Quality and safety standards are important in healthcare systems. One of the key areas to focus on in improving quality in healthcare is medical errors. Many reports show that medical errors have dramatically increased in recent years. In the United States, for example, between 44,000 and 98,000 patients die in hospitals each year due to medical errors according to Ramson et al (2001). These errors cost human lives and are an added cost to healthcare providers. Health Authority-Abu Dhabi has recorded 1,304 online reports of adverse reactions to medicines and 1,004 reports for medication errors since it was launched in June 2008. This underscores the need to evaluate and improve quality and patient safety in the Gulf Cooperation Council (GCC) countries specifically and the world in general (Gulf news 2012).
In this paper, the writer shall attempt to explore why applying quality and safety standards in the healthcare system is important and what would result if we failed to apply safety and quality in healthcare. In addition, the paper shall also endeavor to provide evidence on the disastrous results of ignoring quality and safety standards. Furthermore, it will focus on the best catalyst, drivers, and dimensions in healthcare, and how do they affect and impact the delivery of healthcare services. The paper shall also try to explore why the writer believes that patient safety could be the best catalyst and most important dimension in healthcare quality and safety. The writer’s viewpoint as regards the main drivers to improve quality in health care provisions will also be addressed. Finally, the assignment will focus on the quality and safety levels in the writer’s organization. The writer works as a dentist in the ministry of health. The writer will list the safety and quality issues that face the dental practice and how they could be improved.
The importance of healthcare quality and safety as a key component of effective healthcare service provision
In a 2009 Gallup poll, the national journal found that more than half of Emiratis prefer to be treated abroad. Poor communication, far appointments, and lack of specialists are among the reasons which force UAE citizens to seek medical treatment abroad. 30,000 Emarati patients spend about $250,000 per visit to get treatment abroad (The National 2012). The main reasons listed by the patients who took part in the Gallup survey include low levels of quality and safety.
The main goal of any health care organization is to provide services that will optimize people’s health. Improving the quality of these services is the key to achieving this goal. The use of quality tools would be useful in identifying the root causes of the problems ailing our healthcare system and also finding lasting solutions to these problems. The most common problems that we are likely to face in the healthcare system are medical errors, patient dissatisfaction, high cost of healthcare, unnecessary procedures, lack of technology, and lack of qualified and updated staff. Nearly 4 in 5 EU citizens (78%) classify medical errors as an important problem in their country. 23% of Europeans also stated that they have been victims of medical errors (Eurobarometer 2006). The only way to minimize these problems is by applying quality and health standards. The Agency for Healthcare Research and Quality (AHRQ) (In Senate Report 107-84) mentioned several practical points that they applied in certain organizations and which resulted in a reduction of medical errors. One of these points was changing the organization culture by creating a positive safety environment that eliminates blame and shame associated with medical errors. The AHRQ discovered that by introducing such changes in the healthcare system, they were encouraging the staff to report any occurrences of medical errors. Reporting errors will also help to identify the causes of medical errors, and place solutions to prevent their occurrence in the future.
In a study conducted by Pear (2008), many patients reported that they were disrespected by their doctors and that they did not get clear information about post-discharge instructions from the hospital. Implementing quality in the healthcare system will increase patient satisfaction by creating patient-centeredness. Satisfaction will not only enhance patients’ quality of life, but it will work as an important tool to increase staff motivation and strengthen patients’ trust and confidence in the health care system. For example, Fortin (2002) found out that competent clinician-patient communication, as a qualification tool to improve patient satisfaction, is associated with an accurate diagnosis, improved blood pressure, and controlled diabetes.
High cost is another critical problem facing the health care system. By applying quality improvement methods we can reduce the costs incurred by our health care systems. A research study conducted by the Agency for Healthcare Research and Quality AHRQ (2000) revealed that thousands of patients with chest pain who are referred to the emergency department suffer from delay or missed diagnoses because of inconclusive electrocardiogram (EKG). The result was a serious risk on patient’s life, more hospital costs, and malpractice lawsuits. The AHRQ developed software that improved the diagnosis of EKGs and prevented 200,000 cases of unnecessary hospitalization. The software could help hospitals save nearly 728 million dollars a year (AHRQ 2002).
Best practice catalysts, dimensions, and drivers for quality and safety in healthcare
The main catalyst that led to calls for improving quality and safety in the healthcare system was the dramatic increase in medical errors. These errors have resulted in the deaths of thousands of patients while health care organizations have incurred millions of dollars. The Institute of Medicine in its report, “To Err is Human: Building a Safer Health System”, estimated that between 44,000 and 98,000 people die every year as a result of medical errors. Medical error is the ninth leading cause of death in the United States. The cost of medical errors does not only affect the lives and health of people but is also a big waste of money by health care organizations.
According to a report by Ransom et al (2001), the estimated cost of medical errors is between $29 and $38 billion per year. The Institute Of Medicine (IOM) has outlined six dimensions of the healthcare system which are safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (Ransom et al. 2001). One of the best ways to introduce the dimensions of quality in the healthcare system is to use a design like the one produced by Battles (quality and safe by design). In this design, Battles divided the six dimensions into three levels (Battles 2006): Level 1: a patient-centered healthcare system; Level 2: safe care system; and Level 3: a combination of the other four quality dimensions (effectiveness, timeliness, efficiency, and equity). Considering the glaring report by the Institute of Medicine report, placing the safety of the patient at the first level in the center of the design would bring light more on the safety dimension. Therefore, the suggested design of the six dimensions would be as follows:
- Level 1: safe care system
- Level 2: a patient-centered healthcare system
- Level 3: Combination of the other four quality dimensions (Effectiveness, Timeliness, Efficiency and Equity).
Level 1: safe care system: the main reason why we should give the safety of the patient a priority in the healthcare system is the dramatic increase in deaths as a result of medical errors. A report by Aspoden et al (2004) titled, “Preventing Medication Errors” concluded that at least 1.5 million medication errors cause patient harm in the United States each year. The report also estimated that medication errors in hospitals cost $3.5 billion a year. Although it would be very hard to prevent human errors, we can design systems that reduce errors and make them safer for patients (Aspoden et al 2004). Many procedures conducted in the healthcare system could be corrected or eliminated if quality and safety techniques are applied to the system. For example, most of the medication errors are caused by confusion of medicines with similar names. There were 25,530 drug confusion errors reported in the years between 2003 and 2006. These could however be minimized by applying effective quality methods like reporting medical errors and using electronic mechanisms for prescribing drugs and training staff could reduce these errors (Safepatientproject 2009).
We can improve the quality and safety of the healthcare system by embracing a culture of safety in the health organization that includes shared beliefs and values about the health care system, training the medical staff to follow safe procedures, organizational commitment to detect and analyze medical errors, and open communication to discuss causes and results of errors (Aspoden et al. 2004).
Level 2: a patient-centered healthcare system: patient-centeredness is a dimension that shifts the control and power out of the hands of the healthcare providers into the hands of those who receive healthcare services. Berwick (2009) encountered three useful maxims that could help in defining patient-centeredness. They are: (1) “The needs of the patient come first;”(2) “Nothing about me without me” and (3) “Every patient is the only patient;”( Berwick 2009). During practice, we found out that a patient is likely to show more cooperation when he/she feels in control of his/her own decision. Ignoring a patient’s preferences may affect the treatment procedure. The Institute for Healthcare Improvement (2001) believes that the patient and his family should be allowed to collaborate with the healthcare team in making any clinical decision regarding their health. Studies have shown that detailed explanation and communication between patients and their physicians about prognosis and treatment options encourage patients to adhere to treatments, thereby resulting in improved treatment outcomes. The patient-centered practice would increase the efficiency of care by reducing some diagnostic tests and referrals by 50%. On the other hand, several studies have also demonstrated that poor patient communication could lead to errors following prescriptions, lack of return visits, and poor outcomes (Stewart et al. 2000).
Level 3: Combination of the other four quality dimensions (effectiveness, timeliness, efficiency, and equity). The four dimensions should have equal importance in the healthcare system. Effectiveness entails providing healthcare services based on scientific knowledge. Timeliness is reducing waits and harmful delays for both patients and healthcare staff. Efficiency has to do with avoiding waste. Equity is providing the same level of quality healthcare care without showing any differences because of gender, ethnicity, geographic location, and socioeconomic status. The six dimensions enable us to achieve a high level of quality and safety in offering healthcare services to patients. Also, more patients will get better, safer, reliable, responsive, and more available healthcare (Institute of Healthcare Improvement 2001). Many driving forces impact the health system and act as a guide to improving quality and safety in the healthcare system. Leadership is one of the most important drivers of quality improvement on health outcomes since leaders have the power and the responsibility to introduce change. There are two forms of leadership, according to Trofino (1995):
- Transactional leadership, in which the relationship of a leader with his/her staff is based on the exchange of transactions. It is a limited, weak, and nonproductive relationship.
- Transformational leadership by which leaders and staff engage with each other to raise one another to higher levels of motivation.
Some of the results that we can get from effective leadership in the healthcare system are improving the quality of the health system, improving the organizational culture to increase productivity, managing recourses more effectively, improving patient satisfaction, and eliminating medical errors. In 1998, Leadership Development Program trained about 125 leaders on leading and managing skills and principles. They found a magnificent improvement in health. For example, in the city of Aquiraz, 100% of infants under the age of one had all their vaccination compared to 84% in 2001. At the same time, infant mortality decreased from 26 to 11 deaths per 1,000 live births between 2001 and 2005, according to statistics released by Management Science for Health (MSH) (2006).
Since the patient or the client is the most crucial element in the healthcare process, their needs and expectations must be identified so that they can be met. A survey published by (ANZMAC) revealed that 39% of patients consider communication issues as the most important. 36% of patients considered doctors’ knowledge as most important. 17% of patients considered facilities and operational issues as most important. Such statistics drive the healthcare institutions to work on applying quality and safety standards to achieve patient satisfaction (Quality Insight of Pennsylvania 2010). An increase in the number of the elderly population also acts as a driver to the health care system to follow the appropriate plans that will limit the additional costs associated with this problem (Rechel et al 2009).
To bring change and improvement to the healthcare system useful tools and methods are applied. Some of the best tools used in quality improvement include continuous quality improvement (CQI). CQI is a method that reduces and eliminates the problem by taking the necessary steps to correct the process. It also meets regulations placed by regulators and the expectations of the patient (Quality Insight of Pennsylvania 2010). Another effective tool used to improve quality is Lean which means the removal of wastes. In the healthcare system, waste has many forms including waiting time, excessive resources, and cost of patient readmissions, among others. Eliminating waste in the healthcare system could lower expenditures (Philips Healthcare 2011). The Institute for Healthcare Improvement (2001) believes that lean principles can be applied successfully in the delivery of health care. Lean principles would help health care organizations to improve processes and outcomes, reduce costs, and increase satisfaction among patients (Institute for Healthcare Improvement 2005). Sami Bahri, a dentist, studied lean for years and applied it in his clinic. The results were more treatment time that increased from 77 hours per week in 2005 to 140 hours per week. Also, the patient completed their treatment in 10 days instead of 99 days. The surprising thing was that there was no increase in the number of staff (Lean in Dentistry 2011).
Another important rule used to bring about change and improvement to the delivery of health care is the PDSA. This tool evaluates the challenges that face the health system and follows it through a cycle of four steps to have at the end and outcome. The outcome can either be adapted, abandoned, or adjusted. The four steps of the cycle are:
Plan: the most important piece of the cycle is where we identify the problems that need improvement.
Do: the stage of collecting data and information
Study: to examine, analyze and evaluate the data and observation about the change to make.
Act: to decide if the change will be implemented, abandoned or some adjustments need to be introduced.
The SOP is another tool used to measure and assess the quality of healthcare. It is based on three dimensions of quality: structure, process, and outcomes. Structure refers to resources and administration. It includes the education and training of the staff that provides care and the equipment and the overall organization. Process refers to culture and professional relationships. It depends on two aspects appropriateness and outcome. Appropriateness measures the cost of care and patient satisfaction. This tool helps in identifying the source of the poor outcome. For example, the tool can be used to determine if the problem is with the structure such as lack of enough staff, or whether there is a problem in the process like staff members who are not doing their job appropriately.
The writer’s organization (introduction, context & current status)
The writer works as a dentist at a Dental Center that is managed by the Ministry of Health in the United Arab Emirates (UAE). The dental center is located in the city of Ras al Khaimah and serves a population of 100,000 people. Over ten dentists work at these other government dental clinics. The staff consists of five General Practitioners (GPs), eight specialists, thirteen nurses, two X-ray technicians, four lab technicians, four receptionists, and four employees working in the administration. The Dental center provides services to Emirate people only. It offers preventive, restorative, prosthetic, orthodontic, and surgical treatments. The center also provides services for emergency treatment within the day hours. The center suffers from a shortage of staff and this has caused other serious problems like a long waiting list and stress on the staff. However, this problem cannot be solved by increasing the number of staff unless the ministry of health does that. Therefore, most of the solutions to the problems facing the dental center have to be linked with the Ministry of Health policies.
Analysis of the writer’s organization in the context of best practice catalysts, dimensions, and drivers
When the writer related the best catalyst, drivers, and dimensions in quality and safety in healthcare to his organization he found the following:
In general, the building of the Dental Center is clean and properly maintained. In addition, the building that houses the Dental Center also has adequate lighting and ventilation with modern dental chairs and updated dental equipment. All X-ray machines used in dental treatment are available although there is a need to update them with the most modern technology. The center contains a lab with qualified technicians which cover the needs of the prosthodontic and orthodontic departments.
However, the building lacks some important facilities like a pharmacy. As a result, patients have to go to the nearest hospital which is about 2 km away from the Dental Center to get their medication. Also, the staffs have a very small and congested break room that makes most of them very uncomfortable. Ulrich et al (2004) indicate that poor ergonomic design of staff stations would cause back stress, fatigue, and other injuries among the staff.
Regarding the issue of patient-centered, the dental center administration has made it clear to staff members that the focus should not be on treating the patient only; they should communicate with the patient and allow him/her
to express his/her needs and opinions. Most young doctors in the center have achieved patient-centeredness. However, some of the old doctors prefer the traditional model of the doctor-patient relationship where they make most of the treatment decisions. The obstacle in achieving patient-centeredness is the limited time of the doctor to allow each patient to talk and communicate. I found that patients prefer a doctor who can communicate with them, show empathy, and give them options and freedom to make their own decisions. Patients showed more cooperation, followed instruction, and stuck to their appointments. They showed less anxiety levels when they communicated with their dentist.
Almost all patients attending the dental center complain of far appointments. Some specialized treatments like endocentric treatments may wait for two months before they get to see a specialist. The main causes of far appointments could be the insufficient dental staff and broken appointments by some patients. Increasing the number of staff and clinics in the center would solve part of the problem. A clear and strict policy for appointments should be implemented to force patients to stick to their appointments. For example, calling and confirming an appointment one day before would also reduce the chance of missing an appointment. Efficiency levels need to be improved at the Dental Center. Several things lead to wasted time and effort at a healthcare facility. For example, some dental assistants could waste time searching for certain instruments, taking a long time to mix materials, or filling diagnostic sheets. Another example is the disorganized and poor storage of patients’ medical records. Patient dental records are written in papers and maintained in folders. The staff takes a lot of time searching for the file when a patient arrives for his/her appointment. Also, some folders could go missing owing to poor storage of files. To improve the quality and safety in the medical recording field, it is better to introduce Electronic medical records that will ease the maintenance, accessibility, and storage of patients’ medical records files. Effective preventive programs directed toward school students are supervised by the Dental Center. They open special clinics in the school health centers for purpose of educating students on dental hygiene as well as applying preventive treatment for students. That would be very useful to lower the percentage of oral problems among children.
In a Conference about patient safety and quality in the Middle East, it was mentioned that the GCC is suffering from a lack of research, education, and staff motivation. This has led to gaps in patient safety (The National 2012). This calls for urgent action to investigate and evaluate the level of quality and safety in our healthcare system. Every day we read more about fatal medical errors done in our health organizations. The expenditure on healthcare is increasing with questionable outputs. No doubt that quality and safety have a long way to go and it needs more commitment and collaboration from all levels.
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