A Compendium of Safety Strategies
We have proposed five broad safety strategies each associated with a family of interventions. We have provided illustrations of how each strategy might be applied in hospital, home and primary care. The reality is no doubt considerably more complicated and needs to be further explored. But even now, with incomplete understanding, we can set out a suite of potential interventions to improve safety and manage risk.
Table 11.1 brings together many of the strategies and interventions described in previous chapters and offers some comments on their applicability, current use and challenges for implementation. The strategies and interventions can operate at different levels and have divided these into frontline, organisation and system levels. This is not a complete account by any means as, for one thing, we have not included patients and families as users of these approaches. However it makes the general point that some interventions are more useful on the frontline while others are more useful at system level. Care bundles for instance are a frontline team intervention, although managers and regulators may encourage and even mandate their use. Risk control approaches can be used within a clinical team in deciding not to start an operation unless all the equipment is available. However, most risk control interventions, such as restricting demand or controlling working conditions, will be at organisation or system level and require considerable authority to implement. To be effective of course they also need the backing of frontline staff.
Table 11.1 A compendium of safety strategies and interventions
We realise that these proposals are just a starting point in that considerable work is needed to map and articulate the full range of strategies and interventions that are currently in use and which might be adopted. This has been done for 'best practice' approaches, and to some extent for interventions to improve the system. But we need a much fuller description of all types of strategy and intervention if we are to develop a truly comprehensive approach to safety.
We can point to similar developments in other fields which may serve as a model for how this might be done. There is, for instance, enormous interest in influencing the behaviour of people in a variety of ways; these include diet, smoking, exercise, road safety, the payment of taxes and a host of other policy objectives. There are numerous psychological and social theories which purport to explain changes in human behaviour through a variety of mechanisms each with implications for intervention. In weight loss for instance one might seek to enhance self-esteem as a means of increasing adherence to a diet or place more emphasis on extrinsic motivations such as offering financial incentives (Box 11.5). Susan Michie and colleagues have developed the Behaviour Change Wheel (BCW), a synthesis of 19 frameworks of behaviour change found in the research literature (Michie et al. 2013). The BCW has at its core a model of behaviour known as COM-B standing for capability, opportunity, motivation and behaviour. The BCW identifies different intervention options that can be applied to changing each of the components and policies that can be adopted to deliver those intervention options.
Box 11.5. Contrasting Approaches to Changing Risky Behaviour
Suppose one wished to reduce the propensity of young drivers to engage in risky driving practices such as driving too fast. One would canvass all the options including improving their 'capability' to read the road and adjust their driving to the conditions, restricting their 'opportunity' to drive recklessly by means of speed limiters or speed humps, and establishing whether a promising approach would be to try to change their 'motivation' to drive safely through mass media campaigns or legislation and enforcement. Any or all of these may have some effect. The Behaviour Change Wheel provides a systematic way of determining which options are most likely to achieve the change required.
Adapted from Michie et al. (2014)
Changing behaviour is of course one way of managing risk, particularly in respect of adherence to safety critical procedures. However, in this context, we are drawing a broader parallel with the strategic approach to classifying, interpreting and designing interventions. Michie and colleagues point, as we do, to the plethora of potential interventions, to the fact that most interventions are used singly or in limited combinations. Their approach has been to draw out the distinguishing features of each approach, to classify and integrate in a broad conceptual framework of behaviour change interventions.
Our 'incomplete taxonomy' is a first step towards a similar initiative in the systemic management of risk in healthcare and potentially in other settings. We now need to map the landscape, assess the distinctive assumptions and approach of each strategy and intervention and begin to consider how to customise and combine the interventions to the challenges facing us. At the moment, in most cases, we are only using a fraction of the potential interventions open to us. Drawing on the full range and intervening at all levels of the system would give us much more leverage and power in confronting the challenges of keeping healthcare safe in a time of austerity and rising demand.
• There are five major transitions between the current vision of patient safety and the broader one we need for the future.
• Our current approach to patient safety assumes generally high quality healthcare punctuated by occasional safety incidents and adverse events; this as a vision of safety from the perspective of healthcare professionals. We need to also understand risk and harm through the patient's eyes
• Viewing safety through the patient's eyes has the immediate consequence that we need to view safety in the context of the patient journey. This means that we need to examine episodes of care and consider both benefit and harm within an extended timescale.
• Patient safety is the art of minimizing incidents but also managing risk over longer time periods which will require additional skills and methods. We accept in this vision that errors will inevitably occur but that, in a safe system, very few will have any consequences for the patient.
• Safety needs to be approached very differently in different environments.
Healthcare has many different types of activity and clinical settings and so we cannot use one primary model.
• We need to develop a wider range of safety strategies and interventions.
We should extend our safety strategies to include risk control, monitoring and adaptation, and mitigation
• We have very limited safety strategies for dealing with the day to day realities of healthcare. People adapt and cope, but on an individual basis rather than with a considered team based strategy. Developing considered approaches to the management of risk in such situations is a priority for the next phase of patient safety.
• A compendium of safety strategies and interventions is already available.
The slow progress in patient safety is in part due to the fact that we are not using the full range of interventions available. It is like driving a car using only first gear.
• Considerable work is needed to map and articulate the full range of strategies and interventions that are currently in use and which might be adopted.
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