Improving safety and quality: how can education help?

A consistent theme in publications on quality and safety is the importance of clear, accurate and timely communication among clinicians, patients, carers and management. The link between mistakes and inadequate communication (ie, inadequate, wrong or no communication) is firmly established.17-19 Treatment outcomes are also influenced by how well clinicians communicate with their patients and other health care workers.20-22 How do doctors engage with their patients? What is the best way to convey risk information? What steps must a doctor take to provide complete information after adverse events? How do doctors show respect for cultural differences? A competent doctor would demonstrate these competencies relative to their level of knowledge and experience.

Teaching communication skills is now firmly embedded within undergraduate programs, but a greater challenge is learning how to communicate in complex environments where multiple people are involved in the care of each patient. Simulator centres are used for training and assessment of team communication in emergency scenarios. However, there has been little attention to less acute settings, although regional general practitioner training programs are beginning to address these issues in primary care.

Adverse events occur across the health system. Most health organisations have, or are implementing, methods for reporting and analysing serious adverse events.23 Doctors need to recognise errors and system failures, understand the underlying factors, and know how to make the necessary improvements to prevent them recurring. The common use of the word “stuff-up” to describe a mistake or error suggests inadequate preparation and knowledge, and an inappropriate focus on the individual rather than the system. Research shows that an understanding of the nature of errors and application of quality improvement concepts reduces errors, waste and inefficiency.24,25

The constantly changing clinical environment requires doctors to regularly update their knowledge and skills. They can no longer rely on prior learning;26 they need to know how to formulate relevant clinical questions, how to efficiently find the best evidence, and how to incorporate the findings into practice.27 Many medical courses have addressed the need for graduates to have the skills required for evidence-based decision-making and lifelong learning.

Health informatics refers to the systematic application of computer science and technology to health practice, health care services, research and education.28 Evidence suggests that routine use of information and communication technology improves patient care.29 However, many clinicians are unaware of the developments in informatics and their potential role in patient safety. Come the genomic era, doctors will require skills and knowledge about new technologies and computer-generated tests, such as genetic testing. They will be expected to understand clinical informatics and how IT can reduce errors in the workplace. They will use IT tools to measure performance and to identify, access and interpret online health-related information and data.

Another common theme in quality and safety publications is the role of the multidisciplinary team in improving quality and continuity of care. Communicating accurate information in a timely way to the right people can be complex and difficult because of the spread of clinical responsibility among members of the health care team.19,30 Hospital doctors may identify others within the hospital-based medical team but may be less familiar with other teams responsible for patients, such as GP- and community-based teams. Effective health care teams communicate with one another and combine their observations, expertise and decision-making to optimise patient care.1

Effective teamwork is known to reduce errors caused by miscommunication, poor handover, and delayed diagnosis and treatment, particularly for those with a chronic illness.31-33 Yet, the role of effective teamwork in reducing risks and improving continuity of care may not be readily appreciated by clinicians, as they are trained to accept individual responsibility. Nor is the role of human factors in reducing errors fully understood; otherwise, checklists and use of protocols would be the rule rather than the exception. Junior doctors are particularly vulnerable to errors during handover on rostered nights and over weekends, yet no particular training occurs to improve patient safety. The State Postgraduate Medical Councils have collaborated on producing a national curriculum for pre-vocational training, which includes safety and quality as a learning area, and will be available for consultation later this year. Knowledge about organisational complexity and the different professional and organisational cultures is critical for understanding the influence of the environment and poorly designed systems on quality of care. This, too, is poorly understood; otherwise, multidisciplinary morbidity and mortality meetings, handovers and clinical review meetings would be common. They are not.

Medical ethics, clinical ethics and ethical practice are now receiving greater attention in education and training because of the increased use of technology, the range of care and treatment options, and greater demands for accountability by the public and professional registration authorities. State Medical Boards, the Colleges and accrediting bodies, such as the Australian Medical Council, stress the importance of professionalism and its role in maintaining community trust. The NPSF identifies ethical and professional practice as a key area in patient safety. Reason argues that a systems approach to error management necessarily incorporates strong professional regulation.34 The perceived contest between individuals and bad systems as the cause of patient injuries temporarily confused many clinicians and managers, but individuals have always remained accountable when they act unprofessionally.

Two learning topics describe the competencies for clinicians in relation to “fitness to practise” and “professional and ethical behaviour”. Junior doctors, for example, are expected to practise at the standards required by their medical registration board and set by their professional body. They would be expected to know how to report unsafe, incompetent and unethical coworkers and unsafe work situations, and know how to maintain their knowledge and skills. They would also provide a good standard of service, work within their knowledge limits, keep up-to-date with laws and regulations, willingly consult coworkers, participate in clinical audits, and delegate and report appropriately.

Professionalism is now a priority standard for most health professions. The term covers the attitudes and behaviours that promote and maintain the patient’s best interests above and beyond all other considerations. An ethical health professional (irrespective of their position) would put patients’ interests above their own, avoid harm, respect patient autonomy, maintain competence, and work and practise within the bounds of their knowledge and experience.

Health registration boards, health departments, hospitals and other health services are increasingly providing guidance to clinicians on the importance of professionalism. Most Australian medical faculties have professionalism as a key teaching and learning domain, with innovative approaches to assessment, including peer feedback and reflective portfolios.

Teaching is a long recognised responsibility of clinicians, but the infrastructure to support clinician teaching is inadequate. Passing on skills and knowledge to the next generation was once relatively easy, with greater patient access and time for small-group tutorials, but today clinicians are finding teaching difficult. Many have received little training in educational methods, and their teaching activities are often an add-on to other duties. New innovative methods, such as ambulatory teaching clinics, are urgently required to support clinical teaching.

The organisation of health services and high workload in hospitals and private practice, coupled with rapid changes to health information, make it impossible for individuals to keep up-to-date using the traditional methods of reading journals or attending lectures and conferences. New competencies in workplace learning are required. Working in health care is a lifelong journey that requires the application of self-directed learning, self-monitoring and self-assessment techniques, coupled with peer validation.