Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...

3 Prescriptive- How can the results be translated to general strategies that a board canapply to lead patient safety improvements?Methodology – literature research and case study strategyThis research is composed of three parts: a theoretical part, an empiricalpart and a prescriptive part.- For the theoretical part a literature research has been conducted to build anhypothesis on how boards could effectively lead patient safety improvements.- For the empirical part the case study strategy has been used to examinethree cases which were part of the hospital wide patient safety program inthe University Medical Center Utrecht, the Netherlands (UMC Utrecht) inthe period 2003-2006. The strategies used by the board are identified andtheir effect is analyzed. Because the direct effect on patient safety couldnot be measured, proxy measures were used (e.g. amount of incidentsreported, satisfaction of professionals involved, amount of implementedrecommendations). The outcome of the empirical research is compared tothe outcome of the theoretical research.- Based on this outcome, the prescriptive part recommends which strategies aboard can use to lead patient safety improvements.Theory part 1 - The four traits of patient safetyBased on the literature research, four traits have been identified that make itdifficult for a board to lead patient safety improvements: visibility, ambiguity,diversity and side-effects of professionalism.VisibilityUnsafety in healthcare often hardly visible. There is almost never a visibledistinction between a patient who has died due to a preventable adverseevent, and any other deceased patient. Even if the problem is recognized onthe individual patient level, the magnitude of the problem can remainhidden for the healthcare professionals involved. Serious adverse events canhave a major emotional impact, but they will often be seen as a freak occurrencerather than a daily problem. This low visibility diminishes the opportunitiesfor learning. It also makes it harder to create a sense of urgency.Safety thus often loses the battle for attention against more visible problemsPatiëntveiligheid, de rol van de bestuurder 381