leistikow-proefschrift-patientveiligheid-de-rol-van-de-bestuurder

3 Prescriptive
- How can the results be translated to general strategies that a board can
apply to lead patient safety improvements
Methodology – literature research and case study strategy
This research is composed of three parts: a theoretical part, an empirical
part and a prescriptive part.
- For the theoretical part a literature research has been conducted to build an
hypothesis on how boards could effectively lead patient safety improvements.
- For the empirical part the case study strategy has been used to examine
three cases which were part of the hospital wide patient safety program in
the University Medical Center Utrecht, the Netherlands (UMC Utrecht) in
the period 2003-2006. The strategies used by the board are identified and
their effect is analyzed. Because the direct effect on patient safety could
not be measured, proxy measures were used (e.g. amount of incidents
reported, satisfaction of professionals involved, amount of implemented
recommendations). The outcome of the empirical research is compared to
the outcome of the theoretical research.
- Based on this outcome, the prescriptive part recommends which strategies a
board can use to lead patient safety improvements.
Theory part 1 - The four traits of patient safety
Based on the literature research, four traits have been identified that make it
difficult for a board to lead patient safety improvements: visibility, ambiguity,
diversity and side-effects of professionalism.
Visibility
Unsafety in healthcare often hardly visible. There is almost never a visible
distinction between a patient who has died due to a preventable adverse
event, and any other deceased patient. Even if the problem is recognized on
the individual patient level, the magnitude of the problem can remain
hidden for the healthcare professionals involved. Serious adverse events can
have a major emotional impact, but they will often be seen as a freak occurrence
rather than a daily problem. This low visibility diminishes the opportunities
for learning. It also makes it harder to create a sense of urgency.
Safety thus often loses the battle for attention against more visible problems
Patiëntveiligheid, de rol van de bestuurder 381