Leadership and patient safety - Essay Example

? PATIENT’S SAFETY of Affiliation LEADERSHIP AND PATIENT’S SAFETY Managers and staff in health care facilities are required to work collaboratively to set health priorities, as well as come up with effective reforms to guarantee professionalism. This is to imply that such reforms and priorities are among the critical issues that face health care administrators. Understanding these two aspects is critical in the development of professionalism in health care system. In this paper, I explore the concepts of health care reforms and priorities that guarantee professionalism and patient’s safety in so far as the advancement of health care system is concerned. Introduction I was once treated to a rare and unfortunate scenario during my visit to one of the major private hospitals in America. I bumped into a serious commotion as doctors ran from one place to another trying to find a way to salvage the life of a young innocent boy. The boy was struggling for his life following a mishap by the attending nurse. As the case turned out, the nurse had delayed in administering the prescribed drug, a situation that would then require other additional procedures to help catch up with the medication requirement. Faced with a dilemma on what to do especially worsen by the fact that the boy was intubated the nurse opted to crush the pills and administer it via nosogatric (NG) tube. Due to fatigue resulting from the long working hours and the haste to cover up her lateness, she failed to follow the instructions given on the electronic medication administration record that requires the drug to be administered the way it is without crushing. Following this wrong procedure, the patient heart rate slowed down to almost a systole before an elderly doctor step in just in time to correct the mess. The young boy’s life was saved but the occurrence left him in worse state than the way he was at first. The events triggered in my mind the thought of the thousands of patients that end up dying thanks to the errors made by the medics attending to them. As clear as it may be, many errors characterizing the nursing field can be averted if proper measures are put in place. This will help to not only benefit the nurses but also boost the quality of care given to the many patients visiting the hospitals. The following work serves to detail a number of issues related to achieving professionalism in nursing through provision of quality and safe care. The working condition surrounding nurses while they are engaged in their daily duty bear a close relation to the safety and quality of care given to patients. Being the leading workforce in the health care field, nurses employ much of their skills, knowledge and experience in diverse patients needs. We cannot deny the fact that nurses play a major role with regard to meeting the demands of patients care. Such is the case that nurses are the ones who always shoulder the biggest responsibilities when patients care falls short of any required standards (Institute of Medicine 2004, p. 45). This may come in the form of poor resource allocation (e.g. insufficient medical equipment and workforce) or even inappropriate standards and policies. With this information, one can figure out the present misunderstandings regarding the greater effects revolving around the diverse, multifaceted health care systems and the working environment elements. A good understanding of this work environment and a further move to engage in strategies that seek to improve its effects forms the basis to quality and safer care. High reliability organizations (HRO) that maintain a culture, which puts more emphasis on safety and evidence-based practices guarantee favorable working environment to nurses while at the same time, improve safety and quality. FREQUENCY OF ERRORS Provision of health care services occur in environment characterized with high complexity ensuing from the various interactions of the concerned factors. These factors include the disease process, technology, procedures, policies and resources. Such is the case that interaction of these factors poses a possibility of having harmful and unforeseen results i.e. errors. Human errors is better explained as unsuccessful outcome of a planned undertaking or a series of physical or mental actions to be accomplished as planned, or in some cases the employment of wrong procedure to realize an outcome( Kizer, and Stegun, 2005 pg 135-51). In reality, errors reflect cognitive phenomenon since they take after human doings that are cognitive activities. “Good catches” or near misses comprise events, incidences or situations that could have resulted to unfavorable outcomes and hurt a patient but luckily, they never happened (Hughes, and Blegen, 2008, p. 2-397- 458). Factors identified in situation of near misses can be treated as probable factors i.e. root causes, leading to particular errors especially in conditions where alterations are not made with that will help avert or even stop their probability to realize errors. The second reasoning brings out errors as an outcome of either active factors, simply put as factors ensuing from system factors that produce instant events and usually involve operators such as the nurses involved in complex systems or latent factors that include the organization structure, heavy workload and the work environment (Reason, 1990, pp. 475-84). The latter factors founded and further imposed by systems have the capability to fester overtime, in the offing of the right conditions to summate person’s latent factors and alter the care process, causing what is well thought-out as active error such as an adverse medication incident. The organizations leadership and staff essentially embrace or even invent new latent factors when scheduling, pose to begin working with inadequate training or outdated equipments. As it is today, health care will always depict some degree of latent factors, which have been termed inevitable. These conditions or factors show discrepancies with the way they affect different areas as some are affected more than others owing to their random distribution. The result is the creation of unequal quality and safety. To reduce the number of risks and hazards an effort should be made to eliminate the root causes (Leape, Rogers, Hanna, and 2006 pg 289-95). The above move helps trace the path between active failures back to the latent defects within the organization basing on the time when it occurred, a factor that serves to indicate the process, leadership and culture. Following this, organizations within which nurses work need to get adapted to their individual cognitive highs and lows and should make room for correcting whatever mistakes they make while on duty (Ebright, P. 630-8). The most efficient plans to improve safety focus on latent factors characterizing the organization and its system of care. By this, we imply that improvement of quality and safety largely depend on how systems are made to account and if need being redesign them and their processes to reduce human factors effects. Based on the above concerns, the better part of human mental functioning is rapid, automatic and effortless. The unconditioned thought patterns drawn much from the recurrent incidents marking our daily lives (e.g. cleaning the office table after every working day). Majority of errors reported ensue from flaws in our thought patterns that in turn affect our decision making process. Studies made have effectively shown that nurses’ ability to come up with decision influencing patients safety that are not only logical but also accurate largely depend on the complex factors which include system factors(e.g. interruptions and destructions), workload, availability of necessary information) and their knowledge base. The effects caused by these factors are complicated further by the responsibilities and roles nurses play, the complexity of preventing harm caused to patient by the errors and the availability of resources. When errors crop up, the “deficiencies” characterizing healthcare givers (e.g. in adequate experience or lack of training) and chances to circumvent “rules” are brought out as mistakes, incompetence and violations. Here violations refer to divergence from safe operating methodologies, rules and standards that can be habitual and crucial or entail risk of causing harm. Human vulnerability to fatigue and stress; and human cognitive capabilities, perception and attention span can affect an individual problem solving abilities. Human working and problem –solving capabilities are considered first as based on skills (i.e. pattern of actions and thoughts that rely much on previously recorded patterns of programmed information and those undertaken unconsciously(Leape, Brennan, Laird, pg, 324- 377). Secondly, human working can be considered as being based on rules. The last category is the knowledge based that come I when tackling new situations, which require well-informed analytic process, founded on stored information. Here, the skill –based errors form the “slips” that can be defined as unconscious deviations caused by stored patterns constituting a preprogrammed instructions in a commonly routine activity. Interruptions and destructions can pave the way for skill-based errors, more importantly diverting concentration and causing forgetfulness. Rule and knowledge based errors ensue from errors in conscious thought termed as “mistakes.” Going against rules prohibiting individuals from working around obstacles can be well thought-out as a rule-based error on the ground that it carries the potential to cause dangerous situations. In addition, such a move increases the probability of an individual’s to engage in other unsafe doings (Cook and Woods, 1994. p. 255-310). Work –around can be better taken as “work patterns a person or even a group create to achieve a vital work goal characterizing a system of unproductive work process that makes it hard to achieve the goal or completely works to prevents its achievement (Halbesleben and Wakefield, 2008,p. 73-80). Work rounds have been found to introduce errors in cases where the work process or the workflow is not well taken and accounted for, although they could also serve as “superior process’ leading to the achievement of the desired goals. Nurse’s actions and decision-making process is greatly influenced by “human conditions.” Such is the case that human condition infallibility works to allows individuals change their working conditions to help reduce probability of errors occurring while at the same time make it possible to contain the errors that occur (Henrikson, 2008, Pp. 67– 86). Nurses just like any other human being are limited with regard to attending many things at the same time, performing computations correctly and recalling large amount of information quickly. Here, a need to focus on system failures and not human failures is vital while t the same time develop procedures to assist human interactions to it. These calls for measures that will see the systems redesigned and customized to allow future adjustments that have the potential to reduce human errors through simplification, standardization of apparatus and their functionality, automation and decreased dependence on memory. This “work system” will account for the interrelatedness depicted in individual’s tools and technologies, tools, working condition and physical environment (Wilson, Harrison Gibberd, 1999, 170 -411). In this case, situations that are prone to errors are redesigned to minimize their reliance on memory, establish better information access, standardize tasks, make room for error-proof processes and minimize hand offs. Following this modifications, errors will be noted in advance and corrected, a factor that has been said to cut down the number of latent failure modes and errors reported. The safety and quality care given to patients by nurses is closely linked to a number of factors within the organization, system and the general work environment. The organization setting, processes and the outcomes depend upon each other, such that particular attributes depicted in one affect the other s depending on the relationship strength existing between them. Such is the case that when organization structure elements hold up the care processes and further make allow teamwork, nurses are get motivated, a factor that is closely to patients receiving high quality care (Eddy, 1998, pp. 7-25). Here, a leader within the nursing filed who is transactional i.e. Develop trust while relating with staff members and one who is transformational i.e. Establish strong collective identity that encourages commitment to change play significant role in improving safety and quality care offered to patients. When working groups perform well and organization structure elements hold up their work, results are god, even when considering organizations having highly specialized care for specific needs (Brennan and Leape, 2004 pp. 324: 370). Up to this point, it is worth noting that both individual and group performance depends on certain modalities, which include; leadership, frequent and effective communication, empowerment, governance and the level of understanding when it comes to goals set and roles played by each individual. Nursing as a profession entails a complex work environment characterized by elements that affect the patient and even the nurse outcomes. This includes the leadership quality, workload, staffing resources, job stress and anxiety, effective communication and teamwork. In favorable work environments, nurses “feel valued by their organization” enjoy staff empowerment, standardized working processes, strong leadership, supportive community and bear the knowledge that well calculated decisions affect how units function and the way scarce resources are disseminated. In addition, favorable work environment allow provision of safe and quality care that is also rewarded. Healthy work settings also depend on collaborative relationship and effective communication, a factor that has been said to encourage good decision-making processes among all nurses (Bega, Ellefsen, and Severinsson, 2005 pg, 221). On the other hand, unhealthy work settings pose adverse consequence on safety and quality of care given and in worst cases cause nurses opting to ditch their profession. What Is It Going To Take To Improve the Safety and Quality of Health Care? In a bid to achieve excellent and safety improvement in health care, there is a call to change the work environment. Most errors especially those that lead to unfavorable events are occasioned by the buildup of the petty mistakes in the organizational structures and the care procedures. Therefore, a look at the transformation of systemic approach will concentrate on elements in the procedure that causes such errors and the undesirable events. In this case, those errors that are not inevitable are dealt with by employing such tactics as effectual teamwork and communication, introducing a safety culture, giving care that focuses on patients and applying practice that is factual in order to curb uncertainty and thus make improvements. The Challenge of Change A major concern that arises is the rate of the improvement in the quality and safety of care. It has been a stated by most researchers and leaders that the efforts to see this improvement have been compromised by the parties concerned. Although some areas have made improvements as brought out by some researches this is not so in the others who have made little or no change at all. As brought out by Amalberti et al., the historical and cultural focus on health independence, its economic productivity goal and such elements in its structure, like constant shortage in workers must be gotten rid of so as to attain maximum safety in health care (Murphy, 2005, p. 228). It is argued progressiveness will be achieved by upholding values and practice that advance safety and quality. The call for major enhancement in quality and safety of the patients has been stressed by such organizations as CMS, AHRQ, IOM and the joint commission. However the quality and safety enhancement changes are relative among organizations. The Leapfrog Group for instance has set forth standards for levels of staffing the physicians in the intensive care units, but it is worth noting that most hospitals have not been able to put these standards in practice due to lack of resources and well outlined leadership (McGillis, Doran, 2007, Pp. 64-73). Moreover, improvement of safety through understanding and aiming at the system elements like public reporting are only exercised in certain states such as Pennsylvania and Texas but not in the other states. The Joint Commission stresses on goals of national patient safety in order to enhance safety in places pointed out to be linked with high risk guarded happenings that are reported to the commission. The CMS together with other insurers, as from October 2008, started to refute reimbursement to care providers in an event of care given to patients that engaged eventualities like infections related to health care, surgery done on wrong places and the ulcers that were acquired in the hospital due to pressure(Kilbridge, and Classen, 2002, Pp. 64). Following the position and the influence of these various organizations who affect the health care by their authority over the health care providers’ activities, the managers and the leaders in health care had to boost up their efforts and actively concentrate on quality and safety enhancement in health care. There is a call to organizations to be flexible in their dealings and hence keep the pace of the constant and brisk revolutions in health care and the increasing evidence base. To achieve this, there is need for them to easily take on to the new information and the innovations which include a political and social development which mostly takes care of debates and mentioning other’ view. This process has to be constitutive of all the leaders, staff and managers (Goddard, and Lashinger, 1997, Pp. 44). This will lead to a necessity of the employees in these organizations especially the nurse leaders and staff to go over the roles and tasks of team members and to redesign care (Morath, and Turnbull, 2005, p.3). Pronovost and the colleagues stress the need to realize that change creation is intricate and that the improvement tactics have to contain the following: should avoid occurrence of errors, should raise error-sensitivity and be close to no errors and finally be able to reduce patient harm in an event of an error. From this, it is evident that changing the error-producing elements in the structure of an organization is not a guarantee to the desired improvements in quality. A number of organizations have had hard times in their efforts to improve patient safety. This has been occasioned by absence of transparency in accounting for performance measures, the need for consistency and utility of information technology, and no defined way for improvement. Apart from this, the complexity of the process is occasioned by the improvement initiative outcome. For instance, the computerized entry system used in ordering for medication therapy eliminated certain mistakes especially those in relating to clarity in handwriting but on the other hand brought up mistakes that were voidable if there was a better procedure put into place. Many change tactics have been put into place ranging from single focus to a complex one. These approaches which concentrated on structural approach have been viable in creating and improving the quality and patient safety. An example in this case is implementing a number of evidence-based intrusions to improve several results at the same time, making use of health information technology in the circumstances that this is possible (Cronenwett, Sherwood, and Barnsteiner, 2007, p. 55). The other is the focus on the elements of change process that is to be looked into. Caramanica and colleagues advance that viable improvement tactic was premised on synchronizing the objectives of the organization with those of quality and patient safety improvement, association of interdisciplinary teams, making use of evidence-based practice, and supervising and assessing excellence (Henriksen, 2001, pp. 1-5). Valuable improvement procedures that are corroborated with the standards and the values of individuals and develop the methods being used determine the rate and the spread of change. Many organizations have implemented the plan-Do-Study-Act strategy to effect change, for this case rapid-cycle improvement. Similarly they have applied the Reach-Effectiveness-Adoption-implementation-Maintenance structure to realize the researches done. In tackling the improvement of patients’ safety, the Department of Veterans Affairs aimed at several approaches. These approaches are like leaders participation in making an acceptable environment, putting forth comprehensible targets, having a system that is not blame-oriented, having a clear decision making system, oversee an analysis of the causation of errors, evident involvement of the leaders and the management and performance evaluation(Hatcher, and Laschinger, 1996, pp. 74-94). Although differences in the organizations’ characteristics are inevitable just as the personalities of the leaders and the managers, equilibrium ought to be reached so as to eliminate changes that affect the ultimate outcome. According to IOM improvements have to aim at organizational elements by making use of information technologies, coming up with efficient groupings, synchronizing their dealings with proof, and scrutinizing their performance by using data and information. Paying attention on the role, the impact, and the intricacy of health care procedures by looking at it critically entails understanding the interactions of the individual issues and outcomes with the many other features in the inside and outside the system (Mick and Massey, 2007, p. 499). By this, it becomes realistic to tackle recurring issues with ineffective procedures and poor results even in situations of the failure of earlier attempts. An example is in an event of medication safety, reduction of medical administration mistakes must regard the mistakes related to prescription, transcribing and errors related to giving out as well as those mistakes connected with health information technologies, labeling of products, therapeutic evenness in care settings, and communication failures in drug allergies (Woolf,2004, p.140). So as to have an improvement in safety and quality, health care systems and the organizations are required to enhance the current knowledge and procedures, identify the efficient and the inefficient ones, and then come up with improved ways to enhance the patient results. Transformation in the organizations needs to focus on making use of comprehensive approaches and interventions that concentrate on brightening up structural factors, reviewing the policies and procedures and having a diversified team. Putting in mind the intricacy of improvement of patients’ safety and quality and the health care systems, achieving performance objective and standards can be intervened easily (Kohn, Corrigan, and Donald, 2000, pp. 10-13). Applying a systematic approach in transforming practice premised on proof where possible is needed to enhance patient safety and contribute to the proven knowledge base and universality that ultimately will be spread. This improvement may call for use of mixed or many procedures to keep scrutinizing and putting to test the influence and performance as no method would be estimate the level of changes intervention. Bureaucracy is a factor that significantly reduces the rate of change in any organization. The struggle to improve quality and safety requires supporters in every key area in the organization inclusive of the executive and midlevel administrators. These supporters can also emerge from people who have been victims of adverse events. It is therefore notable that in an event of fresh knowledge and proof to the practice, the professionals and the professional groups have a choice to welcome it or to disregard it spread (Kennedy, 2001, p. 295). The adoption process requires the support and the engagement of the leadership, promoting a good relationship and a possible action, making use of the scrutiny and the evaluation, and showing willingness to change where there is need. As a result the senior leadership could use this in commitment and direct usage of evidence in practice, and the endless evaluation and therefore make changes as it deems fit thereby enhancing the performance of the organization and the patient results. To have an effective transformation in safe and quality care, the interventions must be long lasting, where the causation and the procedures are critically looked at. It is possible that in instances of procedural change that has positive outcome to the patients to have concerns still being raised. Such concerns are like that of sustainability over time due to predisposition of the health care providers to abandon the new standards set (Laschinger, and Havens 1996, pp. 27-35). Therefore, there is need to continually check and manage the processes put in place. In institutionalizing change that is successful, it is expected that the move will be premised on the existing procedures and system, that are clear and produce positive results, are in line with the values and beliefs of the employees, are manageable and is common to the whole organization. Reference Institute of Medicine. (2004). Keeping Patients Safe: transforming the work environment of nurses. Washington, DC: National Academy Press; p. 45. Mick, J.M., Wood, G.L. and Massey, R.L. (2007). The good catch program: increasing potential error reporting. J Nurs Adm; 37(11):499 Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (2000). To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; pp. 1-4 Ebright, P., et al. Understanding the complexity of registered nurse work in acute care settings. JONA 2003; 33(22):630-8. Cook R.K. and Woods, D.D. (1994). Operating at the sharp end: the complexity of human error. In Bogner MS, ed. Human error in medicine. Hillside, NJ: Lawrence Erlbaum; 1994. p. 255-310. Kennedy, E.M. (2001). Heard SR. Making mistakes in practice: developing a consensus statement. Austr Fam Phys; 30(3):295-9. Morath, J.M. and Turnbull, J.E. (2005). To do no harm. San Francisco, CA: Jossey-Bass; p.3. Halbesleben, J.R., Wakefield, D.S. and Wakefield, B.J. (2008). Work-around in health care settings: literature review and research agenda. Health Care Manage Rev 2008; 33(1):2-12. Reason, J. (1990). The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci Series B 1990; 327:475-84. Henrikson, K., et al. (2008). Chapter 5: Understanding adverse events: a human factors framework. In: Hughes RG (ed.), Patient Safety and Quality: an Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; P. 1-67–1-86. AHRQ Publication No. 08-0043. Henriksen, K. (2001). Battles JB. Research on medical error gaining momentum. Hum Factors Bul 2001; 44(12):1-5. Leape, L.L., Brennan, T.A. and Laird, N., et al. (1991). The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6):377-84. Bates, D.W., Spell, N., Cullen, D.J., et al. (1997). The cost of adverse drug events in hospitalized patients. Adverse drug events prevention study group. JAMA 1997; 277:307-11. Brennan, TA., Leape, L.L., Laird, N.M., et al. (2004). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 2004; 324: 370-6. Woolf, S.H. (2004). Patient safety is not enough: targeting quality improvements to optimize the health of the population. Ann Intern Med 2004;140: 33-6 Blumental D. Making medical errors into “medical treasures.” JAMA 1994; 272:1867-8. Phillips DF. “New look” reflects changing style of patient safety enhancements. JAMA 1999; 281: 217-9. Wilson, R.M., Harrison, B.T., Gibberd, R.W., et al. (1999). An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 1999; 170(9):411–5. Kilbridge, P. and Classen, D. (2002). Surveillance for adverse drug events: history, methods and current issues. VHA Research Series 2002; 3:1-48 Classen, D.C., Pestotnik, S.L., Evans, R.S., et al. (1997). Adverse drug events in hospitalized patients. Excessive length of stay, extra costs, and attributable morality. JAMA; 277:301-6. Kizer, K.W. and Stegun, M.B. (2005). Serious reportable adverse events in health care. In: Advances in patient safety: from research to implementation: Vol. 4. Programs, tools, and products. Surveillance tools (p. 135-51). Retrieved Nov 11, 2005 from http://www.ahrq.gov/ qual/advances/Vol4/Kizer2.pdf. Rasmussen, J. (1983). Skills, rules and knowledge: signals, signs, and symbols, and other distinctions in human performance models. IEEE Trans Syst Man Cybern 1983;SMC-13:257-66. Hughes, R.G. and Blegen, M.A. (2008). Medication administration safety. In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; p. 2-397–2-458. AHRQ Publication No. 08-0043. Tang F., Sheu, S., Yu, S., et al. (2007). Nurses relate the contributing factors involved in medication errors. J Clin Nurs 2007; 16: Stelfox, H.T., Palmisani, S., and Surlock, C., et al. (2006). The To Err Is Human report and the patient safety literature. Qual Saf Health Care;15(3):174-8. Pawlson, L.G. and O’Kane, M.E. (2004). Malpractice prevention, patient safety, and quality of care: a critical linkage. Am J Manag Care;10(4):281-4. Mitchell, P. (2008). Defining patient safety and quality care. In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. p. 1-1–1-6. AHRQ Publication No. 08-0043. Leape, L.L., Rogers, G., Hanna, D., et al. (2006). Developing and implementing new safe practices: voluntary adoption through statewide collaborative. Qual Saf Health Care 2006; 15:289-95. Eddy, D.M. (1998). Performance measurement: problems and solutions. Health Aff 1998; 17(4):7-25. McGillis, H.L. and Doran, D. (2007). Nurses’ perceptions of hospital work environments. J Nurs Manag 2007;15(3):264-73. Murphy, L. (2005). Transformational leadership: a cascading chain reaction. J Nurs Manag; 13(2):228-37. Begat, I., Ellefsen, B., and Severinsson, E. (2005). Nurses’ satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses’ experiences of well-being—a Norwegian study. J Nurs Manage 2005; 13(3):221-30. Hatcher, S. and Laschinger, H. (1996). Staff nurses’ perceptions of job empowerment and level of burnout: a test of Kanter’s theory of structural power in organizations. Can J Nurs Admin 1996; 9 (2):74-94. Goddard, P., and Lashinger, H. (1997). Nurse managers’ perceptions of power and opportunity. Can J Nurs Admin 1997; 10 (2):44-6. Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. (2007). Quality and safety education for nurses. Nurs Outlook 2007; 55:122-31. Laschinger, H.K., and Havens, D.S. (1996). Staff nurse work empowerment and perceived control over nursing practice: conditions for work effectiveness. J Nurs Admin 1996; 26 (9):27-35 Read More