Patient Safety and Quality Improvement in Health Care
By Don NixdorfFeatures Clinical Patient Care
On April 12-14, I attended Canada’s Forum on Patient Safety and Quality
Improvement in Toronto. The volume of information, and magnitude of the
impact of this issue on the public, was a new experience for me,
regardless of the exposure I’ve had to countless government, research
and profession-specific meetings.
On April 12-14, I attended Canada’s Forum on Patient Safety and Quality Improvement in Toronto. The volume of information, and magnitude of the impact of this issue on the public, was a new experience for me, regardless of the exposure I’ve had to countless government, research and profession-specific meetings.
The conference’s attendees and their organizations are too numerous to list, but should be reviewed at www.patientsafetyinstitute.ca/English/news/canadaForum/Pages/default.aspx by all boards and members to appreciate the scope and future role for safety and outcomes discussions. Notable speakers included the Deb Matthews, Ontario Minister of Health; Jim Eaton, National Health Service UK; and Dr. Jason Leitch, National Clinical Lead for Safety and Improvement Scottish Government.
A brief review of the conference will demonstrate that the first and major awareness of injury and death is associated with hospital and related institution-based care. However, conference discussions clearly indicated that this was just the most easily observable environment. Primary care, or that occurring in physician clinics, is understood as equally a concern and will be the subject of focus and action at a future date.
In this report, I will attempt to review some of the salient features of the conference. I must mention that I also include some of my own impressions, herein.
A NAKED ACKNOWLEDGMENT
It was stated by keynote speakers at the conference that health care is safe, but not safe every day for every patient. The opening presentation, in fact, reported on thousands of needless deaths associated with preventable infection. The largest prevention measure, in 2010, was the act of washing hands, an easy activity that, studies have shown, actually has a very low compliance rate amongst health care workers!
But, the full range of specific examples, and identification of all preventable mistakes causing injury and death, was beyond the scope of this, and likely any, conference, regardless of organizations involved. The fact is, there are too many preventable health-care mistakes, as documented by a variety of publications and reports, including those authored by coroners and physicians, among others.
My first reactions from reading over 90 poster presentations – primarily from hospital-based clinicians, staff, and researchers – listening to presenters and speaking with attendees from across Canada were combined sadness/depression and hope. The sadness was from the repeated documentation of the almost countless injuries and lives lost arising directly, and indirectly, from the actions of health-care providers of all categories. (The numbers are actually even higher since, due to lack of awareness and under-reporting of daily mistakes, some cases are not represented in the literature). This was openly documented and discussed, with awareness, but, it seemed, almost with too much regard for being objective. Hope came from the fact that the conference scope and attendees were dedicated to increasing both awareness of cause and prevention of these daily mistakes.
IT’S THE SYSTEM AND THERE IS NO BLAME
The presentations and discussions at the conference repeatedly characterized the existence of injury and death from treatment as a system failure. This included the concept that there should be no blame attached to the individual(s) involved in the cause of the adverse event. (This would be understandable if the subject of adverse events were solely in the domain of those responsible.) Perhaps the real issue is not blame but discipline findings. But, this shows little respect for the patients who are injured or the family of those who passed away as a result of preventable mistakes. Perhaps the dialogue should focus on when, and what sort of, discipline is appropriate. Without acknowledging the need to employ discipline when it is called for, there is the probability of diminished responsibility and less chance for early meaningful change that may save lives and reduce injury. We should remember health care is for the public, and promoting the absence of blame for such a major problem is not necessarily reassuring to the public.
CHIROPRACTIC IN SAFETY AND OUTCOMES
It is important to state that the subject of informed consent also was mentioned by speakers. Informed consent was a signifigant lead-in to the reminder that patient safety should not avoid, but include, the public in the awareness and actions that may put an end to preventable injury and death within the health-care system.
As I’ve stated, although the approximately 400 attendees and speaker presentations represented government and professions that were primarily focused on patients in hospital-based care, this did not exclude the concern and awareness of the need for safety, outcomes and informed consent in the private practice/primary-care environment. It is in this area that chiropractic has an immediate opportunity to participate in all patient safety organizations regardless of country, patient or health authority.
The frank awareness and magnitude of injury and death gave me a moment of pause to reflect on the years of information and participation, in many initiatives, of the chiropractic profession. Chiropractic education, practice and research does focus on patient outcomes, and safety. It does so as a normal, responsible function of a profession and its individual doctors. It has also done so as a response to historic and contemporary detractors – in short, chiropractic is no stranger to the issues of patient safety and consent.
Upon considering the diversity and sheer frankness of information offered at the conference, including the Canadian Medical Protective Association manuals openly advising its medical members on how to address an adverse event with a patient, some observations can be drawn:
- Patient safety is primarily a provincial government and advocacy organization process. Therefore, provincial chiropractic organizations can and should immediately become familiar with their province’s participants and process, keeping in mind that health reform is largely a provincial government function.
- Individuals and chiropractic organizations should seek and identify grass roots patient-based patient safety organizations as these are often made up of victims and their families/friends who are committed to the cause of advocacy and improved measures. Examples include The Empowered Patient, a group based in British Columbia.
- Our profession is, in fact, a leader in safety and improved outcomes. Indeed, a poster presentation or an appropriate presentation on the issue of safety and outcomes at future conferences is more than warranted.
- Chiropractic participation means the acknowledgment and free discussion of the known risks and outcomes of the various treatments offered by chiropractic doctors. The limited nature of these risks is already identified in public literature, as well as the substantive literature on the outcomes of spine adjustment.
- Chiropractic participation can and should take the lead in the matter of informed consent. The profession’s legal and internal history with respect to informed consent issues is unparalleled and should serve as a foundation at patient safety conferences, in particular patient-based safety conferences. The public should know that when seeking care from any health professional, they should expect the same standard of informed consent the chiropractic profession at large demonstrates.
Among comparable health professions/providers, the chiropractic profession has the documentation making it a leader in informed consent (the cornerstone of safety), provides among the safest of care, and can demonstrate substantial positive patient outcomes. Therefore, it should be present to participate in discussions and conferences dealing with these issues.
The conference underscored the mistakes arising from human nature. No one attempted to suggest suing, or otherwise negatively described an entire profession. In addition, where explanations of adverse events occurred, they were objective explanations delivered by peers or representatives of the responsible practitioner, not individuals claiming to speak for that practitioner’s entire profession. This avoided giving the public and media the misleading perception that the adverse events were possibly characteristic of the entire profession.
The conference concluded that there is an international urgency for safety and sustainability of health care. With almost one-third of all daily primary care being for the spine and related conditions, the chiropractic profession should be visible, in each province, to demonstrate that chiropractic is aware of the problem and is part of the solution. •
Dr. Don Nixdorf has been the executive director of the BCCA since 1985, was BCCA and BCCC president from1982-1985, governor and secretary-treasurer of the CCA from 1987 to 1989 and served as chair of the Commission on Chiropractic Education (Canada) from 1994 until 1999. From 1982-1991 he was staff chiropractor/consultant to the Workers’ Compensation Board of B.C. and has been a participant in National E-Claims Standards since 2001. He is a former committee member of the BC government Health Information Standards Council. Dr. Nixdorf is also co-author of Squandering Billions: Health Care In Canada, which analyzes the causes of the crisis in health care and strategies for its survival. He can be contacted at firstname.lastname@example.org
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