Quality and safety while enhancing rights and respecting risk

CHAPTER 8 Quality and safety while enhancing rights and respecting risk



Joseph Ibrahim, Susan Koch, Anne Holland, Linsey Howie



FRAMEWORK


The dilemma that arises from taking risks and protection from harm is addressed well in this chapter. The governance issue is further discussed in Chapter 20 but the relationship to risk management cannot be over-emphasised. The scenario in the vignette takes the risk management approach across all sectors of health care and raises many issues for the care of older people. Evidence-based practice can alleviate some of the decision-making dilemma posed as staff try to do what is considered safe and right for the client. The nature of chronic or acute disruptions to health experienced by older people often makes their contribution to decision making difficult for staff to understand. How people live with and manage their health problems is often very different from what the professional provider thinks should be the case. Depression and/or dementia also changes the way in which people make decisions. Managing risks in aged care is a complex matter and one in which quality outcomes are difficult to measure. [RN, SG]



Introduction


Improving the quality of care is an important priority for all health and aged care services and changes required to achieving better care are being actively addressed. However, improving quality and safety while enhancing rights and respecting risk of an individual is a much more complex challenge. To meet this challenge requires understanding the theoretical concepts and constructs of quality, evidence-based practice (EBP), risk, rights, and balancing the needs and wants of the individual with those of the community.


This chapter begins with a vignette that follows an older person’s experiences as an individual citizen, an acute hospital patient, a community service client, and resident in an aged care facility. The second section addresses the basic concepts and constructs of quality, risk, rights and EBP. The third and fourth sections explore, respectively, the approach to these ideas in acute health care and the other care settings in which the older person receives health care.


The vignette provides a practical framework that assists in understanding the theoretical concepts and how these may apply in practice. The reader is asked to reflect on the vignette throughout the chapter.



VIGNETTE



Individual citizen


Mr M is a 75-year-old male with a medical history of Parkinson’s disease, osteoporosis, diabetes mellitus and incontinence of urine. He lives alone in a ground floor unit but his daughter lives close by and visits on most days. Mr M pays for additional services to assist with cleaning and receives one meal delivered each day. He is an enthusiastic rose gardener and is well known for growing vegetables that he gives to family and neighbours.


After a number of falls at home, his general practitioner (GP) organises an assessment by a specialist in geriatric medicine. The geriatrician explains the falls are related to a combination of factors and recommends wearing hip protectors at all times to prevent a serious injury.


Mr M wore the hip protectors for only one week after he purchased the items. He explained this to the GP when he next attended for a routine check-up.



Inpatient acute hospital care


Several weeks later, on a Sunday, Mr M’s daughter finds him in a state of confusion and disorientation. A visit to the hospital emergency department leads to an admission to the hospital ward for treatment of a urinary tract infection with antibiotics.


Assessment on the medical ward determines that Mr M is at a high falls risk. Whilst in hospital, a multi-faceted falls prevention plan is documented and implemented. This included the wearing of hip protectors.


Mr M’s daughter tells the nursing staff that the hip protectors are at home; that her father did not currently use them because they are uncomfortable and made it difficult to go to the toilet, especially when he was in a hurry. The staff explained they would assist with the hip protectors during the hospital stay and that the confusional state increased the risk of falls.


The hospital insisted and ensured Mr M wore the hip protectors during the stay in hospital.



Community care


After several days, Mr M’s confusion resolved and he was deemed ready for discharge home. His daughter expressed concern about his ability to cope at home, particularly with his reduced mobility and self-care. The multidisciplinary team agreed that he was at risk and a package of community supports was put in place, including personal care, continence nurse, physiotherapy and assistance with transport.


When the community-based nurse and physiotherapist visited Mr M at home, his daughter was present. Mr M still had an unsteady gait even with a walking aid and was unable to negotiate the two steps to his unit without significant assistance.


The discharge summary from the hospital did not mention the need for hip protectors but his daughter asked the community clinical team whether he should be wearing these at home. The physiotherapist agreed this should occur and would ask the personal carer to assist.


Mr M agreed to wear the hip protectors to allay the concerns of his daughter. However, he only wore them on the two days of the week that the personal carer attended.



Residential care


Mr M’s mobility did not recover to his pre-morbid level. The frequency of falls increased over the following months and these resulted in a number of hospital attendances for minor injuries. Eventually his daughter and the GP with the community clinical team agreed that a move to a residential aged care facility (RACF) would be appropriate.


At the time Mr M entered the RACF, their policies included respecting the rights of the individual residents, adherence to health care recommendations, promoting quality improvement, and the reduction of preventable harm.


Falls were identified as a major source of preventable harm and there was an organisation-wide campaign to promote the use of hip protectors. This was supported by the board of management at the facility who had recently resolved a medico–legal dispute following the death of another resident from a fall.


Mr M reiterated his preferences and did not agree to wear the hip protectors.



Research evidence: hip protectors


Although early studies indicated that hip protectors were a very effective strategy for preventing fractures in older people, more recent evidence is less conclusive.


Hip protectors result in a small but significant reduction in the incidence of hip fractures in RACFs (relative risk 0.77, 95% confidence interval 0.62–0.97). However they appear to have no beneficial effects for older people who are living in the community (Parker et al 2005). The usefulness of hip protectors in hospital settings is unclear. Multifaceted falls prevention strategies in hospitals, which may include wearing hip protectors, result in a reduced rate of falls (relative risk 0.82, 0.68–0.997). However, there is no effect on fracture rate (Oliver et al 2007).



image How do we balance risks and rights?


All studies report that acceptance and adherence to hip protectors is poor. It is common for 30% of eligible people to decline to participate in hip protector studies, whilst adherence is often as low as 30% by the end of the trial (Parker et al 2005).


The main reasons given for poor adherence are discomfort, poor fit and skin irritation. In residential care it appears that those with a history of falls and those who are more physically dependent demonstrate greater adherence (Cryer et al 2008; O’Halloran et al 2007). Males and those with lower limb arthritis are less likely to be adherent (Cryer 2008; Hayes et al 2008).


Given the modest benefits of hip protectors and the variations in outcome across settings, an approach to the prescription of hip protectors that balances risk and autonomy may be required.



Quality, rights, risk and evidence-based care


What is our initial response to the care Mr M received in the different settings?


How do we judge the quality of care? Is it according to the level of adherence to EBP, the management of rights and risks, or the balance of all factors?


Does our judgment alter if:


• As an ‘individual citizen’ Mr M falls and fractures his hip at home prior to any medical intervention?

• As an ‘individual citizen’ Mr M falls and fractures his hip at home after the geriatrician’s recommendation and the GP is told that he stopped wearing the hip protector?

• As an ‘inpatient acute hospital care’, Mr M falls and fractures his hip in hospital after being assessed as high risk and hip protectors are not worn because the hospital does not supply the equipment?

• As ‘a client of community care’, Mr M falls and fractures his hip at home and is not wearing the hip protectors because the personal carer did not attend that day?

• As a ‘resident of an aged care facility’’ Mr M is assessed as high risk and the facility staff comply with his request to decline to wear hip protectors — he subsequently falls, fractures his hip and dies?


Quality


The definition of quality is central to addressing these situations and is often taken for granted because it is a word used every day and confusion arises because we do not provide an explicit statement to achieve a common understanding.


‘Quality’ is defined in the Oxford English Dictionary (Sykes 1982) as ‘the degree of excellence’. A more explicit definition that can be used to measure performance requires specifying to whom and how the word is used.


The first step is to separate and recognise the differences between the ‘quality of health care’ and ‘quality of life care’. Arguably this is an artificial distinction because our health and our way of life are intertwined and interwoven. However, a clear definition and separation of the two concepts is necessary if we are to understand why rational professionals who are committed to EBP will deliver seemingly contradictory approaches to two individuals with the same disease.



image A clear definition of quality is necessary if we are to understand why rational professionals who are committed to EBP will deliver seemingly contradictory approaches to two individuals with the same disease.


The quality of life care is a concept that is typically applied to the individual — that is, the patient or resident — whilst the quality of health care is a concept that applies to the health care providers or organisation. The quality of health care provided does not necessarily equate to or ensure a particular quality of life.


The World Health Organization (1946) defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.


The Institute of Medicine (Lohr et al 1991) defines health care quality as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’.


Defining the ‘quality of life’ is complex and incorporates mental and physical health and wellbeing as well as social and environmental aspects.


However, what we want to know is: how do we measure the quality of health care in the different clinical settings (i.e., acute, community and residential care) and what is the impact of care on health and quality of life?


Understanding the difference in health, quality, health care quality and quality of life are important if we are to successfully integrate respecting rights of an individual with risk management in an organisation.



Rights


Rights are basically a set of entitlements (e.g., legal, social, financial, health) that may apply to the individual or community. The nature of entitlements may vary between communities and alter with the passage of time. In this chapter we consider the term to refer to fair, just treatment and this includes the individual’s entitlement to determine how they choose to live their life.


One of the key principles when we seek to respect the rights of an individual is our responsibility to ascertain that the individual has the capacity to make a decision. This requires an individual to understand the nature of the risk, the potential consequences, and alternative options available to them. An informed choice becomes possible if these conditions are met.


Although the rights of the individual are important, there is always a tension between respecting the rights of the individual and the rights of a collective. We can reflect on the vignette and ask, ‘Who has rights?’. Most people would automatically consider the rights of Mr M as the recipient of care to be paramount. The others to consider are the organisations and staff providing the care, as well as those who live in the broader community who may be directly or indirectly impacted by Mr M’s decisions.



image There is always a tension between respecting the rights of the individual and the rights of a collective.


The rights of the hospital, community care program and RACF to enforce or withhold care usually only come into sharp focus when an individual has an adverse outcome.


For example, if Mr M falls and fractures his hip in hospital and was not supplied with the hip protectors, is it reasonable? What if the hospital states they have the right to determine how resources are allocated to meet the needs of all patients?


Contrast this with the hospital enforcing the wearing of hip protectors against Mr M’s wishes, arguing that research evidence supports the use of the equipment and the hospital is penalised by their regulator if they fail to apply EBP.


Our evaluation of care is often biased when we judge based only on outcomes. For example, let us assume Mr M receives identical treatment, be it with or without hip protectors in residential care. He falls and sustains minor bruising. Contrast this with the outcome of a fall causing a hip fracture that contributes directly to his death.


The matter of how competing interests of an organisation or care provider influences the ability and appropriateness of respecting the rights of an individual requires an understanding of risk.



Risk


Risk is defined as a ‘hazard, chance of bad consequences, loss etc’ (Sykes 1982). If we assume the overall quantitative risk of harm following a fall and the benefit of hip protectors is the same for Mr M, why are there different approaches to his management?


One factor is that the individual’s or an organisation’s perception of risk is an important influence in determining the management of the risk. The perception of risk is usually different from the actual or measurable level of risk. This is because an individual’s perception of risk is influenced by past experiences, attitude, culture, inherent human frailties and biases in decision making and ability to understand and interpret information.



image The perception of risk is usually different to the actual or measurable level of risk.


Consider what your advice to Mr M would be if you had recently provided care for another older person who had recently fallen, fractured a hip and died.


The other major factors to consider when examining risk are who suffers the ‘loss or bad consequence’ and what that person(s) considers to be an acceptable level of risk.


When we consider who is at risk we discover that it is all the persons involved in the provision of care and not just the patient or resident. This becomes clear when we explore the different types of consequences that may arise. Reflect on the vignette and we see that Mr M is at risk of physical injury from falling and that it is his right to determine where and how he lives his life. He is accepting the risk of harm to himself.


However, on closer examination, the hospital is at risk of damage to their finances and reputation if Mr M comes to harm under their care and litigates. This may impact on their capacity to fund services in another part of the hospital.


The residential aged care facility is potentially caught in two ways. First, if they enforce the wearing of hip protectors they risk harm to their reputation and potential sanctions from regulators for failing to respect resident rights. Alternatively, if they respect Mr M’s rights and he comes to harm, they risk damage to their reputation from adverse media publicity, adverse professional assessment and potential sanctions for failing to adopt EBP.


Mr M’s daughter is at risk of social and emotional harm if her family and friends believe her actions are not in her father’s best interests.


Therefore whenever we consider the matter of risk, it is important to consider the roles of all stakeholders, the nature of the risk or potential consequences to the individual and organisation, and the likelihood of that occurrence.


The consequences may include physical, mental or financial harm to the individual who is the recipient of care. The providers of care either as individuals or as an organisation may also suffer the same harm, as well as damage to professional standing and reputation, legal ramifications and loss of good will.

Related posts:

  1. Collaboration in ageing research and education
  2. Innovative responses to a changing health care environment
  3. Supporting independent function and preventing falls
  4. Health care in a longevity regime

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Dec 10, 2016 | Posted by in NURSING | Comments Off on Quality and safety while enhancing rights and respecting risk

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