A novel tool for organisational learning and its impact on safety culture in a hospital dispensary

Incident reporting as a key mechanism for organisational learning and the establishment of a stronger safety culture are pillars of the current patient safety movement. Studies have suggested that incident reporting in healthcare does not achieve its full potential due to serious barriers to reporting and that sometimes staff may feel alienated by the process. The aim of the work reported in this paper was to prototype a novel approach to organisational learning that allows an organisation to assess and to monitor the status of processes that often give rise to latent failure conditions in the work environment, and to assess whether and through which mechanisms participation in this approach affects local safety culture. The approach was prototyped in a hospital dispensary using Plan-Do-Study-Act (PDSA) cycles, and the effect on safety culture was described qualitatively through semi-structured interviews. The results suggest that the approach has had a positive effect on the safety culture within the dispensary, and that staff perceive the approach to be useful and usable

Organisational reporting and learning systems : innovating inside and outside of the box

Reporting and learning systems are key organisational tools for the management and prevention of clinical risk. However, current approaches, such as incident reporting, are struggling to meet expectations of turning health systems like the UK National Health Service (NHS) into learning organisations. This article aims to open up debate on the potential for novel reporting and learning systems in healthcare, by reflecting on experiences from two recent projects: Proactive Risk Monitoring in Healthcare (PRIMO) and Errordiary in Healthcare. These two approaches demonstrate how paying attention to ordinary, everyday clinical work can derive useful learning and active discussion about clinical risk. We argue that innovations in reporting and learning systems might come from both inside and outside of the box. ‘Inside’ being along traditional paths of controlled organisational innovation. ‘Outside’ in the sense that inspiration comes outside of the healthcare domain, or more extremely, outside official channels through external websites and social media (e.g. patient forums, public review sites, whistleblower blogs and Twitter streams). Reporting routes that bypass official channels could empower staff and patient activism, and turn out to be a driver to challenge organisational processes, assumptions and priorities where the organisation is failing and has become unresponsive

Participatory system dynamics modelling approach to safe and efficient staffing level management within hospital pharmacies

With increasingly complex safety-critical systems like healthcare being developed and managed, there is a need for a tool that allows us to understand their complexity, design better strategies and guide effective change. System dynamics (SD) has been widely used in modelling across a range of applications from socio-economic to engineering systems, but its potential has not yet been fully realised as a tool for understanding trade-off dynamics between safety and efficiency in healthcare. SD has the potential to provide balanced and trustworthy insights into strategic decision making. Participatory SD modelling and learning is particularly important in healthcare since problems in healthcare are difficult to comprehend due to complexity, involvement of multiple stakeholders in decision making and fragmented structure of delivery systems. Participatory SD modelling triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. It provides decision-makers with an evaluation and learning tool to analyse impacts of changes and determine which input data is most likely to achieve desired outcomes. This thesis aims to examine the feasibility of applying participatory SD modelling approach to safe and efficient staffing level management within hospital pharmacies and to evaluate the utility and usability of participatory SD modelling approach as a learning method. A case study was conducted looking at trade-offs between dispensing backlog (efficiency) and dispensing errors (safety) in a hospital pharmacy dispensary in an English teaching hospital. A participatory modelling approach was employed where the stakeholders from the hospital pharmacy dispensary were engaged in developing an integrated qualitative conceptual model. The model was constructed using focus group sessions with 16 practitioners consisting of labelling and checking practitioners, the literature and hospital pharmacy databases. Based on the conceptual model, a formal quantitative simulation model was then developed using an SD simulation approach, allowing different scenarios and strategies to be identified and tested. Besides the baseline or business as usual scenario, two additional scenarios (hospital winter pressures and various staffing arrangements, interruptions and fatigue) identified by the pharmacist team were simulated and tested using a custom simulation platform (Forio: user-friendly GUI) to enable stakeholders to play out the likely consequences of the intervention scenarios. We carried out focus group-based survey of 21 participants working in the hospital pharmacy dispensaries to evaluate the applicability, utility and usability of how participatory SD enhanced group learning and building of shared vision for problems within the hospital dispensaries. Findings from the simulation illustrate the knock-on impact rework has on dispensing errors, which is often missing from the traditional linear model-based approaches. This potentially downward-spiral knock-on effect makes it more challenging to deal with demand variability, for example, due to hospital winter pressures. The results provide pharmacy management in-depth insights into potential downward-spiral knock-on effects of high workload and potential challenges in dealing with demand variability. Results and simulated scenarios reveal that it is better to have a fixed adequate staff number throughout the day to keep backlog and dispensing errors to a minimum than calling additional staff to combat growing backlog; and that whilst having a significant amount of trainees might be cost efficient, it has a detrimental effect on dispensing errors (safety) as number of rework done to correct the errors increases and contributes to the growing backlog. Finally, capacity depletion initiated by high workload (over 85% of total workload), even in short bursts, has a significant effect on the amount of rework. Evaluative feedback revealed that participatory SD modelling can help support consensus agreement, thus gaining a deeper understanding of the complex interactions in the systems they strive to manage. The model introduced an intervention to pharmacy management by changing their mental models on how hospital winter pressures, various staffing arrangements, interruptions and fatigue affect productivity and safety. Although the outcome of the process is the model as an artefact, we concluded that the main benefit is the significant mental model change on how hospital winter pressures, various staffing arrangements, interruptions and fatigue are interconnected, as derived from participants involvement and their interactions with the GUI scenarios. The research contributes to the advancement of participatory SD modelling approach within healthcare by evaluating its utility and usability as a learning method, which until recently, has been dominated by the linear reductionist approaches. Methodologically, this is one of the few studies to apply participatory SD approach as a modelling tool for understanding trade-offs dynamics between safety and efficiency in healthcare. Practically, this research provides stakeholders and managers, from pharmacists to managers the decision support tools in the form of a GUI-based platform showcasing the integrated conceptual and simulation model for staffing level management in hospital pharmacy

Managing the patient safety risks of bottom-up health information technology innovations : recommendations for healthcare providers

Health information technology (IT) offers exciting opportunities for providing novel services to patients, and for improving the quality and safety of care. However, the introduction of IT can lead to unintended consequences, and create opportunities for failure, which can have significant effects on patient safety. In this paper I argue that many health IT patient safety risks are probably quite predictable, but are often not considered at the time. This puts patients at risk, and it threatens the successful adoption of health IT. I recommend that healthcare providers focus on strengthening their processes for organisational learning, promote proactive risk management strategies, and make risk management decisions transparent and explicit

An organisation without a memory : a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety

Following the Public Enquiry into avoidable deaths and poor standards of care at Mid Staffordshire NHS Foundation Trust, the English National Health Service (NHS) is aiming to become a system devoted to continual learning and improvement of patient care. The paper aims to explore current perceptions of healthcare staff towards reporting and organisational learning for improving patient safety. Based on a Thematic Analysis of semi-structured interviews with 35 healthcare professionals in two NHS organisations, the paper argues that previously identified barriers to incident reporting remain problematic, and that less centralised processes that aim to learn from everyday clinical work might be better suited to generate actionable learning and change in the local work environment. The findings might support healthcare organisations in understanding better the practical processes of organisational learning at the local level. The findings might also support researchers in developing new approaches and strategies for integrating learning about risk at the local level with effective organisational change to improve patient safety