Quality and Safety From Evolution to Revolution

Abstract

In order to improve safety, the organization of care is evolving from safety models centered on the individual, towards “systemic” models such as the “Swiss cheese” model developed by James Reason. I will describe how the University Hospitals of Geneva (HUG) have integrated such a model and has set up an incident reporting system. The use that can be made of such a system will then be illustrated by several case analyses, which include improvement strategies. To speak of errors invariably raises the question of disciplinary measures. Should one aim for a “Blame Free Culture” or adopt the concept of a “Just Culture”. To help managers develop a “Just Culture” and determine which errors deserve disciplinary measures, I will present the “incident decision tree”. Finally, I will explore the importance of human factors on safety through various research projects. One must not lose sight however, of the fact that safety is only one of the six dimensions of quality. The others, effectiveness, efficiency, patient-centeredness, timeliness and equity are equally important. Processes play a pivoting role in enabling one to juggle these different dimensions and thus provide optimal care. To master such processes one can look to the industry for concepts and tools. I will examine how these can be applied to reduce unjustified variability by for example developing clinical pathways. Strategies implemented to improve all aspects of health care quality are also evolving from an individual approach (centered on a practitioner or a hospital) to a more systemic one. The new challenges today are to decompartmentalize, to share expertise among the different actors (physicians, hospitals, insurance companies), to pool information vital for coordinating professionals and evaluating processes and to develop new regulation models between health care providers. The ultimate goal is not to provide more care, but care of higher value. That is why we can speak of a revolution and not merely an evolution