Why wait for a health-care crisis to put patients' safety first?
Here's a wacky idea: Instead of waiting for a health-care disaster to happen, enduring the media pummelling, staging a public inquiry, then settling the raft of lawsuits, why not learn from others and be proactive about patient safety?
The harrowing levels of abuse and neglect that occurred at Stafford Hospital in Britain led to hundreds of deaths between 2005 and 2008. Since then, there has been much political fallout and soul-searching, and no fewer than five public inquiries, resulting in hundreds of recommendations for improving care.
Of course, it's easy for Canadian hospitals and policy makers to say "that can never happen here," and dismiss it all as someone else's problems.
Yet, beyond the specific failures within Stafford Hospital and its funding body, the Mid Staffordshire Trust, the scandal exposed some troubling realities about health-care culture, namely that patient safety is rarely a priority.
Consider that, in Canada, somewhere between 9,000 and 24,000 people die prematurely each year because of adverse events. Much work remains to be done.
The latest report from Britain, titled "A promise to learn – a commitment to act," was prepared by a committee led by Dr. Don Berwick, founder of the Institute for Healthcare Improvement. It focuses on how to improve patient safety in Britain's National Health Service (NHS). But it offers much food for thought (and tools for prevention) for health-care administrators around the world, including Canada.
Dr. Berwick's report begins with some general but important observations: Patient safety problems exist, to varying degrees, in every health system in the world; in the vast majority of cases, it is systems, procedures and work environment – not staff members per se – that create the problems; the central focus of health-care institutions should be patients, but it rarely is; responsibility for patient safety is often diffuse – when too many are in charge, no one is responsible; improving safety requires investment, support and effort – it won't happen magically.
To address these fundamental issues, Dr. Berwick and his team said health-care systems need to make some fundamental changes, including: State clearly and courageously that systemic change is required to improve patient safety; abandon blame and trust the goodwill and good intentions of staff; recognize that transparency is essential and expect and insist on it; ensure that who is responsible for overseeing safety and quality improvement is stated clearly; use targets, but use them judiciously – they should never displace the ultimate goal of better care; ensure that health professionals can take pride and joy in their work; they should not live in fear.
Dr. Berwick said the single most important change the NHS (and any other health-care system for that matter) could make is to embrace education and training to create a "system devoted to continual learning and improvement of patient care, top to bottom and end to end."
The report concludes with 10 specific recommendations that reinforce that philosophy:
1. Embrace wholeheartedly an ethic of learning.
2. Make quality of care the top priority in every aspect of the health system – political, regulatory, executive, clinical and advocacy.
3. Patients should be actively involved in every level of health-care organizations.
4. Ensure sufficient staffing; however, the report rejects the notion of legislating staff-to-patient ratios.
5. Make patient safety a key component in the education of health professionals and administrators.
6. Create and support the capability for learning and continuous improvement.
7. Transparency should be "complete, timely and unequivocal;" All quality and safety data should be shared openly.
8. When monitoring safety and quality of care, the input of patients and families should always be sought.
9. Supervisory and regulatory systems should be simple and clear.
10. Regulation by institutions and professional bodies is necessary but recourse to criminal sanctions should be "extremely rare."
There are those who will complain that these recommendations are too vague and idealistic. But they are not. Improving quality of care and patient safety is, above all, about changing culture.
For far too long in medicine, the sole focus has been on treating conditions, often to the detriment of treating the whole person. Giving patients the final word in their care shifts the power base of medicine fundamentally. So too does transparency.
The changes Dr. Berwick is promoting are profound – almost revolutionary – but necessary. He knows this and that's why he has put so much emphasis on education and on fostering and nurturing change.
The underlying message here is that greatest impediment to safer health care is actually fear – fear of doing things differently.
But different – better – is what patients need, and deserve.