Improving the Quality of Healthcare

The National Health Service (NHS) definition of clinical governance is a “framework through
which organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical care will flourish” (Gottwald & Lansdown, 2021, p.10). It aims to ensure both patients and staff are well taken care of. Clinical governance involves implementing education and training, audit, risk management, evidence-based practice, clinical effectiveness and research, public involvement, and staff management to improve health outcomes (Gottwald & Lansdown, 2021). Clinical quality is the main objective of clinical governance. According to the Institute of Medicine, quality of care is measured by how well the health services increase the desired outcomes (Joel,2022). Quality is also measured by consumer satisfaction in services that meet their needs and expectations. The provider views it as delivering medically safe, professionally ethical, accessible, and acceptable health services. The stakeholder’s perspective of quality care is health services that are safe, gratifying, affordable, accessible, and delivered in a technically competent manner while observing cultural humility.

Medication errors have been a major quality issue in Hong Kong. Types of medication errors include prescription error, omission, administration of an unauthorized drug, preparation of a wrong dose, dispensing errors, and administration errors (Tariq et al., 2021). Administration errors occur when a drug is administered using the incorrect route, to the wrong patient, or at the wrong rate. A report done by the Hospital Authority Hong Kong showed that out of 50 serious untoward events in 2020, 45 were medication errors (HA, 2020). Out of the 45 cases of medication errors, 31 resulted in minor consequences, six moderate consequences, and eight temporary major consequences (seeappendix A). The pattern of medication errors in Hong Kong public hospitals comprises 53.4% prescription error, 29.0% drug administering error, and 17.6% dispensing error (Kwong & Fong, 2020). This paper analyzes the causes of medication errors, the application of clinical governance to tackle this issue, and the recommendations to eradicate these errors, consequently improving the quality of healthcare in Hong Kong.

The nursing role has expanded with clinical governance. The Australian Commission on Safety and Security in Quality Health Care (2017) identifies several roles of nurses for clinical governance: governance and leadership, designing patient safety and quality systems, maintaining optimal competence and clinical effectiveness, providing a secure environment for the provision of care, and working with consumers to ensure quality. Nurses should participate in hospital processes supporting patient safety by reporting incidents and near misses. The clinical governance framework requires nurses to use and improve organizational systems to support broad organizational and societal priorities. Open disclosure with patients and families and availing of health information ensures public involvement in care. Nurses are responsible for analyzing and addressing adverse events, including morbidity and mortality meetings. They should report any opportunities for improving the environment of care. Nurses are expected to escalate patient safety issues to managers. Managers are responsible for modeling exemplary professional conduct and are committed to enhancing the quality and promoting patient safety.

Clinical governance emphasizes accountability and transparency among primary caregivers. Clinicians are held accountable to the community, the NHS hierarchy, and peers in the same primary care group ((Moran et al., 2021)). Good management and multidisciplinary collaboration in clinical governance have resulted in adherence to policy and procedures and accurate documentation of all care, consequently boosting health care quality. Clinical governance incorporates staff management, ensuring adequate resources, and good working conditions to support healthcare workers in providing quality services. Supporting employees in career development and providing employee training has enabled nurses to perform to the highest possible standards (Gottwald & Lansdown, 2021). Clinical governance challenges clinicians to apply evidence-based practice and performs clinical audits to ensure the provision of healthcare services that are safe, effective, of good quality, and continuously improving.

There have been several high-profile damaging clinical issues that have resulted in the implementation of clinical governance. From 2004 to 2006, more than 90 patients succumbed to Clostridium difficile due to the absence of infection prevention and control procedures(Gottwald & Lansdown, 2021). Others included high pediatric mortality rates in Bristol, the deaths caused by Beverley Allitt and Dr. Harold Shipman, and substandard care reported between 2005 and 2009 in the UK (Gottwald & Lansdown, 2021). Several political, economic, social, technological drivers are improving healthcare quality.

The Hong Kong Hospital Authority (HA) was established in 1990 to ensure quality healthcare. Since 2009, hospital accreditation programs have been adopted in Hong Kong to identify opportunities for quality improvement. One of the strategic plans in the HA Annual plan 2021-22 is to improve the quality of health services (see Appendix B). These political drivers have been instrumental in improving the quality of medical care within healthcare organizations in Hong Kong.

Economic constraints are another driver of quality. Errors increase the cost of care. Complying to standards and procedures of quality is important to cut costs associated with errors. Social drivers of quality involve consumers. Patients are more informed about service delivery and determine whether the services they received were quality. Technological drivers of quality include the improvements in drugs, medical devices, and surgical techniques.

Moulin (2002) defines total quality management (TQM) as a continuous process that requires commitment from everybody in the organization to satisfy the needs of consumers and other stakeholders at reduced costs. TQM is achieved through quality control and quality assurance. Quality control involves activities that evaluate, monitor, and regulate the care provided to patients. It involves measuring quality processes, gathering and analyzing data timely, and effective supervision. Quality assurance involves setting specific, measurable, achievable, realistic, and time-bound (SMART) standards, reviewing and auditing processes, and staff training to drive up standards continuously (Moulin, 2002). Quality is assessed against quality indicators at the individual level by healthcare providers, group-level, system-level, and societal levels (Joel, 2022). The Hong Kong HA is responsible for assessing and monitoring quality for hospitals in Hong Kong. Structures of TQM involve integrating staff, consumers, and providers to maintain a high quality of health services. Good governance and organizational structure are important in TQM.

Health Quality Improvement Partnership defines quality care as evidence-based care that applies proven methods to ensure clinical effectiveness, patient safety, and a positive patient experience ((Fereday, 2015). Quality issues do not meet the above descriptions. Medication errors are among the most prevalent quality issues in health. The HA Annual report of Serious Untoward Events (SUE) reported 45 cases of medication errors in 2020 (see appendix A). The most prevalent medication errors were eleven wrong anticoagulant prescriptions, seven known drug allergies, four dangerous drug cases, and four insulin cases (see Appendix A).

Ishikawa’s Fishbone Analysis of medication errors.

When he pioneered quality management processes, Doctor Kaoru Ishikawa invented the fishbone diagram to analyze the cause-effect relationship of quality issues (Gottwald & Lansdown, 2021). The heading of the diagram is the  qualityissue, which is the effect, and in this case, medication errors and the bones are the causes. Common causes of medication errors are associated with people, place, policies, and procedures.

Distractions from the environment cause healthcare workers to make computer entry mistakes, increasing opportunities for medication errors to occur (Kwong & Fong, 2020). In a study by Ruiz et al. (2016), distractions accounted for 59% of medication errors made in a neonatal unit. Medical practitioners have a heavy workload and constantly work under high pressure and critical circumstances. Kwong and Fong (2020) suggest that the stressful environment contributes to medication errors. A study undertaken by Lifschitz showed that a higher number of medication errors took place in the Emergency Department, which is a high-stress environment (Gottwald & Lansdown, 2021). Proper drug storage requires good workplace organization. Storage of drugs in incorrect categories or incorrect boxes confuses the nurse and can lead to medication errors. Drug proximity caused 10 cases of medication errors in a study by Ning et al. (2017). Disorganization and the lack of staff to confirm drugs being administered due to workplace deficiencies increase the risk of medication errors.

Human factors are frequently the primary cause of medication errors. Incompetent physicians lack adequate pharmacological knowledge leading to prescription errors such as prescribing contraindicated drugs or known drug allergies (Kwong & Fong, 2020). More than fifty percent of the medication errors reported in the annual Hong Kong HA report were prescription errors (HA, 2020). Fatigue due to long working hours affects the performance of healthcare workers (Kwong & Fong, 2020). Illegible handwriting leads to confusion, consequently increasing the risk and frequency of medication errors (Kwong & Fong, 2020).

Not following the procedures of prescribing, preparing, and administering medication results in medication errors. A study done by Leung et al. (2007) showed that non-compliance with these procedures was the leading cause of medication errors. According to this study, several nurses considered the procedure of three checks and five rights for drug administration not viable and unrealistic due to staff deficiency, time constraints, and heavy workloads. Poor documentation and failure to document increase the chances of medication errors. Verbal orders that are given during emergencies, phone instructions, spelling errors, and using non-standard abbreviations are reported as the common documentation issues causing medication errors (Kwong & Fong, 2020). Ning (2017) identified poor communication and lack of clarification as another cause of medication errors.

According to Leung et al. (2007), nonadherence to policies governing safe drug administration has resulted in medication errors. The HA Guidelines on medication management require the patient’s drug allergy status to be assessed and a wristband worn for those with allergies. A study by Tsang (2013) reported a lack of drug-allergy checking. The HA annual report reported 7 cases of administration of drugs of known allergy (see appendix A). Healthcare workers have complained that some guidelines are not practical in the current circumstances (Kwong & Fong, 2020). Inaccessible guidelines make them circumvent the correct steps, increasing medication error opportunities. Tsang (2013) demonstrated that knowledge deficit regarding policies for medication safety contributed to errors.

Lewin’s Force Field Analysis model of change for medication errors. The force field analysis is applied to create desired change by reducing resistive forces and increasing driving forces (Sale, 2005). It happens in three stages, namely unfreezing, change, and refreezing. Unfreezing involves the assessment of the status quo to identify areas that require change. Here, it is important to educate employees on the necessity of the change and prepare them. An action plan is implemented in the change stage to reduce the resisting forces and build on driving forces ((Gottwald & Lansdown, 2021)). In the refreezing stage, the change is reinforced and becomes routine. Kurt Lewin established this Change Management theory to create and sustain change.

In the unfreezing stage, we identify medication errors as the problem. The aim is to reduce them to improve the quality of healthcare. The resistive forces are deficient knowledge, non-compliance to safe medication administration procedures, and a stressful work environment. We identify the three driving forces for change: staff education and training, increased staff accountability, and patient complaints. We establish a plan to weaken the restraining forces and strengthen the driving forces. Healthcare workers should have regular education and training to teach them policies, pharmacological information, and evidence-based practices. The hospital can avail resources in the workplace to provide them with the information and perform regular clinical audits to improve compliance with procedures. Healthcare organizations should deploy employees appropriately considering the workload of the different areas to ensure sufficient staff in all areas and reduce burnout. Employees should be urged to report incidents to increase accountability.

Healthcare workers should inform patients of their rights to quality care and the processes of reporting such errors. Reinforcing change is the last step. Healthcare organizations should perform regular clinical audits, and managers should provide frequent staff education and training. Hospitals should submit incident reports related to medication errors. Managers should report understaffing to the administration, and patients’ complaints should be acted on. These systems will ensure sustained change.

Education and training.

To provide high-quality service through clinical governance, employees need updated knowledge, skills, and competencies. They are acquired through lifelong learning, continuous professional development, and education and training (Gottwald & Lansdown, 2021). One of the strategies in the HA annual plan 2021 to 2022 is to enhance education and training (see Appendix B). Wright and Hill state that education and training occur at the individual, team, and organization levels (Gottwald & Lansdown, 2021).

At the individual level, medical personnel should be attentive to their professional responsibility to administer medications safely (Gottwald & Lansdown, 2021). They should adhere to the trust policy on reporting medication errors. Medical practitioners should regularly read to keep updated on recent quality reports on safe medication practices. At the team level, continuous professional development workshops should be held to ensure the staff is conversant with the policies and procedures of medication safety (Gottwald & Lansdown, 2021). Managers should educate their teams on proper documentation and proper storage of drugs. Multidisciplinary collaboration between physicians, pharmacists, and nurses is important at the team level to note and correct mistakes promptly to prevent incidents related to medication errors. Gottwald and Lansdown (2021) suggest that near misses should be utilized as opportunities for team learning to prevent future occurrences of medication errors. Hospital administration should communicate their policies to all staff at the organizational level to raise awareness on local methods. The organization can provide learning materials such as charts to staff to support medication safety efforts.

Audit.

An audit is an integral pillar of clinical governance. Clinical audit is an ongoing process seeking to boost patient care and health outcomes through a systematic review of the care provided against a standardized criteria and the implementation of change. NICE recommends that clinical audits be central to all clinical governance systems (Gottwald & Lansdown, 2021). During the audit, existing processes are examined to ensure that standards are reached, and resources are used effectively and efficiently to provide care.

The healthcare organization should be aware of the ideal practice and evidence-based practice recommended in medication safety to perform an audit. Stage one involves comparing current practices against ideal standards (Gottwald & Lansdown, 2021). All healthcare workers and consumers are involved. In stage two, the organization and medical teams identify SMART standards as the outcome criteria. Medication prescription, preparation, and administration processes are monitored, and data on errors made are collected in stage three. Data can be collected using inspection, observation, inquiry, and analyzing patient records. The data collected is then compared to the set standards, and the organization identifies why they are not achieving the desired outcomes. Feedback is communicated to the medical personnel.

Stage five involves changing practice by developing an action plan to reduce medication errors (Gottwald & Lansdown, 2021). In this case, the action plan is staff education and training to improve medication practices. The organization establishes training programs and provides learning materials to improve safe medication administration practices. They develop ways to evaluate current practice against set standards to determine if the change occurs. Hospitals should involve the public by developing patient systems to report medication errors and near misses. The last step is to re-audit to check the impact of the process. The healthcare organization determines whether the medication errors have been reduced and quality achieved according to the SMART standards.

Developing SMART standards is part of the audit process. Setting specific, measurable, attainable, realistic, and time-oriented standards is important in quality measurement and assurance (Gottwald, 2021). In this case, the quality issue is medication errors. A healthcare organization should develop SMART standards as the criteria for checking quality. For example, by the end of 2022, medication errors should have dropped by 60 percent. Healthcare workers should be involved to determine whether it is achievable. The organization should determine systems to measure these standards.

Another example is all medication errors should be recorded in an incident book over one year. Organizations can also employ SMART standards to evaluate the clinical governance strategies in managing medication errors. The organization can set SMART objectives like, by September 2022, 500 employees should have been educated and trained on safe medication prescription, preparation, and administration procedures and practices. These SMART objectives are goal-oriented, motivating everyone involved to participate in achieving them.

Despite being preventable, medication errors are common quality issues worldwide. The Hong Kong HA annual report shows that medication errors are the most common serious untoward events, and most occur through prescription errors. This paper uses Ishikawa’s Fishbone analysis to identify the following causative factors of medication errors: stressful environment, distractions, poor workplace organization, poor handwriting, long working hours, deficient knowledge, non compliance to policies, and procedures, poor documentation, poor communication, and inaccessible guidelines. Using Lewin’s force field analysis, this paper assesses the potential for quality improvement in medication safety practices. The clinical governance framework is used to make recommendations to improve healthcare quality by reducing medication errors. As a clinical governance strategy, education and training are discussed as important to boost safe medication practices. Recommendations are made on applying the audit process to create and sustain change. Setting SMART standards is critical in ensuring total quality management to prevent medication errors. Clinical governance is identified as a continuous process necessary for continuous quality improvement to drive up standards of care.

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Appendix A: Annual Report on Sentinel and Serious Untoward Events October 2019- September 2020.

Medication errors are the major SUEs derailing healthcare quality in hospitals in Hong Kong. This paper discusses the errors reported from the annual report and their implications on the patients. In the annual report, 50 cases of SUEs were reported, 45 being medication errors and five patient misidentification events. The pie chart below indicates the ratio of medication errors to patient misidentification between 2019 to 2020.

The events resulted in 35 minor consequences, seven moderate consequences, and eight temporary major consequences. Medication errors contributed solely to the major consequences.

Prescription errors were the most common, with 11 anticoagulant prescriptions, seven known drug allergy cases, four dangerous drug cases, and four other insulin prescriptions.

Appendix B: Hong Kong Health Authority Annual Plan 2021-22.

The paper discusses the 2021-22 HA annual plan for improving health care quality in Hong Kong. This plan has five main strategic goals and target programs, two discussed in this paper. One of the strategic objectives is to improve service quality, which this paper discusses as a political driver for quality. They plan to achieve this by promoting day services, establishing more options for patient care, strengthening service coordination and collaboration, enhancing society-based care, refining technology planning and adoption to keep pace with international standards, and empowering patients for self-care. On pages 16 to 24 of the attached document, they discuss specific action plans to achieve these targets.

The other strategic goal relevant to this paper is to enhance staff training and career development. This paper discusses education and training as a clinical governance strategy to curb medication errors, aligning with the HA Annual Plan 2021-22. They hope to achieve adequate staff training and career development by establishing a mechanism to align training with career development and establishing a quality assurance framework, and providing more staff training opportunities. The annual plan includes specific actions to ensure quality assurance through continuous employee training and staff career development. These actions are found on pages 35- 38 of the document attached below.

Source: (Hospital Authority, 2021)

ANNUAL PLAN 2021-22 – ha.org.hk