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 harm is small, and reversible, not all is trivial. It must never the thought that rehabilitation is free of risk, or cannot cause harm. (here) All healthcare workers need to prioritise a patient’s safety at all times, and always to strive to improve service quality. This is equally true of professionals working in rehabilitation. Many aspects of safety and quality improvement are common with all other areas of healthcare. In all healthcare, the major risks arise from the interaction between two systems, such as operating theatres and radiology departments. In rehabilitation the risks are multiplied by the many services and completely separate organisations involved, and the lack of any overarching responsibility for patient safety and ‘whole patient service’ quality. The required capability to manage this 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.” The content of this page is summarised in a MindMap here. This capability must be read in the context of the other six generic capabilities (here) and the seven rehabilitation capabilities (here).
In most complex systems, the biggest risks occur at boundaries, whether boundaries in time (e.g. handover of care), or in space (between two nations), or 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, it is the boundaries that offer the greatest opportunities for quality improvement, not simply by reducing risk, but also through being more efficient or effective.
Healthcare systems are said to be among the most complex systems known, and among healthcare I suspect that rehabilitation must be one on the most complex. (For a brief explanation of complexity, go here, and for an illustration look at the figures here.) 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 own bureaucracy, priorities, culture etc.
Misinterpretation of laws, and/or overzealous or excessively cautious interpretation of laws obstructs almost all sharing of information. Patients are repeatedly assessed, even if information is shared, because of a lack of trust and a bureaucratic insistence on using the services own measures, even if indistinguishable from others already available. This failure to share information is worsened in health by the lack of any inter-operability between electronic patient records.
Considering these difficulties, it is perhaps surprising how little severe harm occurs. On the other hand, most patients and families complain, with complete justification, about how inefficient, non-patient-centred, and sometimes hostile the service they receive is.
It is this context that the expert rehabilitation professional has to work. The key attitudes needed in 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
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 “some one else will or should do something about this” and carrying on.
The behaviours outlined here all follow on from one premise – you, personally, are responsible for acting on anything and everything you notice concerning risk of harm, or is obviously of low quality. This might lead to being unpopular with other professionals, and to being overworked. One solution is to make sure that the patient or patient knows that 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, 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 very brave and tenacious, or the harm or risk is great, then you can approach higher powers (here).
The biggest problem is that no-one accepts any 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 space 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 in shared care, 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/or 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 is probably dependent on persistence, doing the right thing. Nevertheless, some knowledge will certainly 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: he or she should know:
- How to raise any concern about safety and how to report incidents with the organisation worked in;
- How to undertake an investigation into 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 major causes of patient harm.
The second four pieces of knowledge that an expert rehabilitation professional should known concern quality improvement: she or he 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, in order to understand and analyse the risk or low quality, and then the development with others of a plan to improve the situation.
The expert rehabilitation professional needs to be able to:
- Identify when harm has occurred and report it in a clear, non-judgemental way;
- undertake an investigation fairly, to analyse it, to draw conclusions from it, and to 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 to contribute constructively to other projects;
- Use computer systems and software
This page has outlined generic rehabilitation capability four, which concerns specifically reducing the risks of harm to a patient and responding to actual harm 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 so many boundaries. (see here.) It suggests that involving patients in the process may well help gain support from reluctant organisations or people.