High Reliability Healthcare

16 October 2009

Patient Safety Events - a Global Problem:

10% of hospital patients suffer an adverse event each year (UK, New Zealand, Canada and Europe)16.6% of hospital patients suffer an adverse event (Australian study)1.4 million hospital patients worldwide acquire Healthcare Associated Infections (HAI) 100,000 cases of HAI lead to 5,000 deaths a year (UK)1 out of every 135 hospital patients acquires HAI (USA) 98,000 hospital deaths every year through medical error (USA)

High Reliability Healthcare

Systems

Safe, high quality care

Provider Market

Evidence Based

Practice

Governance

Regulatory

Framework Political Legislative

Commissioning for Quality

Insurers

Service

Users, Public

Key Levers and Drivers

Key Ingredients

Person-centred careOpen and transparent learning cultureStrong leadership, governance, accountability, management and team workingClinicians in executive management Fit for purpose workforceEffective information management and measurementInformed decision-makingRobust quality assurance – internal and external

“Systems and processes are only as good as the people

who work within them”

COMMUNICATIONS

LEADERSHIP

MULTI-DISCIPLINARY TEAM WORKING

BEHAVIOURS

CULTURE

RELATIONSHIPS

Open and Transparent Culture…

“…as soon as we knew we’d made the mistake we met with the family and told them”

“…telling relatives – well you see, we don’t do that here it’s not in our culture”

“…I thought I’d made myself clear, I don’t speak to patients, I have people who do that for me”

A culture and ethos of professionalism, courage,

openness, informed decision-making, effectiveness,

efficiency, learning, innovation and knowledge.

High Reliability Culture

Leadership

“Us, doing the right thing”

If we are ever in doubt about what to do, it is a good rule to ask ourselves what we shall wish on the morrow that we

had done. 

John Lubbock