Towards Safer Hospitals : A Managerial Approach.
Dr. Mohamed Naguib RatebVisiting Professor at the Egyptian Military Medical AcademyKing Khaled University ??“ Jizan Community College ; Kingdom of Saudi ArabiaABSTRACT While hospitals are constructed, equipped, and operated for the benefit and welfare of human beings; they expose people to Many Risks. Health services organizations are known to be dangerous places, hospitals are the most complicated form of these organizations. The risks in the hospital environment has tremendously escalated and multiplied during the 20th Century; mainly due to unplanned and / or indiscriminate acquisition and operation of the very modern and up-to-date equipment. As this will continue in the foreseeable future; thus it would be predicted that hospitals will increasingly be more and more hazardous, risky and even unsafe workplaces for both providers of hospital care and the recipients of such care. Though it is a seldom achieved objective even in the most sophisticated western hospitals; however, hospital safety is a legal, professional, technical, ethical, and moral obligation to hospital management. This article tries to deal with this real managerial challenge through speculating, defining and analyzing the possible threats to hospital safety; then recommending a practical managerial approach that, when implemented, would make the hospitals less risky and more or less safer institutions.Towards Safer Hospitals: A Managerial Approach.
Dr. Mohamed Naguib RatebVisiting Professor at the Egyptian Military Medical AcademyKing Khaled University ??“ Jizan Community College; Kingdom of Saudi ArabiaI ??“ INTRODUCTION AND BACKGROUND: Hospitals, all over the world, are being as integral parts of human communities. Every civil community, nowadays, has its comprehensive hospital system of Governmental, or Non- Governmental, charity or profit- making, general or specialized, and small, medium sized, or large hospitals.
Hospitals are defined in a different way by different people because every person or group of persons conceptualize them from different perspectives. Perhaps the best description of the hospital is that denoting that a hospital is a microcosm. This is true because every hospital is a very complex organization that gather a multitude of categories of human resources, of tools, equipments, and of users and beneficiaries under a single roof. It would be concluded that hospitals are unique and unusual place where unusual collection of people are performing unusual transaction. Traditionally, the hospitals were only resorted to; by strangers, indigents, and/or gravely sick people. However; the hospital today is totally different than what it used to be half a Century ago. Many factors led to an increase of hospital use by the public of all categories and of all social classes.
Scientific medical and technical progresses led to the inventory of modern diagnostic and therapeutic tools, instruments, and equipment. These progresses dictated major changes and additions to the composition and capabilities of the health care teams. Thus the equipment and instruments multiplied, health care team has expanded to the extent that no other place can gather them under a single roof except the hospital. Hospitals incur very high and rapidly increasing costs to institute, construct, establish, equip and still more to operate. The increment in cost is mostly directed towards the acquisition and upgrading of the modern and high technological equipment without which hospitals are deemed to be less useful, less attractive to both staff and clients, thus less efficient.
The technical staff with their excellence are almost always affecting the managerial decision making in assigning high budgets for the purpose.(1) The acquisition and operation of newly developed mechanical, electrical, electronic, and radiology equipment brought about the need for organizational response by addition of new categories of human resources. The proliferation of technical staff required to install, maintain, operate, and / or repair of these equipment necessitated the creation of new specialist engineer namely the clinical medical engineer.
While hospitals are constructed, equipped, and operated for the benefit and welfare of human beings; they expose people to Many Risks. Health services organizations are known to be dangerous places; hospitals are the most complicated form of these organizations. The risks in the hospital environment has tremendously escalated and multiplied during the 20th. Century, mainly due to unplanned and/or indiscriminate acquisition and operation of the very modern and up-to-date equipment. As this will continue in the foreseeable future; thus it would be predicted that hospitals will increasingly be more and more hazardous, risky and even unsafe workplaces for both providers of hospital care and the recipients of such care. Though it is a rarely achievable objective even in the most sophisticated western hospitals; however; hospital safety is a legal, professional, technical, ethical, and moral obligation to hospital management.
This article tries to deal with this real managerial challenge through speculating, defining and analyzing the possible threats to hospital safety; then recommending a practical managerial approach that, when implemented, would make the hospitals less risky and more or less safer institutions.II ??“ THREATS TO SAFETY: Hospitals are professionally, ethically, managerially, and legally held responsible to provide safe environment for the patients, employees, as well as visitors. However; it is reported that there is simply no issue more important in health care than ensuring safety of the patients.(2) On the other hand, it is reported that in terms of health and safety any health care organization (HCO) and more specifically a hospital is a dangerous place.(3) This is true because in these organizations any person may be affected by caustic and toxic chemicals to be found in laboratories and pharmacies, slicing equipment in food services, radiation in radiology, toxic gases used in sterile supply processing, infections in patient care areas.
The mentioned examples are a few of hundreds of hazards that make health care delivery a potentially dangerous activity.(4) The hospital??™s threats to human safety can expand to cause major environmental problems through improper handling and disposal of institutions waste products. In addition to the general (solid) wastes that may be produced by any other institution; hospitals generate other 4 separate categories of wastes i.e.
infectious, bio-hazardous, radioactive, and hazardous chemicals.(5) Other threats to hospital safety can affect patients due to adverse reactions, incidents, and / or malpractice either due to human errors or to negligence. Distressing facts are reported by the World Health Organization commenting on the issue indicating that the various studies have investigated the extent of adverse events and results of one study performed in USA indicated that 4 % of patients suffer some kind of harm in hospitals. In the meantime, variable rates of adverse effects were reported by different countries, 10 % of hospital admissions (estimated 850,000 adverse events a year) in UK(6) and in Europe in the year 2000, 16.6 % among hospital patients in Australia.
(7) The News headlines in the USA is said to be featuring the problem. Examples of these headlines are, ???Medicines are more deadly than thought, 100,000 killed, 21 million, hurt a year???, ???2 million Are Infected Each Year???, ??? How Can We Save the Next Victim: People don??™t make errors because they want to, or because they??™re bad people. Every body makes errors, every human being, what we need to focus on is how best design our systems so that those errors are caught before they reach the patient???.(8) In our countries; it would be safely assumed that threats to hospital patients, employees and visitors are similar; if not more than those in the developed countries. However; due to the dearth of data and information, it is not clear what are the types or the extent of the problems endangering the safety in our countries.III ??“ HOSPITAL RESPONSIBILITIES AND DUTIES RELATED TO SASFETY: The responsibility is something that is performed without being requested; while a duty is what one is obliged to do. Duties are imposed by law; and can be enforced by legal proceedings. Traditionally; the liability and accountability for patient injury or less than satisfactory outcome were related to physicians.
The modern medical practice brought new members to the health care team, thus the liability issues expanded to include them. The extension of liability to hospitals in USA occurred in 1965.(9) Some of the main duties of HCOs are:(10) 1 ??“ Duty to provide Propitious treatment.
2 ??“ Duty to provide adequate staff. 3 ??“ Duty to provide adequate facilities and equipment. HCOs must be designed, constructed, equipped, and maintained to provide safe, healthy, functional, sanitary, and comfortable environment for patients, employees, and the public. Buildings and equipment should be maintained and operated to prevent fire and other hazards to personal safety. Patient rooms should be designed and equipped for adequate nursing care, comfort, and privacy. Mechanical, electric, and patient care equipment should be maintained in a safe operation condition. 4 ??“ Duty to provide satisfactory patient care. This duty includes the maintenance of satisfactory standard of medical care through supervision of the medical, nursing, and ancillary staff of the organization.
A staff member or employee has a duty to recognize and report abnormalities in the treatment and condition of patients. If an attending physician fails to act after being informed of such abnormalities, it is incumbent on the organization staff to so advise management so that appropriate corrective action can be taken. 5 ??“ Duty to provide safe environment. Although one cannot guard against the unforeseeable, a HCO is liable for injuries resulting from dangers that it knowingly failed to guard against or those that it should have known about and failed to guard against. Each hospital is responsible for providing safe environment for patients, staff, and visitors. The hospital plant services / engineering unit or department is responsible for this function among other services such as provision of ventilation, heat, water, electricity, and refrigeration in addition to maintenance of equipment and physical plant.
(11) The Joint Commission on Accreditation of Health-services Organizations categorized the hospital??™s responsibilities in relation to the environment of care as : safety, security, hazardous materials and wastes, emergency preparedness (disaster planning), life safety, medical equipment preventive maintenance, and utility systems as provision of backup emergency generator testing.(12)IV ??“ MANAGERIAL APPROACHES TOWARDS SAFER HOSPITAL CARE: Relatively; management sciences are modern compared to other sciences as law, medicine and engineering. Thus it is not an easy task to set a definition to express the terms management or managerial approaches. However, and for simplicity purposes, we may define management as a set of activities carried out to ensure a proper transformation of given resources (inputs) into required product (output) that may be goods or services. For example; in UK a new agency ???National Patient Safety Agency??? (NPSA) has been set up to boost patient safety in the National Health Services (NHS). The NPSA is an independent body that is to:(13) 1- Collect and analyse information on adverse events from local NHS organizations, NHS staff, patients, and carers. 2- Assimilate other safety ??“ related information from a variety of existing reporting systems and other sources in the country and abroad.
3- Learn lessons and ensure that they are fed back into practice, service organization and delivery. 4- Produce solutions to prevent harm where risks are identified and set out national goals and establish ways to tracking progress towards these goals. The agency??™s system of identifying, recording, analyzing and reporting adverse events will be at the heart of a shift to a more blame-free, open NHS, where lessons are shared and learnt. Everyone who comes into contact with the health service will have a part to play, from patient to clinical staff and managers.
Over time, learning from them Agency??™s unique database will be the way in which one patient??™s bad experience will help hundreds of others. It will make the NHS a safer place for everyone that uses it. On the other hand; multitude of approaches are being carried out in other countries. For instance; aiming at safer health care organizations (HCOs) and hospitals in USA a legislation known as occupational safety and health act (1970) led to the establishment of occupational safety and health administration (OSHA) to implement the law to control health problems associated with the complex and dangerous machinery, chemicals, pollutants and environmental threats. Legally the organizations are required to perform 3 major activities:(14) 1 – Promulgation and enforcement of safety standards to eliminate or lessen hazards. 2 ??“ Record keeping. 3 ??“ Training and education.
Health care organizations in the USA are required to institute safety committees. Any of these committees is generally charged with the responsibility for overseeing the organization??™s safety management program. The safety committee at any HCO is generally charged with the responsibility for overseeing the organization??™s safety management program. The committee reviews and acts on reports involving organization??™s:(15) 1 ??“ Emergency preparedness program (disaster planning). 2 ??“ Equipment management program (a program for ensuring user training, new equipment testing, proper documentation of all repairs, maintenance, and contracted maintenance services including biomedical, clinical, and electrical equipment. 3 ??“ Life safety programs.
4 ??“ Risk management program. 5 – Safety management program. 6 ??“ Utility management program. Some authors contend that safety programs in USA have evolved into a broader concept of risk management (RM). The functions of RM include a broad range of administrative activities intended to reduce losses associated with patients, employee, or visitor injuries; property loss or damages and other sources of potential organizational liability.(16) A comprehensive risk management program includes identifying, controlling, and financing risks of all types.
RM programs are now common in American health care organizations, especially hospitals. RM is seen to have a good relationship to quality management as they share in the following:(17) 1 ??“ Common database. 2 ??“ Identification of problems leading to adverse events. 3 ??“ Interventions to prevent likelihood of recurrence. 4 ??“ Patient focus. 5 ??“ Continuous monitoring systems.
6 ??“ Information analysis. 7 ??“ Clinical and managerial expertise. 8 ??“ Staff education. 9 ??“ Financial support. 10 ??“ Top management accountability.V ??“ RISK MANAGEMENT: This term could be explained as a series of activities designed to reduce unplanned or unexpected loss to an organisation.
This loss can be human, environmental or financial. 1 ??“ The concept and principles: (18) As mentioned before; safety in HCO could be achieved in the broader concept of risk management (RM). RM is based upon several principles and is dependent upon the performance of different steps that may include: Identifying, evaluating, eliminating, reducing, and or transferring. The most common way to identify risks is to collect, and aggregate data about problems so that patterns become foci for action. RM should not be only reactive, but it must be proactive by concentration on eliminating, reducing and transferring risk. In USA the Joint Commission on Accreditation of healthcare Organizations requires notification of given incidents named sentinel events.
The identification of these events is followed by root cause analysis that enables HCOs to eliminate or reduce the incidence of risks. Evaluating risks is carried out through reviewing and categorizing information about problems over time. Prospective evaluation to identify problem areas is achieved by safety inspections and audits. Eliminating and reducing risks would be achieved by sponsoring education and awareness programs and by many ways such as: A??“ Modifying physical plant and structure. B??“ Enhance credentialing process.
C??“ Review of clinical staff activities and applying of Quality assessment / improvement programs. D ??“ Initiating material management systems. E ??“ Improving patient??™s and staff relations. Elimination is preferable to reducing, but for many types of risks, this may be impossible.
Therefore, the emphasis must be on minimizing risk. Transferring risks is carried out through contracts, but for the non-transferable and non-eliminable risks, management is carried out through insurance. 2 ??“ The Risk Management Program: The first practical step to operate a RM program in any HCOs is by the initiation of RM committee and the appointment of a risk manager.
The committee is an interdisciplinary one, typically chaired by the risk manager. The role of the committee is to develop policy and provide general oversight. In large institutions a full ??“ time risk managers is nominated, while in small ones a part ??“ timer may be satisfactory. The nominated risk manager ought to have a good scientific background in security, safety, loss prevention, and experience in law enforcement and investigative techniques. Since his work is dependent upon the work of the various HCO??™s departments and units, thus he requires excellent interpersonal skill and ability to coordinate and integrate different sources and resources of information. The role of the risk manager may include:(19) A ??“ Identifying and analyzing risk. B ??“ Developing, implementing, and monitoring insurance programs.
C ??“ Maintaining and distributing RM manual D ??“ Developing and maintaining reporting and analysis systems for risk and loss. E ??“ Attending and giving seminars that will improve personal and managerial risk management skills. 3 ??“ The Risk Management Process: The process of RM is dependent upon the following steps: A ??“ Report circumstances that put HCOs at risk such as fire, safety problems, accidents, and / or any type of negligence. This report is called incident report, and it alerts the risk manager. B – Aggregated reports show problem areas and patterns of threats to hospital patient safety. C ??“ Analyze data from reporting system, results are sent through a feedback loop to inform risk managers about problems and to suggest steps to correct them. Examples of incident analysis are shown in figures (1 ??“ 3) D ??“ Use in-house legal counsel. Figure No(1): Example of incident analysis.
|Incident | |Analysis || | | || |Report | ||Excessive patient falls |To risk manager |Cause may be excessive waits to || | |get assistance to go to w. c. || | | || | | || | |Due to shortage of nursing staff || | | ||Control |Increase nursing | ||of patient falls |staff | | Figure No(2): Example of incident analysis.
|Incident | |Analysis || | | ||Post surgical wound infection |Report |Cause may be || |To risk manager | || | |Failures in CSSU || | |Or || | |Faulty hand washing techniques || | | ||Control | | ||of Post surgical wound infection |Train CSSU staff | || |Or | || |Teach correct hand washing to nursing staff | | Figure No(3): Example of incident analysis. |Incident | |Analysis || | | ||Back injury amonge staff who lift patients |Report |Cause may be || |To risk manager | || | |Improper lifting || | | || | | ||Control of back injury |Training about proper lifting techniques | || | | || | | | 4 ??“ The incident report: An incident is any event not consistent with normal hospital operations or patient care. There should be a form “report” known as incident report that could be used to report patient, visitor, and off-duty employee related incidents. Incidents may or may not involve injury. Reportable incidents include death, serious illness or injury.Once an incident took place the involved person must: A – Fill in areas applicable to the incident.
B – Stick to the facts. C – If equipment is involved in the incident, include the Biomedical tag number. D – Do not refer to the Incident Report when documenting the incident in the medical record. E – The staff member must give the Incident Report to his supervisor promptly. Managers or supervisors are responsible to ensure that the following steps have been taken in every incident involving the use of an instrument: A – The equipment is removed from service. B – The equipment is labeled as defective.
C – An incident report is completed and signed by a manager or a supervisor. D – All packaging and the device itself is saved. E – Risk management is notified.VI ??“ CONCLUSIONS AND RECOMMENDATIONS: In terms of health and safety any health care organization and more specifically a hospital is a dangerous place. HCOs staff and management share the liabilities if an adverse incident took place. These organizations are obliged to carry out its responsibilities and duties regarding patient safety and risk prevention. On the other hand every medical encounter carries the risk of an adverse outcome, but every adverse outcome need not lead to a malpractice claim. Since disease carries morbidity and human life has a finite span, there must be a way to ensure that bad outcome is either correctable or inevitable.
In the mean time, hospitals themselves may be subjected to risks and threats that may affect any other community institutions. To guarantee a higher level of safety; different countries applied different approaches. In our countries; a recommended promising managerial approach towards safer hospitals is dependent upon the application of a comprehensive program that require full political and senior managerial support. The elements of the program would comprise the following: 1 ??“ At the National level: At this level much of the work must be initiated, planned, supported and supervised as the safety issue in hospitals is not ??“ at all – a purely medical issue that would be assigned or carried out by the ministry of health or by the HCOs. The proposed lines of action or components of hospital safety program from managerial point of view may be: A ??“ Issuing of a law that mandates the institution of a reporting system in every HCO to create a database on the problem. B ??“ Institution of a supreme multidisciplinary hospital safety agency to collect data, carry out root cause analyses, supply feed back information together with drawing the outline of the strategy pertinent to risk management.
C ??“ Drawing of an overall emergency medical and disaster plan and arranging for upgrading the capabilities of accident and emergency departments in all HCOs. D ??“ Reformulation of health professional education to induce a shift of culture, concepts, and behavior towards adverse effects of treatments, from shame and blame culture to report and disclose attitude. E ??“ Encourage the public to report any alleged unnecessary exposure to suffering, complication, injury, and / or death. 2 ??“ At the local level: A – Insistence and persistence of the senior management on the critical issue of safety in the HCOs. B ??“ Institution of risk management committee supported with the required database and the adoption of the most suitable techniques to manage risks and raise the level of safety. C ??“ Nomination of a full time or a part time risk manager dependent upon the size of the HCO. D – Reorganization of the structure of HCOs to allow the appointment of a clinical medical engineer.
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