Described by conference speaker Dr Neil Bacon, founder of Doctors.net and iwantgreatcare.org, as “the smoke detector of patient safety”, patient experience captures both excellence and the potential for improvement. As well as patient experience, MPS’s conference – held on 15-16 November 2012, at Church House Conference Centre, Westminster, London – addressed quality, safety culture, cost and professionalism. In partnership with the Canadian Medical Protective Association (CMPA) and MDA National, and key supporters CRICO and PIAA, MPS’s conference welcomed more than 250 international delegates from around the world, including Argentina, Australia, Canada, the USA, the Caribbean and Bermuda, Uruguay, Norway and Ireland, as well as the UK.
Dr Gerald Hickson, Assistant Vice Chancellor for Health Affairs, Vanderbilt University Medical Centre, and Director of Centre for Patient and Professional Advocacy, delivered the first keynote address on delivering quality and trust. Quality, he said, is about making medicine kinder and safer. Each doctor has a duty to address faulty systems; rather than talk about each other when things go wrong, doctors need to talk to each other. Quality is also about promoting reliability – doctors need to know they will be supported by their organisation if they raise any concerns. Similarly, organisations need to tackle unreasonable variations in the performance of healthcare professionals that threaten safety and quality.
Most healthcare organisations have at least 250 guidelines; yet typically, healthcare professionals only put five into practice
Quality, however, means different things to different people. The pursuit of quality in challenging circumstances has one main goal for Dr Devi Prasad Shetty, Chairman, Narayana Hrudayalaya Group of Hospitals – to dissociate affluence from healthcare. Quality is being able to reduce the costs associated with cardiac surgery, by putting a price tag on human life out of necessity. Delivering cardiac surgery for $800 involves streamlining processes, reducing costs, and involving families as primary care providers. Typically, it takes a catalyst for new aims to be set, or behaviours to alter.
If something goes wrong, writing a policy to improve patient safety is the default mechanism, said keynote speaker Dr Carol Haraden, Vice President at the Institute for Healthcare Improvement (IHI). Yet often, there is no well-developed execution strategy – and so excellent ideas and aims to improve patient safety are lost in documentation. Most healthcare organisations have at least 250 guidelines; yet typically, healthcare professionals only put five into practice.
Force won’t work: the best leaders never bully, but lead by example. Forecasting medicolegal risk would allow medicolegal institutions (eg, liability insurers, medical boards, hospital risk management departments) to become more proactive in quality and safety improvement efforts, argued Professor David Studdert, Professor and ARC Laureate Fellow at the University of Melbourne. His study is using a unique national dataset on patient complaints against Australian doctors to develop new methods and tools for predicting a clinician’s risk of a further complaint. Over a ten-year period, 18,900 complaints were received about 11,000 doctors in Australia.
The research looked at practitioners’ sex, age, practice location and specialty. For all practitioners, standards of clinical care and communication were the main issues. The more complaints a doctor received, the more they were at risk of further complaints. Prof Studdert explained how the PRONE score (PRobability Of New Events) predicts doctors’ medicolegal risk, which could be used as a simple prediction tool for targeting interventions and reducing clinical negligence costs.
Tony Mason, former Chief Executive of MPS, explored the rise in negligence costs in a global context. For some doctors and hospitals, they have already proved to be unsustainable; in the UK, clinical negligence costs are the highest anywhere in the world, except the United States. The Panel Discussion provoked a lively debate about potential ways forward to address this unsustainable rise.
But the fallout from an adverse event is often not about the money... It is about communicating effectively when things go wrong
But the fallout from an adverse event is often not about the money, argued Dr Lucian Leape, Adjunct Professor of Health Policy at Harvard School of Public Health, in his keynote address on disclosure and apology. It is about communicating effectively when things go wrong. A serious preventable injury is devastating for the patient – they are doubly wounded. Not only do they suffer a physical wound (the adverse event), they also suffer an emotional wound, the betrayal and loss of trust in the healthcare professional. A serious preventable injury is a medical emergency. If a doctor does not act quickly, things become much worse. The necessary treatment is open, honest and full communication.
In this medical emergency, there is a second victim, the caregiver. Shame, guilt and fear can take over if the situation is ignored. Apologising or admitting something has gone wrong can be difficult, yet Dr Leape suggests it is essential for the caregiver to heal. Dr Stephanie Bown agreed, outlining MPS’s belief in the necessity of a culture of openness. Legislation cannot work: it only serves to encourage fearful behaviour. Mistakes do occur. Quality, however, is never an accident: it is always the result of high intentions, said Dr Jason Leitch, Clinical Director at The Quality Unit, Scottish Government, in his keynote address on safety and outcomes.
Safer care can only be delivered by frontline professionals doing common things uncommonly well. To achieve a culture of safety, we need a culture of improvement. John Tiernan, Director of MPS Educational Services, closed the two-day conference with a question: “Delegates from around the world have come to the conference and will leave with great ideas. What will you do with the information you have learnt?”