A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Evolving IT management frameworks towards a sustainable future

Information Technology (IT) Management Frameworks are a fundamental tool used by IT professionals to efficiently manage IT resources and are globally applied to IT service delivery and management. Sustainability is a recent notion that describes the need for economic, environmental and social development with- out compromising the ability of future generations to meet their own needs; this applies to businesses as well as society in general. Unfortunately, IT Management Frameworks do not take sustainability into account. To the practitioner this paper demonstrates sustainability integration thereby allowing CIOs and IT managers to improve the sustainability of their organisation. To the researcher this paper argues that sustainability concerns need to be provided to IT Management through its integration into the mainstream of IT Management Frameworks. This is demonstrated through the high-level integration of sustainability in Six Sigma, C OBI T, ITIL and PRINCE2

The administrative burden reduction policy boom in Europe: comparing mechanisms of policy diffusion

Much has been written on the diffusion of public management and regulatory reform tools. Available evidence suggests that cross-national policy diffusion is an increasingly significant phenomenon, especially in the European context. While internationalisation of policy discourses and expert communities are regarded as key driving forces of policy diffusion, public management reforms are also said to be particularly vulnerable to mechanisms of 'diffusion without convergence'. This paper analyses the case of policies aiming at reducing administrative burdens of regulations through the lens of the literature on policy diffusion. The diffusion of the so-called Standard Cost Model for measuring administrative burden between 2003 and 2007 is used as a case to explore the mechanisms facilitating policy diffusion in this domain. The analysis reveals patterns of rapid diffusion. This policy boom has been driven by a combination of different mechanisms of policy diffusion rather than by a single driving factor

Corporate governance

Governance is largely about the decision-making process in a complex organization Shareholders (owners) delegate authority to professionals who have the managerial skills to increase shareholders’ wealth. As a consequence the contributors of a firm's capital base are usually different from the contributors of its management base. This separation of ownership from control has led to organizations establishing a system of corporate governance controls designed to discourage managers from pursuing objectives that fail to maximize shareholder wealth. These controls constitute the firm's corporate governance framework. Corporate governance controls are designed to monitor managers behavior or align the goals of management with the goals of shareholders. In this chapter, a corporate governance framework is developed that outlines the roles and responsibilities of participants involved in governing the organization and portraying information to the capital market

Organisational culture in airworthiness management programs: Developing a measurement model

All civil and private aircraft are required to comply with the airworthiness standards set by their national airworthiness authority and throughout their operational life must be in a condition of safe operation. Aviation accident data shows that over twenty percent of all fatal accidents in aviation are due to airworthiness issues, specifically aircraft mechanical failures. Ultimately it is the responsibility of each registered operator to ensure that their aircraft remain in a condition of safe operation, and this is done through both effective management of airworthiness activities and the effective program governance of safety outcomes. Typically, the projects within these airworthiness management programs are focused on acquiring, modifying and maintaining the aircraft as a capability supporting the business. Program governance provides the structure through which the goals and objectives of airworthiness programs are set along with the means of attaining them. Whilst the principal causes of failures in many programs can be traced to inadequate program governance, many of the failures in large scale projects can have their root causes in the organisational culture and more specifically in the organisational processes related to decision-making. This paper examines the primary theme of project and program based enterprises, and introduces a model for measuring organisational culture in airworthiness management programs using measures drawn from 211 respondents in Australian airline programs. The paper describes the theoretical perspectives applied to modifying an original model to specifically focus it on measuring the organisational culture of programs for managing airworthiness; identifying the most important factors needed to explain the relationship between the measures collected, and providing a description of the nature of these factors. The paper concludes by identifying a model that best describes the organisational culture data collected from seven airworthiness management programs

Organisational performance management as a mechanism to improve service delivery in the South African public sector: the contribution of internal auditing as an enabler

The advent of democracy in 1994 prompted the South African government to provide public goods to the entire population as opposed to providing services along racial lines, as was the case during the apartheid era. Consequently, government expenditure increased considerably. However, continuous service delivery protests in recent years indicate that government has not been operating optimally. The Department of Planning, Monitoring and Evaluation and National Treasury introduced Organisational Performance Management (OPM) to improve service delivery. Government also adopted internal auditing as a mechanism to improve OPM because of internal auditing’s mandate, role and body of knowledge. This study explored the implementation of OPM as a management tool to assist national departments in effectively delivering goods and services to the public economically and efficiently. The study also explored the adoption of internal auditing by national departments as a mechanism to improve OPM. The study followed a sequential mixed methods approach. The chief audit executives of eighteen national departments participated in the quantitative phase. Interviews were held with employees from four national departments as well as two monitoring departments. Departmental officials included five deputy directors-general, three chief directors, four directors, one deputy director and one senior internal auditor. Seven focus group discussions were held with twenty-two internal auditors from the four departments. Sixty-four documents were analysed. The study found that national departments have implemented systems of OPM and the reporting of quarterly performance information but are at different levels of maturity. However, governance and reporting fatigue and a reluctance to implement effective consequence management for poor performance may be undermining optimal performance. National departments may be also preparing strategic plans, annual performance plans and annual reports simply for compliance rather than for optimal performance. The study also found that internal auditors may not have a thorough understanding of the department’s performance environment and consequently undertake limited assessments of OPM, focusing mainly on quarterly performance information (PI) and documentation rather than on organisational strategy. However, management’s expectations from internal auditing go beyond assessing the quarterly PI and require advice and guidance on strategic imperatives. The appropriate skills, knowledge and training of internal auditors therefore require review. Management expects assurance of sustainable future performance of the department. Internal auditing currently stands positioned to make an evolutionary transformation into becoming the most important strategic partner to management. However, under-theorisation and a restricted internal auditing approach inhibit its natural evolution.College of Accounting SciencesD. Phil. (Accounting Sciences