Patient safety and empowering the workforce

EVERYONE associated with health care knows there is no pause button, no way of putting on hold the scenarios that unfold each day in hospitals, the community and at home.

For the past 18 months, the COVID-19 pandemic has justifiably drawn attention and resources, but the usual health care needs of our community do not stop. Labour contractions cannot be put off to a more convenient time, an illness following its course needs attention, and an accident victim cannot be turned away.

In recognising the World Health Organization’s World Patient Safety Day on 17 September, on behalf of all Australians, we should salute our 586 000 registered health care practitioners who are fighting on two fronts: addressing the enormous challenge of COVID-19 while also continuing to meet the everyday health care needs of our community.

The theme of this year’s global awareness raising event for patient safety is “Act now for safe and respectful childbirth”. This is not only a very valuable focal point but one that again reminds us that the normal health needs of a community continue during a pandemic. Around the world, the statistics are staggering: 6700 newborns die every day, while 810 women die daily from preventable causes related to pregnancy and childbirth.

In Australia, where more than 300 000 babies were born in 2019, the picture is far better, but even one avoidable death in childbirth of a mother or baby is a tragedy. In the latest figures for Australia, there were 15 maternal deaths in 2018 with the top cause being complications from pre-existing cardiovascular disease.

Here’s another number: 11 million. That’s how many people are admitted to hospital each year in Australia. The safety of these patients and the quality of care they receive through our health system is of paramount importance and has been under the spotlight for decades.

The first widescale review of the quality of care delivered in Australia was published in the MJA in 1995, with this and subsequent research showing around one in ten people experienced some form of harm in the health system, with a proportion of those suffering substantial harm. The figure has remained stubborn ever since, with the Australian Institute of Health and Welfare’s latest figures showing 80 people experienced wholly preventable, significant harm or death from health care in 2017–2018. There’s many more, less serious reportable incidents every year.

Since March 2021, COVID-19 has added another layer of complexity, with the Sydney Morning Herald reporting one in five people who die from COVID-19 caught the virus in hospital and more than 100 people caught the virus in Sydney public hospitals. The risk is there for staff as well, with Professor Raina MacIntyre of University of New South Wales publishing research estimating health care workers are almost three times more likely to contract COVID-19 than the general public.

Despite all this pressure, the health system has proven to be remarkably responsive and resilient. The pivot to telehealth not only enabled patients to maintain a continuity of care when they could no longer visit a hospital or GP, but also opened opportunities for people in rural and remote communities to better access health advice for the first time. Health services are now using telehealth to enable low risk patients with COVID-19 to remain at home, with clinical help only a phone call away.

The cooperation of private hospitals in sharing capacity with public hospitals was a pandemic-induced initiative from which we all benefited and could well do so again. Much is to be gained from a health system that breaks down the financial, administrative, and geographic silos of service and works flexibly to offer care where and when it is needed.

Striving for the safer administration of medication for patients while in hospital is also a global concern that never stops. Significant inroads have been made by the Sydney Children’s Hospitals Network and the Australian Institute of Health Innovation on reducing medication errors through reviews of guidelines and changes to electronic systems. For high risk medications in children’s hospitals, for instance, the introduction of electronic systems was shown to reduce the error rate by nearly 40%.

Meanwhile, there is justifiable concern over the mental health of the Australian community due to lockdowns and uncertainty. The delivery of virtual psychiatric, psychological and counselling services has met some of the need. Services, however, are undoubtedly being stretched, and there will be more pressure to come.

Some would say our modern health system has never faced a more clear and present danger. The ability of not only frontline workers but also administrators and policymakers to see through the complexity of competing threats and opportunities is critical. For more than two decades, prominent researchers such as Professor Trish Greenhalgh in the UK and teams at my own research enterprise, the Australian Institute of Health Innovation, have sought to promote complexity theory as a way of understanding and addressing the multifaceted beauty and beast that is the health system.

They contend that rather than thinking of it as a linear system, where understanding of simple cause and effect logic gets results, we recognise it as a complex adaptive system. Health care comprises multiple human interactions (patients, families, doctors, nurses, cleaners, administrators), layered with situational complexity (intricate cultures, professional dynamics, politics, and other variables), medical complexity (symptoms, testing, diagnosis, management, follow-up) and system complexity (labyrinth-like budgets, policies, procedures).

Navigating all of this with skill and persistence is key. Admittedly, for some, this concept might prove too theoretical. Yet how else did the vaccine roll-out in Australia become so slow and confusing but for the fact that this is a complex adaptive system with many moving parts, and you can’t just command and control the way to success? Despite what was said federally, it always was a race, but one where we need everyone on board – the slow-moving and the fast, the advocates and the naysayers, politicians, regulators, policymakers, managers, clinicians, researchers, modelers, the public, journalists, the hesitant.

For others, this understanding of complexity is what they have always intuitively known: that in order to manage a pandemic, protect patients and deliver high quality care, we must think dynamically. Not in straight lines but in terms of systems subtleties, feedback, emergence and relationships.

In order to introduce a new intervention to a setting, effort must be made to understand and engage with people and circumstances at the local level. Recent work with the Australian Genomics Health Alliance to guide new evidence into practice to support families, for example, has shown that understanding the social dynamics of teams is invaluable in implementing new care processes. The research found that interdisciplinary teams of clinical specialists, laboratory scientists, genetic specialists and counsellors, learning from each other, and from practitioners they admired, was pivotal in taking up clinical genomics into routine health care.

So, individuals in all corners of the health system must be treated as part of a multifaceted solution to problems, and be empowered to make improvements – not by telling them what to do, with detailed prescriptions. Hierarchies that are too dogmatic can hinder progress – and time and again research has shown that where senior management supports staff to own patient safety practices, higher quality care results. Working with, not against, the natural properties of health care – its networks, cultures, professional mores, and dynamics – takes longer than just insisting everyone on the front lines conform to instructions, but it’s a much better model for teaching the system how to learn. We’ll need that to get through this pandemic, and the next one.

In the end, the not-so-secret ingredient for a better health system, safer care for mothers and babies, and everyone else is promoting a culture of collaboration, not a culture of compliance; motivating those on the front lines and enabling them to be the best they can be. World Patient Safety Day brings a timely reminder to support our nation’s clinicians like never before.

Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation and Professor of Health Systems Research at Macquarie University. Professor Braithwaite is President of the International Society for Quality in Health Care.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.