Guest Post: “Do No Harm” – Patient Safety is Defined by Standard of Care
Mark's Note: I met today's guest blogger, Gus Lusack, when I was working with a hospital pathology department in the British NHS. Gus was the microbiology manager at the time and, while most of my engagement was in the core lab, we had many great conversations about Lean and healthcare improvement. He's now working as a consultant and I'm happy to share his post below (with more to come, possibly).
By Augustus (Gus) Lusack:
The “Do No Harm” standard of care applies to every employee in every healthcare setting and it is a legitimate expectation of every user of healthcare services. The overwhelming majority who access healthcare do not expect to be caused any harm – not by failure to follow manufacturers' instructions or any other conceivable inadequacy or complacency!
Yet it is not uncommon to hear some serious and even fatal errors explained away by the phrases “The manufacturers' instructions were followed – unfortunately it was just one of those things!” or “It's been done like this for years and there have been no problems – this is a one-off; something else must have caused the problem.” Worse still, is when people seek to conceal errors.
When it comes to patient safety and standard of care, there can be no hiding place behind the validation of regulatory agencies and accreditation bodies, either! Inspections and audits by these bodies have an important role to play, but they are too infrequent to provide adequate assurance of safety and high enough standards of care across the board in our fast evolving healthcare settings. Inspections and audits are no more than a snapshot of a limited range of activities upon which a clean bill of health is issued to healthcare organisations.
Besides, it is common knowledge that, before such visits, there is often frantic activity in the host organisation to ensure that any lapses in documentation or procedure are carefully managed in order to avoid the embarrassment of serious noncompliance, thereby compromising the effectiveness of the visit. In recent years, we have all been shocked to the core by hospitals that had been given a clean bill of health by regulatory or accrediting bodies when, in reality, there were cauldrons bubbling underneath with practices that did the ultimate harm to their patients – kill them!
Systems and technology can fail. Caregivers will make mistakes. Regulatory and accreditation guidelines and recommendations alone will not ensure patient safety. They give an indication of minimum standards of care patients should receive. Their audits, reports and recommendations should complement an internal framework of higher standards that must include an overarching continuous improvement programme through audits, training, competency assessments, and risk assessments. Strong leadership is a requirement and there is no place for complacency in this framework.
It is worth remembering that, as organisations in the healthcare business, we deserve what we tolerate!
About Gus Lusack:
Gus has a passion for using Lean tools and methods to create safer, better quality, and more efficient healthcare. He is an experienced Medical Scientist with a Master of Science (MSc) degree in Immunology, a Master of Business Administration (MBA) degree and a Lean Six Sigma Black Belt. Gus is also runs a Lean Six Sigma Consultancy and speaks on improving processes and operations in healthcare organisations. You can find him on the web at http://www.whynotsolutions.co.uk/.
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