Clinical Management Workshop – Managing Hospital Safe-Guards

Introduction

Managing  Hospital Safeguards was the topic aired on 22 January 2013 in the Clinical Management Workshop series, the very topic which launched the CMWS series 14 months ago. Patient safety is an important issue: just today in a newspaper article, the Onderzoeksraad voor Veiligheid stated that ‘patient safety falls short” (Volkskrant – 24 January 2013) .

Case Discussion Dana Farber Cancer Institute

Prior to the 22 January workshop the participants had received the Harvard Business School case of the Dana Faber Cancer Institute which describes in detail the situation where a patient dies due to a chemotherapy overdose. Once the facilitator, Prof. dr. Fred Eenennaam had outlined the case and peeled it down to its basic elements, the case discussion became animated and energetic. The many elements that play a role in the occurrence of this incident were discussed: the culture, the individual failure(s), the system that was in place to prevent failure, and the role and responsibility of the board. The participants came from various hospitals or associations connected to healthcare, but all involved in some way with patient safety. The richness of their experiences was brought into the discussion. Some of the comments/conclusions

Key Learnings for the Dutch situation

  1. Systems and culture: A good balance between safety systems (with checklists, digital checks, etc.) and personal awareness and responsibility embedded in the culture is essential
    Hospitals need to be more creative in thinking of ways to change culture behavior. Improvements should be able to be measured.
  2. Sustainability: Safety systems are never finished, but rather require continuous development in line with the development (growing complexity, specialization) of healthcare delivery.
  3. Responsibilities: To ensure patient safety it is preferred that a hospital has a medical expert in the supervisory board and someone with responsibility for patient safety in the board of directors.
  4. Organizational structure: To ensure patient safety both the formal and the informal organizational structure need to be considered.

Further Reading

During the session various references were made to studies and reports. Here you can find links to several of them for further reading on the topic:

  1. The USA Joint Commission 2011 National Patient Safety Goals (http://www.jointcommission.org/hap_2011_npsgs)
  2. The Dutch safety management system VMS (http://www.vmszorg.nl/10-Themas)
  3. Often quoted report and key reference from the Dana Farber case: To err is human (1999): http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf and the follow-up study (2001): www.nap.edu/html/quality_chasm/reportbrief.pdf
  4. The Dutch Healthcare Inspection report on the Maasstad hospital case: http://www.igz.nl/Images/okt%202011_Tussenrapportage%20Maasstadziekenhuis_tcm294-310284.pdf