Clinical Leadership: Using Observations of Care to Focus Risk Management and Quality Improvement Activities in the Clinical Setting
Ferguson, Lorraine, Calvert, Judy, Davie, Marilyn, Fallon, Mark, et al., Contemporary Nurse : a Journal for the Australian Nursing Profession
The pace of change and reform in health care continues to accelerate and with that change and reform there is increasing concern from health care providers, consumers and regulators about the quality and safety of the care delivered. The Safety and Quality in Australian Health Care Study (Wilson et al. 1995) identified the extent of patient safety issues in the Australian health care system in the 1990's and since that time a number of task forces and expert panels have been established to make recommendations to improve the safety and quality of patient care (Rubin & Leeder 2005). Many of the recommendations (the development of evidence-based standards for care, monitoring, investigation and reporting of incidents, adverse events and near misses and ongoing professional development and accreditation of health personnel to improve the safety of care) have been, or are being implemented, but to date there is little evidence to suggest that health care is any safer in Australia than it was in the 1990's (Wilson & Van Der Weyden 2005; Rubin & Leeder 2005;Van Der Weyden 2005).
The Institute of Medicine (IOM) in the United States of America went through a similar process of studying the quality of health care in America, establishing expert panels, publishing a number of reports and making recommendations for building a safer health care system.The recommendations were related to creating a national focus on leadership, research, tools and protocols for systems improvement, and raising performance standards and expectations for improvements in safety through regulatory mechanisms, professional groups, health care funding agencies and consumers themselves (Institute of Medicine 1999).
A more recent report by the IOM (2003) which focused on how transforming the work environment of nurses contributes to patient safety identified four major threats to patient safety and four safety defences that health care leaders, particularly nurse leaders, need to address in order to improve the safety and quality of health care. Whilst this IOM report acknowledged the critical role that nurses have in relation to patient safety it also concluded that the working environment of nurses posed many serious threats to patient safety (De Groot 2005).
According to De Groot (2005: 37) the safety threats include 'poor management practices, unsafe workforce deployment, unsafe work and workspace design', along with organisational cultures of blame that hindered reporting and learning from errors. The 'safety defences' recommended by the report include the need for leadership and management practices that are 'transformational' and evidence-based; the provision of an adequate number of nursing staff that have appropriate knowledge and skills to provide safe and coordinated care in collaboration with the interdisciplinary team; the redesign of nursing structures, processes and work spaces to decrease the likelihood of error and the creation of an organisational culture that focuses on safety and engages and supports the workforce in their efforts to take action in dangerous situations to prevent harm and promote patient safety (De Groot 2005; IOM 2003).
Throughout the quality and safety literature there are continuing calls for 'leadership' from senior executive management through to senior clinicians, clinical teams and individual clinicians at the bedside to take action to improve the safety of health care provision. The National Health Service (NHS) in the United Kingdom (UK) as part of its reform agenda has focused on clinical governance, service improvement and leadership development as means of'modernising health care services and improving the experience and outcomes of patients' (NHS Institute 2005). While in the 1980's and 1990's the UK NHS had an emphasis on improving health services management, in the 2000's it has leadership and leadership development as the central tenets of its reform and modernisation policies (Hewison & Griffiths 2004). …