{"id":2190,"date":"2012-10-13T12:10:45","date_gmt":"2012-10-13T12:10:45","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=2190"},"modified":"2012-10-13T12:10:45","modified_gmt":"2012-10-13T12:10:45","slug":"safety-by-despair-desire-or-design","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=2190","title":{"rendered":"Safety by Despair, Desire or Design?"},"content":{"rendered":"

\"\"<\/a>Imagine the health and safety implications of landing a\u00a0helicopter carrying a critically ill patient on the roof of a hospital.<\/p>\n

Consider the possible number of ways that this scenario could go horribly wrong. But in reality it does not because this is a very visible hazard<\/strong> and the associated risks<\/strong> are actively mitigated.<\/p>\n

It is much more dangerous for a slightly ill patient to\u00a0enter the doors of the hospital\u00a0on their own two legs.\u00a0 Surely not!\u00a0 How can that be?<\/p>\n

First the reality – the evidence.<\/p>\n

Repeated studies\u00a0have shown that about 1 in 300\u00a0 emergency admissions to hospitals\u00a0do not leave alive and their death is avoidable.\u00a0And it is not just weekends that are risky. That means about 1 person per week for each\u00a0large acute hospital in England. That is about a jumbo-jet full of people every week<\/em> in England. If you want to see the evidence click here<\/a>\u00a0to get a copy\u00a0of a recent study.<\/p>\n

How long would an airline stay\u00a0in business if it crashed one plane full of passengers\u00a0every week?<\/p>\n

And how do we know that these are the risks? Well by\u00a0looking at hospitals who\u00a0have recognised the\u00a0hazards and the risks and have actively\u00a0done something about it. The ones that have used Improvement Science – and improved.<\/p>\n

\n

In one hospital\u00a0the death rate from\u00a0a common, high-risk emergency was\u00a0significantly reduced<\/strong>\u00a0overnight simply by\u00a0designing and implementing a protocol that ensured these high-risk patients\u00a0were admitted to\u00a0the same ward. It cost nothing to do.\u00a0No extra staff or extra beds. The effect was\u00a0a consistently better\u00a0level of care through proactive medical management. Preventing risk rather than correcting harm. The outcome was not just fewer deaths – the survivers did better too. More of them returned to independent living – which had\u00a0a huge financial implication for the cost of long term care. It was cheaper for the healthcare system.\u00a0But that benefit was felt in a different budget\u00a0so there was no direct financial reward to the hospital for improving\u00a0the outcome. \u00a0So the improvement was not celebrated and sustained.\u00a0Finance trumped Governance. Desire to improve safety is not enough.<\/p>\n

\n

Eventually and inevitably the safety issue\u00a0will resurface and bite back.\u00a0 The Mid Staffordshire Hospital debacle is a timely reminder. Eventually despair will drive change – but it will come at a high price.\u00a0\u00a0The emotional knee jerk reaction driven by public outrage will\u00a0be to add yet more layers of bureaucracy and cost: more\u00a0inspectors, inspections and delays.\u00a0 The knee jerk is not designed to understand the root cause and correct it – that toxic combination of ignorance and confidence that goes by the name arrogance<\/em>.<\/p>\n

\n

The reason that the helicopter-on-the-hospital is safer is because it is designed to be – and one of the tools used in safe process design is called Failure Modes and\u00a0Effects Analysis\u00a0<\/strong>or FMEA.<\/p>\n

\"\"<\/a>So if\u00a0there is anyone reading this who is\u00a0in a senior clinical or senior mangerial role in a hospital\u00a0that has any safety issues – and who has not heard of FMEA\u00a0then they have a golden opportunity to learn a skill that will lead to safer-by-design hospital.<\/p>\n

Safer-by-design hospitals are less frightening to walk into, less demotivating to work in and cheaper to run.\u00a0 Everyone wins.<\/p>\n

If you want to learn more now then click here <\/a>for a short summary of FMEA from the Institute of Healthcare Improvement.<\/p>\n

It was written in 2004. That is eight<\/strong> years ago.<\/p>\n","protected":false},"excerpt":{"rendered":"

Imagine the health and safety implications of landing a\u00a0helicopter carrying a critically ill patient on the roof of a hospital. Consider the possible number of ways that this scenario could go horribly wrong. But in reality it does not because this is a very visible hazard and the associated risks are actively mitigated. It is … <\/p>\n

Continue reading “Safety by Despair, Desire or Design?”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[15,21,22,35,38,45],"tags":[],"class_list":["post-2190","post","type-post","status-publish","format-standard","hentry","category-design","category-governance","category-healthcare","category-reflections","category-safety","category-what"],"_links":{"self":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/2190","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2190"}],"version-history":[{"count":0,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/2190\/revisions"}],"wp:attachment":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2190"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2190"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2190"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}