Patient safety is one of the biggest healthcare problems today (106). There are international data indicating that clinicians have poor compliance with evidence-based guidelines where consistent use of these guidelines increases quality and patient safety. The current situation is that only approximately 50%
of patients receive recommended therapies (107). Translating evidence into clinical practice has been challenging. Now there has been developed an explicit model for a collaborative transition of knowledge into practice (108). A flowchart of this method has been illustrated in appendix 7.
We know that the explanation of physicians’ behavior and their poor guideline compliance is not an easy task. This may be the reason why there have been developed approximately 13 different current explanation models. However, there are many other barriers than the behavior of the clinicians and their compliance to the guidelines. Generally, barriers or factors to guideline compliance may be divided into four categories namely clinician -, system -, guideline -, and implementation factors (107). System factors (like non-compliance) are the crucial variables in occurrence of errors and accidents.
System may be defined as the sum of the structure, process, and culture in the unit. The important system factors include task factors (e.g. availability of protocols and test results), team factors (e.g. care -, crisis – and hand-over communication, seeking help, supervision, team structure and leadership), environment (e.g. physical environment, staffing levels, work load, skills mix, administrative and managerial support, availability and maintenance of equipment), and organizational factors (e.g. the culture of unit, communication, teamwork) (107;109). With this background it would be predictable that uni-factorial interventions like education alone might not be the solution of compliance with evidence-based guidelines and there is a need for multi-factorial interventions (107).
These multi-factorial interventions should first of all eliminate the preventable harm resulting from failure to standardizing care and failure to use evidence-based guidelines. Accordingly, professionalism should be strengthened meaning that evidence should be translated into practice (108) and should be implemented. There certainly would be barriers to implementation of evidence
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where necessitating the use of a systematic and practical tool to identify and eliminate them. Professor Pronovost has described one such a tool called
“Barriers Identification and Mitigation (BIM) Tool” (110) (appendix 8). It should be stressed that a tool like BIM would operate most optimally in the context of a larger and more extensive patient safety program like “Comprehensive Unit-Based Safety Program (CUSP)” (111). There exists also a web-based version of CUSP (112). The use of checklists is of paramount importance for securing the process of translation of evidence to practice as well as its implementation (113;114). In fact the use of checklist was one of the main pillars in the developing CUSP (111).
Culture is of central importance for any comprehensive patient safety initiative to be successful. Changing the culture and instituting a new culture of patient safety, not only in the front line institutions like university hospitals but also across the whole healthcare system and at the patient and practitioner level, is a demanding process. A survey of current culture in the unit should be the first step in the course of changing the culture towards a culture of patient safety.
For this reason there have been developed culture survey questionnaires with approved validity and reliability (115)
(http://www.ahrq.gov/qual/patientsafetyculture/hospscanform.pdf).
The survey of current culture should preferably be incorporated in a more comprehensive patient safety program, like CUSP. In fact the first step in CUSP is performing a culture survey. In other words, CUSP safeguards the right approach to both culture and professionalism in a patient safety initiative.
“The Agency for Healthcare Research and Quality (AHRQ) announced in October 2009 that a program called the Comprehensive Unit-based Safety Program (CUSP), which successfully reduced central line-associated blood stream infections in intensive care units, will expand to all 50 States and additional hospitals in States already participating in the CUSP, extend to other settings in addition to intensive care units, and broaden its focus to address other types of health care-associated infections”.
(http://www.ahrq.gov/qual/haicusp.htm) (www.patientsafetygroup.org/program/index.cfm)
A flowchart of CUSP has been demonstrated in appendix 9 to facilitate the understanding of the steps involved in the program.
Expectedly, dysfunctional systems, sometimes created by non-competent providers or administrators, make it difficult to act correctly.
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System thinking, however, combined with the notion that “most errors are committed by good, hardworking people trying to do the right thing” has built the platform for “no blame” culture. Now, this culture has begun to be questioned and the need for accountability for failure is gaining some grounds.
The need for a “just culture” which differentiates blameworthy from blameless acts has been declared (116).
Promoting quality and patient safety in general may necessitate the implementation of a global, versatile, and comprehensive system, much alike that of clinical governance from NHS. Moreover, the measures for promoting patient safety may be divided in two categories; measures at the unit level and measures at national level. At the unit level (micro-level) there is a need for strengthening professionalism as described earlier in this section. In brief, we need to implement more specific programs for translation and implementation of evidence, for identification and mitigation of evidence implementation barriers (like BIM), and for comprehensive patient safety initiatives (like CUSP initially developed for ICUs). Regarding the national level, first it should be stressed that we in the western countries suffer from insufficient training in quality and patient safety depending to our collective failure to comprehend the delivery of health care as a science (117;118). Hence, long term measures in national level should include investigation in the science of quality and patient safety, revising the quality and safety governance in our hospitals, and integrating the roles within the hospitals and medical faculties (117). Short term measures in national level may first include system approaches (like for instance accreditation of hospitals, departments, and units), and then a practitioner approach (like obligatory revalidation). The profession, authorities, and the public should cooperate regarding the type, extend, and comprehensiveness of revalidation (CME/ CPD, Peer review, or both), as well as its financing, organizational forms, and involved penalties or rewards.
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