accessed December 4, 2013.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S., Tetroe, J., Caswell, W., Robinson, N. (2006). Lost in Translation: Time for a Map? The Journal of Continuing Education in the Health Professions, 26(1):3-24

Kenney, Charles, Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience. Productivity Press (2010).

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