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This paper is devoted to the critical analysis of the performance improvement initiative in relation to the reduction of medication errors. The relevant strategic organisational goal was determined. The relevant indicators were analysed. The role of transformational management was examined.
Keywords: performance improvement initiative, reduction of medication errors, transformational management
A Critical Analysis of a Performance Improvement Initiative
Improving quality in healthcare refers to making care more patient-centred, effective, safe, timely, efficient, and convenient. Therefore, a relevant performance improvement initiative should be implemented.
It seems that the most urgent performance improvement initiative relates to the reduction of medication errors as this type of errors constitutes a serious problem nowadays. This type of errors represents almost 20% of all medical errors in the US. These figures are even higher in Australia. The corresponding costs in Australia are more than $350 million a year (Roughead, Gilbert, Primrose, & Sansom, 1998).
This type of errors may occur at different stages of the medical process, from prescriptions to delivery of specific medication, and in almost any area of the health system. It is necessary that improvements are supposed to be implemented in the majority of spheres of medication services. The relevant strategic goal is minimising the quantity of medication errors in the long run.
Typical errors may include failures to prescribe prophylaxis for some patients, anti-platelet drugs in order to prevent high toxicity, lack of additional monitoring, etc. (Thomsen, Winterstein, S?ndergaard, Haugb?lle, & Melander, 2007). The main cause of medication error is the lack of adequate knowledge of the specific drug. Moreover, the absence of relevant information about a patient is also a widespread cause of medication errors. It is estimated that around 2% of all number of prescriptions may cause an opposite effect. The typical causes are the missing, unclear, and inappropriate doses, and the inadequate directions for use (Hodgkinson, Koch, Nay, & Nichols, 2008). Some medication errors may be related to dispensing. They include the selection of the not optimal product, wrong concentration, or misunderstanding of a prescription.
It is generally recognised that the participation of a pharmacist in patient education and consultation lead to comparatively fewer medication errors (Joanna Briggs Institute, 2009). Thus, it seems that pharmacist consultations should become more widespread.
There is a number of strong reasons not only to involve pharmacists in the performance improvement process within a healthcare system, but to delegate them the leadership roles in it, as well. Pharmacists permanently analyse medication-related sources and may educate other professionals from healthcare and other industries. They are also highly responsible for guaranteeing that all necessary regulations are strictly followed.
Pharmacists should manage and introduce changes within the medication system, including quality of healthcare. They are accustomed to data-collection procedures and methods. They understand the risks present in the medication-management system and are able to identify areas of weakness, and may modify or reorganise systems to improve risk areas. Pharmacists may be useful in analysing medical systems in relation to administration, ordering, and dispensing (AHSP, n.d.).
Analysing opportunities for decreasing waste within the medical system may also decrease both direct and indirect care expenses and medication costs and lead to improvements in inventory procedures and medication use. The expected effect of such measures is supposed to reduce a hospitals drug budget. In this way, additional medical programs may be implemented. If the budget is managed successfully, it is possible to enlarge the staff of a given hospital. Thus, efficient medication management may save much money. The medical organisations may spend less on providing care to patients, and the patients are charged less.
Even small improvements to the present state of affairs will lead to significant results and savings to the system. The failure of introducing these changes may lead to highly negative results.
It seems that almost any system analysis should include decreasing a number of medication errors. A process free of medication-related errors is supposed to result in higher quality of care at the patient level and is expected to be the main goal for all quality improvement initiatives.
Thus, the following recommendations may be presented.
1. Double-checking of potential medication orders by several nurses prior to administration is supposed to reduce the quantity of subsequent medication errors.
2. Pharmacists should participate in double-checking of medication orders and patients consultations.
3. The medication supply systems should be individually packed.
4. The use of bar codes by nurses is supposed to reduce this type of errors in prescribing. It seems that additional time is necessary for education of the stuff and long-term successful use.
5. Computerised physician order entry is supposed to highly reduce the possibility of misreading in prescriptions. In this way, medication errors may be minimised.
Lewins force-field analysis may be used for the purpose of minimising the number of medication errors. It provides a model for analysing forces that affect different situations including medical issues. It determines forces that enable movement toward a specific goal or making this movement more difficult. The model in a general form is presented in Chart 1.
Chart 1. Lewins Force-field Analysis
It seems that proposed changes may get support from both medical staff and patients. However, some obstacles may prevent successful solution. They include possible clinicians resistance to change and the limited amount of resources for solving this problem.
Performance measurement may be defined as the process that assesses the existing performance of a given organisation (Adair et. al., 2003). Performance may be measured for a number of reasons. There are three main purposes of performance measurement: quality improvement, accountability, and performance management. The relevant model is presented in Chart 2 (Baars, Evers, Arntz, & van Merode, 2009).
Chart 2. The Model of Performance Measurement
Performance should be measured in order to encourage improvement activities. The performance measurement for accountability is a general representation of performances that allow comparing performances. The performance measurement for quality improvement is typically used for improvements of the quality.
One of the main purposes of performance measurement is performance management. It involves the capability of a given organisation to provide necessary information for subsequent decisions and may be considered as a part of management control process.
Then, it is important to compare the expected and actual results. In this way, it is possible to implement additional organisational changes in relation to the reduction of medication errors. Much information should be gathered and analysed in this respect. The use of information may be organised in the way presented in Chart 3 (Baars et. al., 2009).
Chart 3. The Use of Information
Thus, all statistical information regarding the dynamics of medication errors should be used for analytical and predictable purposes.
The leadership is also very important for implementing necessary changes in relation to minimising medication errors. Understanding the strategic actions of effective leaders may provide the position with a different viewpoint of how individuals may solve complex healthcare problems, in particular regarding the reduction of medication errors.
Modern leadership refers to a strategic activity that includes developing a vision, modifying organisational structures and processes, affecting change initiatives, and improving capabilities. Accomplishing these tasks demands the abilities of inspiring people and mobilising necessary resources. Leadership that is focused on healthcare issues may be defined as a skill set regarding medical, economic, and social institutions through the decision making and the implementation of strategic policies (Wooten, Anderson, Pinkerton, Noll, Lori, & Ransom, 2006).
It seems that clinical team leadership should be changed in this respect as well. To achieve the aim of integration, the leadership includes engaging and facilitating personnel in a self-organising process. Therefore, personal and managerial authorities should be used in an optimal balance. Achieving this balance in a specific set of circumstances is an acquired skill, not one that may be prescribed. There are six main styles of leadership. They include democratic, authoritative, coercive, pacesetting, affiliative, and coaching styles (Greenfield, 2007). The coercive style refers to a top-down approach, which aims at achieving immediate compliance with directives. However, it may be effective in critical situations. The authoritative style may mobilise people towards a shared vision. Some space for flexibility and innovation should be left in this style. The affiliative style is focused on people, creating necessary commitment and efficient communication among them. The democratic style tries to engage people and encourage participation and productive teamwork. The pacesetting style is focused on high standards of performance. The coaching style tries to develop skills and abilities of the medical team. It usually emphasises development and places it over current work tasks.
It seems that five stages of leadership may be introduced in relation to the reduction of medication errors.
1) Authoritative leadership. The current state of affairs shows that operation is organised on a hierarchical basis. The medical teams are being run as groups with a defined leader.
2) Democratic leadership. This stage enables negotiation of the direction, purpose, and activities of the medical work, rather than ordering what the obligations of the medical team should be. The team may be encouraged to examine the existing arrangements for the provision of medical services.
3) Coercive leadership. In the situation of crisis, this style of leadership may be implemented. It is effective for some short-term medical objectives.
4) Pacesetting and coaching leadership. On this stage, the majority of practical problems may be resolved. Theoretical knowledge and practical skills may be discussed and improved on this stage.
5) Affiliating and democratic leadership. Facilitating the team meetings, it is possible to engage team members in the process of defining the goals and targets of the medical services and taking responsibility for the organising of their work. The quantity of medication errors is supposed to be minimal at this stage.
It should be stressed that collaboration does not always imply harmony. Teams should discuss, debate, agree, and disagree about different ways of organising team work. Different views should be encouraged and analysed. These elements enable improvements in healthcare practices (Wooten et al., 2006).
It is generally recognised that quality improvements in healthcare are typically difficult to achieve. It seems that a more systematic use of theoretical concepts is needed in order to reach long-term results. It should be understood that a whole range of factors interact at all levels of medical practice (patients, professionals, etc.). Therefore, it is necessary to specify whether and to what extent specific change may be achieved. Thus, the potential interacting determining factors should be identified.
All relevant theories may be subdivided into impact and process theories. Impact theories refer to specific hypotheses and assumptions regarding a way how a particular intervention may facilitate a change (for instance, in relation to the reduction of medication errors), as well as factors, causes, and effects enabling progress in improving healthcare practices. Process theories analyse the preferred implementation activities: the way they should be planned, organised, and scheduled in order to become efficient (i.e., the organisational plan) and the way the target group will be affected by these activities (i.e., the utilisation plan). Both types of theories should be integrated in order to reach the desired change.
Changing practice systems should take into account the complex character of the medical practice as a large number of factors may stimulate or endanger changes. Efficient implementation should use a systematic, well-developed approach that analyses all significant issues. This perspective may use both the point of view of the implementer and the point of view of the target group analysing the proposal to change its medical functions.
Capacity building within a healthcare organisation may be a useful tool of reaching long-term stability. It is a specific approach that focuses on analysing obstacles that do not allow fully realising the existing one. In this way, the efficient program is developed, which enables reaching sustainable and measurable results. In relation to the reduction of medication errors, it means analysis of key subjective factors that make the realisation of the program more problematic.
Any process of decision-making at an organisational level has to be specified locally and take into account specific preferences and circumstances. The first step in applying the process in any organisation would therefore be to understand whether this approach needs to be modified to correspond to the existing situation in the best possible way. Ensuring that all elements of the process are addressed will facilitate a complex approach to quality improvement within the healthcare organisation.
The process should be based on the successful experience of development organisations making rational choices regarding the way of advancing a quality improvement in the healthcare industry.
The process of reduction of the number of medication errors includes seven key elements within the basic categories of analysis, strategy, and implementation. Thus, it reflects a frequently used approach to quality improvement understanding the problem, planning, taking action, studying the results, and planning new measures in response. The main conclusion of this approach is that the strategy for quality improvement is not constant. While the key direction of progress is supposed be consistent, responding measures should require important adaptations of some elements of the strategy.
The process of strategy improvement is presented in Chart 4 (WHO, 2006).
Chart 4. The Process of Strategy Improvement
Stakeholder involvement is of utmost significance in the process under consideration. It is necessary to determine who the main stakeholders are and the way they may be involved. Main stakeholders usually include community and political representatives, service users, healthcare organisations, representative and regulatory bodies, etc. Another key group of stakeholders may be the senior officials responsible for this aspect of quality, i.e. for the reduction of medication errors. Depending on the allocation of these responsibilities, there may be a number of policy leaders analysing different aspects of quality. The following recommendations may be presented in this respect.
1. The clear process for the involvement of stakeholders should be introduced.
2. All main stakeholders should be taken into account.
3. Clear terms of reference for all participating parties should be developed.
The leaders may influence main stakeholders in a number of ways. It is generally recognised that people cannot be forced to change their operation. Thus, efficient planning and excellent communication skills are essential in this respect.
Situational analysis should be provided as well. It refers to a basic process, which allows a clear relation to be established in the process of considering new interventions and adapting the existing ones. The key focus of the situational analysis is on the healthcare system. However, it should also make connections between healthcare and other industries and problems, which may influence the performance of the organisation.
Current health priorities and goals in relation to the reduction of medication errors should be established. The aim is to understand the nature of main priorities and goals, the way they may be addressed, and their contribution to the quality improvement in general. Current quality interventions should be established as well. Its effects on the use of standards and regulation, leadership, information, engagement with patients and the population, developing organisational capacity, and models of care should be predicted as well (WHO, 2006).
The key indicator of the results is the statistical dynamics of medication errors in a given organisation. The next stage is the confirmation of health goals. Without agreed and clear health goals, the effectiveness of any new quality intervention is problematic. Moreover, the situational analysis may lead to the revision of some health goals. These goals are usually set through a political process and may be different. All key categories should be taken into account.
The second part of the change management is related to the development of new strategies in response to the previous analysis. Adequate quality goals should be developed. For instance, one of these goals may include the reduction of medication errors by 10% during the following year. This goal is specific, measurable, and its implementation may be controlled and analysed.
The choice of additional quality goals may be influenced by the established health goals, and it should be related to the specific dimensions of quality. The situational analysis may specify judgements about the role of a particular evidence for a given health issue. There may be evidences that delays in access to medications are influencing the number of medication errors. It may be useful to distinguish health and quality goals. For instance, health goal may refer to the improvement of health indicators within a specific territory. Quality goal may include reduction in the number of medication errors.
Then, interventions for quality should be chosen. This stage provides a critical component of a given strategy for improvement, i.e. clarity regarding what the strategy may achieve. Thus, attention is shifted from the purposes to their implementation. Effective judgements about interventions should be made, and agreement regarding the process of their implementation should be reached.
Cognitive theories of change management are typically focused on the rational processes of acting and thinking performed by individual leaders. Rational decision-making theories suggest that in order to supply optimal care services, medical leaders should consider and balance the advantages and disadvantages of all alternative scenarios. These theories consider the availability of necessary information regarding risks and benefits as crucial to the process of performance change (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007). From this perspective, the reduction of medication errors may be achieved through an efficient process of providing necessary information for medical professionals.
The main domains of quality intervention in relation to the reduction of medication errors are presented in Chart 5 (WHO, 2006).
Chart 5. The Main Domains of Quality Intervention
These main domains are not purely theoretical. They are closely related to the strategies for quality improvement. A large number of organisations seem to emphasise only one key domain (for instance, regulation) in their work regarding quality improvement. However, it seems that it is necessary to implement a more complex approach using all six main domains.
Leadership is the first and the most fundamental domain as there are clear evidences that quality initiatives may not be realised if there is not significant and consistent leadership support. In the absence of effective leadership within an organisation, the majority of new strategic interventions are not likely to succeed. Effective interventions are necessary for promoting commitment and leadership capacities. Statistical accountability is important as well.
Development of models of care differs from organisational capacity in a number of ways. It seems that in order to improve quality, it is reasonable to be focused on the delivery system in general. Creation of new models of care should involve an appraisal of evidence, a high level of stakeholder involvement, development of guidelines and protocols, etc. The challenge for leaders is to understand when this approach should be implemented and for which population segments.
Another important outcome that should be achieved is agreement about the detailed plan regarding the agreed interventions. All implementation plans need to meet specific considerations; and leaders play an important role in this process.
Modern medical institution is always a learning organisation. It may be used for the reduction of medication errors. Leadership models should be defined in their social context and include analysis of tactical and strategic approaches to medical problem solving, promoting environments of trust, leveraging resources, conflict resolution, fiscal and specific budget management, creating coalitions and collaborations, etc.
Healthcare organisations usually focus their attention on motivating employees by influencing the first three levels of Maslows hierarchy. These levels may include adequate compensation (physiological needs), secure work conditions (safety), and shared governance (a sense of belonging to the community). However, transformational leadership is able to motivate personnel to satisfy their higher-level needs, including self-actualisation and self-esteem. In this way, personnel are able to make significant contributions to the results of their medical organisation and even become transformational leaders themselves.
Healthcare organisations are typically highly bureaucratic. They usually use transactional leadership strategies, which include a task-and-reward orientation and few opportunities for creative solutions. Though transactional leadership may help organisations in meeting their goals in the short run, it is not always able to provide inspiration for the creation and nourishment of a new culture for medical practice and patient care.
However, transformational leadership makes a significant difference in the life of personnel and medical organisations. The understanding of transformational management has changed recently. Leadership is now understood as crucial for developing a work culture in which personnel and patients may be satisfied. Transformational leaders should have a positive and adequate vision and the needs of all stakeholders should be met. Thus, the performance improvement initiative in relation to the reduction of medication errors is closely related to the effective transformational management.