QUALITY MANAGEMENT VERSUS A WHOLE-SYSTEMS MANAGEMENT APPROACH

Quality management operates within an existing paradigm that can be learned and applied as an independent set of tools and methods. It is an approach in which care providers analyze the elements or parts of a problem or situation to gain a better understanding of it. Alternately, a systems approach considers learning through an understanding of the whole—the parts themselves and the interaction of the parts. Moving forward with the Institute of Medicine (IOM) recommendations related to error prevention in health care will require a whole-systems approach. That is an approach that seeks to understand the parts and their interactions as well as the broader context in which they are embedded, including the expectations, assumptions, habits, behaviors, history, and traditions that influenced a situation. A better understanding of the whole is a prerequisite for intelligent leadership and reliable results in today’s health care organizations.

SENTINEL EVENTS AND THE PATIENT SAFETY MOVEMENT

Sentinel events are any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious, adverse outcome. The events are called sentinel because they signal the need for immediate investigation and response (Speelman, 2001). In 1998, The Joint Commission on the Accreditation of Healthcare Organizations implemented standards and recommendations related to identifying, reporting, analyzing, and presenting sentinel events that had become more commonly reported in health care organizations throughout the country. These recommendations, however, fell short of expectations, and these unfulfilled expectations provided a segue to the patient safety movement.

The patient safety movement, while clearly visible, is still in its infancy. Many hospitals continue to punish care providers for the errors they make, and regulatory bodies are seen as searching for villains and punishing those who get caught. Meanwhile, the focus of many health care leaders has been on acquisitions, mergers, reimbursement, and revenue, rather than on the core focus of patient care. The patient safety movement will not progress until health care leaders move away from traditional models of management that focus almost exclusively on the bottom line to a multidimensional approach that focuses on other dimensions of organizational fitness—that is, the normative, strategic, and operational aspects of the organization (Schwaninger, 2000).

ORGANIZATIONAL USE OF TERCAP®

The Practice Breakdown Advisory Panel (PBAP) developed and used the Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP) audit (introduced in Chapter 1) as one method in a study of practice breakdown in multiple health care settings. The goal of this research (Scott, 2004) was to study selected error-events and identify the multiple individual, team, system, and cultural contributors to the practice breakdown that resulted in harm to a patient. It was asserted that an enhanced analysis would result within the context of a comprehensive framework by incorporating TERCAP into the root cause analysis and investigative process. Data collection included systematic root cause analysis findings and data obtained from medical records, staffing schedules, and physician and employee interviews. TERCAP proved to be a very useful data collection instrument for organizing and analyzing the data.

The purpose of this chapter is to examine the findings from one typical error-event that occurred in a hospital setting. The failure of this event was that a postsurgical patient’s care was inadequately monitored, and this failure resulted in significant harm to the patient. Not surprisingly, findings revealed that harmful patient care errors resulted from multiple failures by many people working in complex systems while carrying out routines of daily practice.

The researcher collected specific information about an error-event that included data from the root cause analysis process and from interviews with individuals who were directly and indirectly involved. The error-event is described in detail to assist readers in gaining a comprehensive multifaceted overview of the case through a whole-systems approach that is rich with information and carries implications for professional education and training, system design, and cultural transformation.