Mark-Alexander Sujan

An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety

Following the Public Enquiry into avoidable deaths and poor standards of care at Mid Staffordshire NHS Foundation Trust, the English National Health Service (NHS) is aiming to become a system devoted to continual learning and improvement of patient care. The paper aims to explore current perceptions of healthcare staff towards reporting and organisational learning for improving patient safety. Based on a Thematic Analysis of semi-structured interviews with 35 healthcare professionals in two NHS organisations, the paper argues that previously identified barriers to incident reporting remain problematic, and that less centralised processes that aim to learn from everyday clinical work might be better suited to generate actionable learning and change in the local work environment. The findings might support healthcare organisations in understanding better the practical processes of organisational learning at the local level. The findings might also support researchers in developing new approaches and strategies for integrating learning about risk at the local level with effective organisational change to improve patient safety.

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary

Incident reporting as a key mechanism for organisational learning and the establishment of a stronger safety culture are pillars of the current patient safety movement. Studies have suggested that incident reporting in healthcare does not achieve its full potential due to serious barriers to reporting and that sometimes staff may feel alienated by the process. The aim of the work reported in this paper was to prototype a novel approach to organisational learning that allows an organisation to assess and to monitor the status of processes that often give rise to latent failure conditions in the work environment, and to assess whether and through which mechanisms participation in this approach affects local safety culture. The approach was prototyped in a hospital dispensary using Plan-Do-Study-Act (PDSA) cycles, and the effect on safety culture was described qualitatively through semi-structured interviews. The results suggest that the approach has had a positive effect on the safety culture within the dispensary, and that staff perceive the approach to be useful and usable.

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions

Aim To prototype a system for identifying and monitoring those organisational processes that give rise to latent conditions that can contribute to failures in a dispensary environment. Methods A proactive risk-monitoring system was prototyped during a 9-month period within the dispensary at Hereford Hospital. The system is used to identify empirically a preliminary set of Basic Problem Factors through qualitative analysis of narratives submitted by pharmacy staff about problems they encountered during their daily work. These factors are monitored and rated based on staff perceptions elicited through a questionnaire. At the concept stage, the system idea was discussed at two stakeholder workshops to ensure plausibility. A Plan–Do–Study–Act approach was used to prototype the system and to evaluate the perceived usability and perceived completeness of the system. Results After four Plan–Do–Study–Act cycles, staff were satisfied with the usability of the questionnaire and the choice of factors being monitored. In total, 11 Basic Problem Factors were identified from the narratives, 10 of which have been monitored over a period of 6 months using a questionnaire. The differences in staff perceptions were statistically not significant. The qualitative and quantitative results led to improvements that included a review of all IT equipment in the department and the clean-up of the work environment. Conclusion A system for identifying and monitoring organisational processes that give rise to latent conditions that may contribute to failures was prototyped at the dispensary at Hereford Hospital. This contributes to the organisations efforts towards creating a proactive safety culture.

Managing competing organizational priorities in clinical handover across organizational boundaries

Objectives Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine). Methods A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically. Results The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other’s goals and constraints as possible ways towards more sustainable improvement. Conclusion Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.

Organisational reporting and learning systems: Innovating inside and outside of the box:

Reporting and learning systems are key organisational tools for the management and prevention of clinical risk. However, current approaches, such as incident reporting, are struggling to meet expectations of turning health systems like the UK National Health Service (NHS) into learning organisations. This article aims to open up debate on the potential for novel reporting and learning systems in healthcare, by reflecting on experiences from two recent projects: Proactive Risk Monitoring in Healthcare (PRIMO) and Errordiary in Healthcare. These two approaches demonstrate how paying attention to ordinary, everyday clinical work can derive useful learning and active discussion about clinical risk. We argue that innovations in reporting and learning systems might come from both inside and outside of the box. ‘Inside’ being along traditional paths of controlled organisational innovation. ‘Outside’ in the sense that inspiration comes outside of the healthcare domain, or more extremely, outside official channels through external websites and social media (e.g. patient forums, public review sites, whistleblower blogs and Twitter streams). Reporting routes that bypass official channels could empower staff and patient activism, and turn out to be a driver to challenge organisational processes, assumptions and priorities where the organisation is failing and has become unresponsive.

Combining failure mode and functional resonance analyses in healthcare settings

Socio-technical systems rely on technological artefacts as well as human and professional practices in order to achieve organisational safety. From an organisational viewpoint of analysis, different safety barriers are often put in place in order to mitigate risks. The complexity of such systems poses challenges to safety assessment approaches that rely on simple, identifiable cause and effect links. Failure Mode and Effects Analysis (FMEA), for instance, is an established technique for the safety analysis of technical systems, but the assessment of the severity of consequences is difficult in socio-technical settings like healthcare. This paper argues that such limitations need to be addressed by combining diverse methodologies in order to assess vulnerabilities that might affect complex socio-technical settings. The paper describes the application of FMEA for the identification of vulnerabilities related to communication and handover within an emergency care pathway. It reviews and discusses the applicability of the Functional Resonance Analysis Method (FRAM) as a complementary approach. Finally, a discussion about different aspects of emerging technological risk argues that taking into account socio-technical hazards could be useful in order to overcome limitations of analytical approaches that tend to narrow the scope

Goal-based safety cases for medical devices: opportunities and challenges

In virtually all safety-critical industries the operators of systems have to demonstrate a systematic and thorough consideration of safety. This is increasingly being done by demonstrating that certain goals have been achieved, rather than by simply following prescriptive standards. Such goal-based safety cases could be a valuable tool for reasoning about safety in healthcare organisations, such as hospitals. System-wide safety cases are very complex, and a reasonable approach is to break down the safety argument into sub-system safety cases. In this paper we outline the development of a goal-based top-level argument for demonstrating the safety of a particular class of medical devices (medical beds). We review relevant standards both from healthcare and from other industries, and illustrate how these can inform the development of an appropriate safety argument. Finally, we discuss opportunities and challenges for the development and use of goal-based safety cases in healthcare.

The development of safety cases for healthcare services : practical experiences, opportunities and challenges

There has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. The paper presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. The paper argues that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.

The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emergency care

Abstract The paper aims to demonstrate how the study of everyday clinical work can contribute novel insights into a common and stubborn patient safety problem—the vulnerabilities of handover across care boundaries in emergency care. Based on a dialectical interpretation of the empirical evidence gathered in five National Health Service organisations, the paper argues that performance variability is an essential component in the delivery of safe care, as practitioners translate tensions they encounter in their everyday work into safe practices through dynamic trade-offs based on their experience and the requirements of the specific situation. The findings may shed new light on the vulnerabilities of the handover process, and they might help explain why improvements to handover have remained largely elusive and what type of future recommendations may be appropriate for improving patient safety.

Safety cases for medical devices and health information technology: Involving health-care organisations in the assurance of safety

In the United Kingdom, there are more than 9000 reports of adverse events involving medical devices annually. The regulatory processes in Europe and in the United States have been challenged as to their ability to protect patients effectively from unreasonable risk and harm. Two of the major shortcomings of current practice include the lack of transparency in the safety certification process and the lack of involvement of service providers. We reviewed recent international standardisation activities in this area, and we reviewed regulatory practices in other safety-critical industries. The review showed that the use of safety cases is an accepted practice in UK safety-critical industries, but at present, there is little awareness of this concept in health care. Safety cases have the potential to provide greater transparency and confidence in safety certification and to act as a communication tool between manufacturers, service providers, regulators and patients.