Does your quality system detect neglect?

Does it? And – if you’re running an acute healthcare service, how long could a consumer go without being offered a wash? These questions have been exercising my mind lately, as I see more and more quality systems focused on risk and compliance, with a bit of improvement thrown in to meet accreditation standards. And reactive risk and compliance at that. Of course standards must be met and risks managed – but driving and supporting the whole consumer experience requires more than that. Imagine the elements that would be missing from other people-related industries such as hotels and aviation if they only met technical standards and managed risks.

We’ve evolved risk management to identify and name key risks, such as pressure injuries and consumer identification, so we can detect, report and count when these things go wrong – and do something about it. This has transformed staff understanding of risk and the need to manage it to prevent harm. But instead of taking this process and applying it to other aspects of care, we seem to have plateaued.

It’s time to move on!  – to getting the care basics right – consistently. There’s no doubt that this happens in every organisation – in pockets. But very few health or aged care services are confident of it happening for every person, every time. What if we applied the same focus to this as we do to risk?; identify the basic care components that need to go right, increase staff understanding of why they’re important, work them into the fabric of daily routines, and detect and report when they are not happening.

Many people say that basic care components are – or should be – self-evident, so we don’t need to be explicit about identifying them. Well, we used to say that about risk and harm too; before the Quality in Australian Healthcare Study showed us that we didn’t know as much about the scope of harm – and why it was happening – as we thought we did.

We don’t need to develop key care components from scratch of course. It seems to me that the US Institute of Medicine (IOM) got it right all those years ago by identifying the dimensions of healthcare quality: safe, effective, patient-centred, timely, equitable, and efficient.  Interestingly, these were expressed as aims for every healthcare episode, not just dimensions. They are meant to be proactive guides.

Many of you will know that if you ask the right questions of any audience – healthcare professional, manager or consumer – about what’s important in a health or aged care episode, they identify these dimensions. Not in these words at first – generally, they’ll describe the actions within each of these dimensions that they want from a healthcare experience. Safety is a critical dimension, of course – but, interestingly, actions related to effectiveness are almost always discussed first, closely followed by issues describing responsiveness to the individual. Continuity and integration of care, seldom seen in current quality systems, also features in what people want from their healthcare. Discussions about aged and community care identify the same dimensions, but the actions within them differ, relative to the sector.

What’s this got to do with a quality system detecting neglect? Everything! Lately, I’ve taken to asking workshop audiences and quality managers one critical question to ascertain where their quality system is up to:

‘Would your quality system detect and prevent a Mid Staffordshire – like decline into poor bedside care and neglect of patients in your organisation?’ (see http:www.midstaffspublicinquiry.com/)

This turns out to be a great question because it makes people stop and think – ‘would it?’ If your quality and risk system relies mostly on incident reporting and accreditation, the honest answer is probably ‘no’.   Clinically-related accreditation standards certainly help – such as the National Safety and Quality Standards in Australia, as they set a high bar for key clinical processes, requiring changes in staff behaviour and proactive monitoring and review.

Mid Staffordshire showed that good care is about much more than this, however. We know staff are pressured, rushed and, at times, frustrated with their jobs.  This environment favours task completion, rather than care. Things get missed and corners cut in the complexity and the rush. But which ones? Would your quality system detect if patients weren’t eating and drinking? Being washed and taken to the bathroom? Having their pain relieved? Understanding what was happening to them? Feeling respected and consulted? Being treated according to best available evidence?

Some people respond that their death review process picks up a lot of issues. And done well, it does. After the event, unfortunately. Is this process working to identify care issues as well as technical clinical issues, however? I wonder how much general ‘poor care’ contributes to preventable deaths.

My motivation for wanting health and aged care services to be as focused on components of care as they are on key risks is mostly about improving the consumer experience. But that’s not all. For me, it’s also about health, aged and community organisations having the satisfaction of moving beyond monitoring and reacting, to achieving their potential for doing good. It’s about healthcare professionals and quality managers enjoying being proactive and making a real difference. I’m not seeing as much of that as I used to. Many quality managers, in particular, are looking more like administrators that technical experts. This does not make for great job satisfaction, as evidenced by the revolving door of people moving in and out of quality roles (which in turn, does not build a solid base of technical expertise…)

Have a think about your bedside/chairside care, beyond clinical standards. Are the key components and expectations of basic care clearly defined with staff? Have consumers had input into what’s important to them? Are you proactive in detecting care ‘slippage’? Or do you only know when it turns into a complaint, or you hear about it at the local supermarket, or in the press? How does your organisation respond?   Sighing about the staff? Or developing a better system of care that guarantees the basics of care for every consumer?

Oh – and how long can consumers go without a wash in the acute sector? Can’t answer that unequivocally. But so far the record is eight days.

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