Generic capability 4
Attending a healthcare service carries danger with it. Estimates of the risk of harm vary but can be as high as 10% for an encounter, depending on its nature and duration. While much damage is slight and reversible, not all is trivial. It must never be thought that rehabilitation is free of risk or cannot cause harm. (here) All healthcare workers must prioritise a patient’s safety at all times and always strive to improve service quality. This is equally true of professionals working in rehabilitation. Many safety and quality improvement aspects are shared with all other areas of healthcare. In all healthcare, significant risks arise from the interaction between two systems, such as operating theatres and radiology departments. In rehabilitation, the chances are multiplied by the many services, separate organisations involved, and the lack of overarching responsibility for patient safety and ‘whole patient service’ quality. The content of this page is summarised in a MindMap shown below and available for download here. This capability must be read in the context of the other six generic capabilities (here) and the seven rehabilitation capabilities (here).
Table of Contents
Generic capabity 4 - patient safety
The capability required to manage the risks associated with the many boundaries crossed in rehabilitation is that the expert rehabilitation professional is “able to monitor and improve the whole network of services involved with a patient, considering safety and quality of their own service, each other service individually, and all inter-service transferring and/or sharing of responsibility.” This is complex because there is no overarching organisation to enforce the quality improvements suggested.
Context: complexity, risk, and safety
In most complex systems, the most significant risks occur at boundaries, whether boundaries in time (e.g. handover of care), in space (between two nations), in organisations (passing care from Health to Social Services), or in services (sharing care between two team members), or in any other boundary (e.g. asking a family member to convey some object or information to a patient). Conversely, the edges offer the most significant opportunities for quality improvement, not simply by reducing risk but also by being more efficient or effective.
Healthcare systems are said to be among the most complex systems known, and I suspect rehabilitation must be one of the most difficult. (For a brief explanation of complexity, go here, and look at the figures here for an illustration.) Within healthcare, many patients will be in contact with three or more services (general practice, disease specialist, expert rehabilitation, another illness specialist or community health services), with social services (home care, day centre), with the department of work and pensions (financial support), with housing etc. Each service will have its bureaucracy, priorities, culture etc.
Misinterpreting laws and overzealous or excessively cautious interpretations obstruct almost all information sharing. Patients are repeatedly assessed, even if the information is shared, because of a lack of trust and a bureaucratic insistence on using the service’s measures, even if indistinguishable from others already available. This failure to share information is worsened in health by the need for interoperability between electronic patient records.
Considering these difficulties, it is surprising how little severe harm occurs. On the other hand, with complete justification, most patients and families complain about how inefficient, non-patient-centred, and sometimes hostile the service they receive is.
Attitude
It is in this context that the expert rehabilitation professional has to work. The critical attitudes needed for this capability are:
- being concerned with patient safety and service quality
- taking a broad view across all services and settings
- looking at everything from a patient’s perspective
- persistence and patience in trying to improve cooperation
Behaviours
Being concerned with the safety and quality of a healthcare service is everyone’s concern. Unfortunately, this often means that it is no one’s concern, with each person thinking, “someone else will or should do something about this“, and carrying on.
The behaviours outlined here follow from one premise – you are responsible for acting on anything and everything you notice concerning the risk of harm or is obviously of low quality. This might lead to being unpopular with other professionals and being overworked. One solution is to ensure that the patient or patient knows you are raising a concern; the NHS supports openness, especially following the Francis Enquiry into events at Mid Staffordshire NHS Foundation Trust. (here) Patient support will not only make you feel better, but it will also help effect action.
One slight (!) problem is that organisations also dislike taking responsibility for action, saying (for example) that “the problem arose in department X, not our department, so we do not need to do anything” even if (a) a patient has been harmed and (b) both departments are in the same hospital organisation. This has happened to me at least once. If you are brave and tenacious, or the harm or risk is great, you can approach higher powers (here).
The biggest problem is that no one accepts responsibility for ‘no man’s land’, the spaces in between, even though many patients spend much of their life waiting in or passing very slowly through the area between boundaries.
The indicative behaviours of an expert rehabilitation professional associated with this capability are:
- Reacts to concerns about safety or quality of care arising in any part of a patient’s care, in any organisation or shared activity, and persists until the matter is resolved satisfactorily;
- Escalates concerns about patient safety, if not taken forward by the initial contact within an organisation, to a national forum if necessary;
- Listens to and acts on any report that raises concern about safety from anyone, especially patients and families;
- Reports all incidents using the organisation’s incident reporting system and ensures a response happens;
- Identifies areas of practice where quality might be improved and initiates work on improving practice;
- Contributes to and leads quality improvement projects;
- Discusses ways to improve team activities pro-actively and regularly at team meetings;
- Actively engages all team members and other colleagues in quality improvement projects.
Knowledge and skills
Success in this capability depends on persistence and doing the right thing. Nevertheless, some knowledge will help, but probably to a lesser extent. Moreover, much of the knowledge relates to the context and cannot be learned from external courses.
The first four pieces of knowledge that an expert rehabilitation professional should know concern patient safety: they should know:
- How to raise any concern about safety and how to report incidents with the organisation worked in;
- How to investigate an incident;
- How to notify responsible organisations about vulnerable adults when abuse or neglect is a concern;
- The importance of human factors and system failures as significant causes of patient harm.
The second four pieces of knowledge that an expert rehabilitation professional should know concern quality improvement: they should know:
- The principles of quality management and quality improvement (previously termed ‘audit’);
- Where to get help from within the organisation worked in;
- How to collect, record, manage and analyse data collected;
- The laws concerning data handling and protection.
The skills are similar to those needed for rehabilitation and concern the focused collection of data to understand and analyse the risk or low quality and then develop a plan to improve the situation with others.
The expert rehabilitation professional needs to be able to:
- Identify when harm has occurred and report it in a clear, non-judgmental way;
- undertake an investigation reasonably, analyse it, draw conclusions from it, and make clear practical recommendations. Last, the professional must be able to write a clear report.
- Identify opportunities for quality improvement that are practical and achievable;
- Lead a project and contribute constructively to other projects;
- Use computer systems and software
Conclusion
This page has outlined generic rehabilitation capability four, which concerns explicitly reducing the risks of harm to a patient and responding to actual damage to a patient, and the more general matter of improving service quality – efficiency, safety, patient experience, etc. – which should help all patients and reduce all risks. It emphasises the need for a rehabilitation professional to take personal responsibility for these matters and the difficulties of doing so because rehabilitation works across many boundaries. (see here.) It suggests that involving patients in the process may help gain support from reluctant organisations or people. The capability is summarised below.