Patient Safety in Hong Kong
Patient safety is a global issue and paramount to the healthcare profession.
In Hong Kong, all public hospitals have quality and safety units which monitor risks and conduct root cause analysis after every incident. In the past six years, the patient relations teams have been working closely with the risk management teams to manage complaints, with particular emphasis on the emotional aftermath.
Dr David Dai – former consultant geriatrician of the Department of Medicine at Prince of Wales Hospital with 30 years of experience in the medical profession – shares valuable insights on what he considers to be good patient safety.
Good Patient Safety
Dr Dai says good patient safety can be broken down into four categories, namely, (1) the patient, (2) the healthcare provider, (3) ethos and (4) leadership.
Focusing on the individual patient via good communication and knowing how to handle complaints when they arise is vital.
Good communication remains at the heart of patient safety. A clear understanding of the patient’s journey and attention to better communication at critical points on that journey will reduce risks of errors and misunderstanding.
Categories of patient that warrant special attention are the young and elderly, plus those with complex medical conditions. An elderly patient with pneumonia admitted to a medical ward, found following admission to have a hip fracture requiring surgical intervention — and later developing complications requiring intensive care — is a good example. Such a patient needs understanding and good communication between treating teams, as well as with the patient and family.
When complaints arise, the patient relations team should help the clinical team meet family members. It must be appreciated that incidents without error can be perceived as negligence in the eyes of the patient and family and such views must be taken seriously.
Mediation skills — often used in a legal setting — become relevant. Activities such as listening, handling emotions, reframing and summarising are important, as are observing non-verbal communication via gestures and by showing empathy. This will assist in restoring trust between the patient, family and the clinical team.
A consistent approach to patient safety via analysis and monitoring is equally crucial.
When analysing an incident, the investigation should identify errors which may be human and/or systemic. Action plans must be realistic, implemented and audited to prevent further occurrence.
Monitoring should also be done though comparing incidents so that any trends can be found, with measures taken to reduce such events.
Ethos underpins good patient safety. It includes a culture of safety, reporting, continuous learning and partnership between clinicians and patients.
A culture of safety derives from clinical leadership. With regard to overall strategy in patient care, there must be crossover between departments when caring for a patient. Differences in culture between departments in the same hospital will lead to varying quality of care and safety. Underlying flaws will exist.
All clinicians are encouraged to report any event that they consider significant from a patient safety or public health perspective through Hong Kong’s Adverse Incident Reporting System (AIRS). Importantly, AIRS is founded on a ‘no fault finding’ principle and the aim is to reduce risks so as to achieve better and safer care.
Partnership between clinicians and patients is important. The clinician should understand that the patient is his/her best partner in future care. Paying attention to the patient’s experience contributes to the planning and refining of treatment. Patient satisfaction surveys to understand patient’s and family’s perception of the healthcare system — and service provided — helps improvement and fills gaps in care. Recognition that all those providing care should have an input is also important, for example, a nurse may be the first healthcare professional to see changes in a patient. These observations may need to be escalated so as to engage further with the patient.
Leadership — as a driver for ethos — is vital in any clinical setting. Approximately six years ago, there began a gradual change in culture led by clinical leaders. Front line senior clinicians brought about change by way of renewed openness and transparency.
Senior clinical leadership is important in bringing about and maintaining the right culture. Middle ranking clinical managers mentor junior staff in patient safety. Communication skills training should be given equal importance as professional skills training. This has been greatly assisted by the promoted culture of “open disclosure” in Hong Kong.
The promoted culture of “open disclosure” derives from an initial apology offered to a patient when a patient considers that care is not at the level that it should have been. This apology goes hand in hand with disclosure, i.e. helping the patient and family understand what has happened as accurately as is known up to that moment in time, is a vital part of the process.
The clinical staff involved are also recognised as victims going through a professional process of guilt, fear and potentially isolation. Clinical staff should be looked after.
Finally, trusting the integrity of healthcare professionals and their commitment to do good work remains at the heart of Hong Kong healthcare. Public trust has largely been a product of continuous developments in better communication at all levels – between the clinician, patient, family, public and in hospital governance, along with clinical leaders at various levels driving ethos.
A Caring Future
Dr Dai’s insights reflect the impressive steps Hong Kong has taken in the last six years and can continue to take to improve patient safety.
The Hospital Authority has already led the way in ensuring that systems are in place for better patient safety, including AIRS, which encourages openness through reporting incidents based on a no fault principle. The Department of Health is following suit in reviewing and developing guidance on patient safety in a private healthcare setting. Further, the Apology Bill that passed in Hong Kong on 13 July 2017 means an apology, if made by a clinician, will not be taken as an admission of guilt or as a legal liability (albeit subject to certain exemptions). Being able to say sorry without fearing legal consequences should further facilitate communication between clinicians, patients and all concerned parties.
Incidents left unaddressed, without the positive steps highlighted above, will result in a culture of complaint and blame that deters professional interaction with a patient and system and, ultimately, obstructs quality patient care.
Direct and respected clinical leadership — together with good communication with patients — work on conflict resolution, openness and a willingness to apologise will continue to enhance patient safety.