Framework for better care: reconciling approaches to patient safety and quality
Andrew Johnson A , Robyn Clay-Williams
B C and Paul Lane A
A Townsville Executive Team, Townsville Hospital and Health Service, Douglas, Qld 4814, Australia. Email: andrew.johnson@health.qld.gov.au; paul.lane@health.qld.gov.au
B Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109, Australia.
C Corresponding author. Email: robyn.clay-williams@mq.edu.au
Australian Health Review 43(6) 653-655 https://doi.org/10.1071/AH18050
Submitted: 14 March 2018 Accepted: 6 June 2018 Published: 16 August 2018
Journal compilation © AHHA 2019 Open Access CC BY-NC-ND
Abstract
In September 2017, the Royal Australasian College of Medical Administrators adopted a new clinical governance framework that recognised healthcare as a complex adaptive system, and embraced the need for resilient thinking and understanding the differences between work-as-imagined by managers and work-as-done at the front line of patient care. Directors of medical services may soon be implementing the framework in health services across Australia. This perspective describes a new conceptual model that underpins the Royal Australasian College of Medical Administrators framework, and characterises the challenges faced by all healthcare professionals when trying to achieve safe care for patients in an environment of variable complexity and unpredictability.
Additional keyword: resilient health care.
References
[1] Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA, Braithwaite J. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197 100–5.| CareTrack: assessing the appropriateness of health care delivery in Australia.Crossref | GoogleScholarGoogle Scholar |
[2] Makary MA, Daniel M. Medical error – the third leading cause of death in the US. BMJ 2016; 353 i2139
| Medical error – the third leading cause of death in the US.Crossref | GoogleScholarGoogle Scholar |
[3] James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013; 9 122–8.
| A new, evidence-based estimate of patient harms associated with hospital care.Crossref | GoogleScholarGoogle Scholar |
[4] Chassin MR, Loeb JM. High‐reliability health care: getting there from here. Milbank Q 2013; 91 459–90.
| High‐reliability health care: getting there from here.Crossref | GoogleScholarGoogle Scholar |
[5] Pande PS, Neuman RP, Cavanagh RR. The six sigma way. New York: McGraw-Hill; 2000.
[6] Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J. Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care 2010; 19 376–82.
[7] Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf 2014; 23 290–8.
| Systematic review of the application of the plan–do–study–act method to improve quality in healthcare.Crossref | GoogleScholarGoogle Scholar |
[8] Hollnagel E, Braithwaite J, Wears R. Resilient health care. Farnham, Surrey, UK: Ashgate Publishing; 2013.
[9] Braithwaite J, Clay-Williams R, Nugus P, Plumb J. Health care as a complex adaptive system. In: Hollnagel E, Braithwaite J, Wears R, editors. Resilient health care. Farnham, Surrey, UK: Ashgate Publishing; 2013. pp. 59–60.
[10] Clay-Williams R, Travaglia J, Hibbert P, Braithwaite J. Clinical Governance Framework. A Report Prepared for The Royal Australasian College of Medical Administrators (RACMA). Melbourne: RACMA; 2017. Available at: http://racma.edu.au/index.php?option=com_docman&task=doc_download&gid=2209&Itemid=154 [verified 3 August 2018]
[11] Hughes RG. Tools and strategies for quality improvement and patient safety. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville: Agency for Healthcare Research and Quality; 2008. Chapter 44.
[12] Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc 2007; 82 735–9.
[13] Kleeman R. Information theory and dynamical system predictability. Entropy (Basel) 2011; 13 612–49.
| Information theory and dynamical system predictability.Crossref | GoogleScholarGoogle Scholar |
[14] Bieder C, Bourrier M. Trapping safety into rules: how desirable or avoidable is proceduralization? Farnham, Surrey, UK: Ashgate–CRC Press; 2013.
[15] Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care 2015; 27 418–20.
| Resilient health care: turning patient safety on its head.Crossref | GoogleScholarGoogle Scholar |
[16] Hollnagel E. FRAM: the functional resonance analysis method: modelling complex socio-technical systems. Farnham, Surrey, UK: CRC Press; 2012.
[17] Hollnagel E. Safety-I and safety-II: the past and future of safety management. Farnham, Surrey, UK: Ashgate Publishing; 2014.
[18] Gaba DM. The future vision of simulation in healthcare. Simul Healthc 2007; 2 126–35.
| The future vision of simulation in healthcare.Crossref | GoogleScholarGoogle Scholar |
[19] Heasley A, Hayden M, Lister B. In situ simulation. Simulation Australasia; 2009. Available at: http://www.simulationaustralasia.com/mysimaust/show_abstract/1308 [verified 10 December 2017].
[20] Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013; 22 468–77.
| In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.Crossref | GoogleScholarGoogle Scholar |
[21] Clay-Williams R, Hounsgaard J, Hollnagel E. Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implement Sci 2015; 10 125
| Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines.Crossref | GoogleScholarGoogle Scholar |
[22] Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A framework for safe, reliable, and effective care. White paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.
[23] Johnson A, Lane P. Resilience work-as-done in everyday clinical work. In: Braithwaite J, Wears R, Hollnagel E, editors. Resilient health care. Volume 3: reconciling work-as-imagined and work-as-done. London: CRC Press; 2016. pp. 71–87.
