Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...
Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ... Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...
- Root Cause Analysis (RCA), a method for incident analysis;- Healthcare Failure Mode and Effect Analysis (HFMEA), a method forproactive analysis of healthcare processes.From diverse sources data was collected showing that the interventions hadan effect on the organization. The effect can be summarized as follows:- The visibility of the targeted problem has increased;Safety awareness increased on both individual and organizational level.Employees were better able to recognize safety problems and more willingto share this information. This could be seen in the RCA and HFMEAreports and the threefold increase in incidents reported in the first fouryears of the interventions.- Ways have been found to handle the ambiguity of the problem;Ambiguity was accepted as a given and ways were explored to cope withthis. Examples are: dropping the discussion about the difference between“adverse event” and “complication”, the fact that RCA teams were able toidentify root causes and suggest ways to prevent recurrence of similaradverse events, the fact that multidisciplinary teams were able so completeHFMEA’s.- The diversity of the problem became less problematic;Ways have been found to handle the immense diversity of safety issues.Examples are: the use of a hazard matrix to help choose which adverseevents should be investigated, the fact that management was able to chooseone healthcare process per division to analyze with HFMEA, the fact thatHFMEA teams were able to choose which failure modes they found relevant.- Negative side effects of professionalism were diminished.As professionals became more engaged in the interventions, they becamemore aware of interdependencies. This led to a better understanding ofothers’ perspectives on safety issues and others’ possibilities and limitationsfor improving the safety. This was seen in the multidisciplinaryteams of RCA, HFMEA and the central incident reporting committee. Anexample of the result is that most recommendations done by RCA andHFMEA teams were implemented. This shows that the teams of professionalswere able to make recommendations that were also acceptable formanagers.Patiëntveiligheid, de rol van de bestuurder 385
Safety issues became more visible and at the same time a system of continuouslearning and improvement evolved. In the three cases the professionalsprovided the subject-matter expertise whilst the board played an initiatingand supporting role. This led to professionals becoming problem-owner andto improvement recommendations that could be implemented with little orno board level pressure. An example is that from the first 8 HFMEA reports,85% of the 96 recommendations were implemented whilst there was nocontrol al all by the board. Five years later, 66% of these were still in effect,showing the sustainability of the recommendations. The RCA’s and HFMEA’salone led to over 120 safety improvement, implemented in first two years.The analysis – strategies usedThe empirical findings largely confirm the hypothesis that was based on thetheory. Two strategies were used that had not been found in the literature:appeal and support. These form an addition to the existing theoreticalframework on process management. The empirical findings show that thefollowing strategies were used for process management:- Openness: everybody was able to provide input;- Safety: each participant’s core values were protected;- Momentum: the process kept its momentum;- Ratio: the outcome was rational;- Appeal: the subject appealed to the healthcare professionals;- Support: there was enough support so professionals could focus oncontent.These six strategies are strongly related to each other. Each strategy leads to acounterforce which is subsequently mitigated by the next strategy. Opennessleads to unpredictability because anybody can influence the agenda. This canmake it unsafe to participate, because participation might lead to an unfavorableoutcome. Therefore participation must be safe. But if each participant’score values are protected but the values are opposed to each other, theprocess is prone to grind to a halt. Pressure is essential to keep momentum.Too much pressure can however lead to the process falling apart or endingin a meaningless or senseless outcome. Therefore, strategies must be used tomake sure the outcome is rational. Even if this is done right, it still does notguarantee that professionals will be willing to invest time in the process. Forthis they must be intrinsically motivated, it must be appealing to them toengage. Participating costs time and this can be a reason for professionals tohold back. Therefore there must be ample support (e.g. planning, maintain-386summary
- Page 335 and 336: 4 BeschouwingInleidingIn de vorige
- Page 337 and 338: ken die aan onveiligheid bijdroegen
- Page 339 and 340: Nuancering van de rol van processtu
- Page 341 and 342: de uitkomsten van dit onderzoek gen
- Page 343 and 344: • In dit onderzoek is gebleken da
- Page 346 and 347: Appendix AReferentiesSamenvattingSu
- Page 348 and 349: 1. Inleiding1.1 Voorgeschiedenis st
- Page 350 and 351: instellen van een Kerncommissie Pat
- Page 352 and 353: 2.4 UitwerkingEr moet één centraa
- Page 354 and 355: - Patiënten Service/ klachtenburea
- Page 356 and 357: Haar taken zijn:1 Het gevraagd en o
- Page 358 and 359: maatschappij kunnen behouden zonder
- Page 360 and 361: 6 Samenstelling Kerncommissie Pati
- Page 362 and 363: - Billings CE. The NASA Aviation Sa
- Page 364 and 365: - Evans RG, Cardiff K, Sheps S. Hig
- Page 366 and 367: - Linkin DR, Sausman C, Santos L, L
- Page 368 and 369: - Stolper E, van Bokhoven M, Houben
- Page 370 and 371: - Zwart DLM, van Rensen ELJ, Verhei
- Page 372 and 373: 3 Prescriptief- Hoe kunnen de uitko
- Page 374 and 375: en dus veilige, zorg te organiseren
- Page 376 and 377: Elke casus bestond uit een aantal o
- Page 378 and 379: ling op de bestaande theorie over p
- Page 380 and 381: - Inbreng;(alle betrokkenen moeten
- Page 382 and 383: 3 Prescriptive- How can the results
- Page 384 and 385: Side-effects of professionalismThe
- Page 388 and 389: ing networks, writing reports) so t
- Page 390 and 391: Dankwoord- Allereerst wil ik mij pr
- Page 392 and 393: - De levenshouding die ertoe geleid
- Page 394 and 395: PublicatielijstPublicaties - boeken
- Page 396: Patiëntveiligheid, de rol van de b
- Root Cause Analysis (RCA), a method for inci<strong>de</strong>nt analysis;- Healthcare Failure Mo<strong>de</strong> and Effect Analysis (HFMEA), a method forproactive analysis of healthcare processes.From diverse sources data was collected showing that the interventions hadan effect on the organization. The effect can be summarized as follows:- The visibility of the targeted problem has increased;Safety awareness increased on both individual and organizational level.Employees were better able to recognize safety problems and more willingto share this information. This could be seen in the RCA and HFMEAreports and the threefold increase in inci<strong>de</strong>nts reported in the first fouryears of the interventions.- Ways have been found to handle the ambiguity of the problem;Ambiguity was accepted as a given and ways were explored to cope withthis. Examples are: dropping the discussion about the difference between“adverse event” and “complication”, the fact that RCA teams were able toi<strong>de</strong>ntify root causes and suggest ways to prevent recurrence of similaradverse events, the fact that multidisciplinary teams were able so completeHFMEA’s.- The diversity of the problem became less problematic;Ways have been found to handle the immense diversity of safety issues.Examples are: the use of a hazard matrix to help choose which adverseevents should be investigated, the fact that management was able to chooseone healthcare process per division to analyze with HFMEA, the fact thatHFMEA teams were able to choose which failure mo<strong>de</strong>s they found rele<strong>van</strong>t.- Negative si<strong>de</strong> effects of professionalism were diminished.As professionals became more engaged in the interventions, they becamemore aware of inter<strong>de</strong>pen<strong>de</strong>ncies. This led to a better un<strong>de</strong>rstanding ofothers’ perspectives on safety issues and others’ possibilities and limitationsfor improving the safety. This was seen in the multidisciplinaryteams of RCA, HFMEA and the central inci<strong>de</strong>nt reporting committee. Anexample of the result is that most recommendations done by RCA andHFMEA teams were implemented. This shows that the teams of professionalswere able to make recommendations that were also acceptable formanagers.Patiëntveiligheid, <strong>de</strong> <strong>rol</strong> <strong>van</strong> <strong>de</strong> bestuur<strong>de</strong>r 385
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