INTEGRACIÓN: MEDITACIÓN EN ACCIÓN

An overview of this thesis both with regard to its contents and to its research path is given in this section.

1.6.1 Overview of the thesis

The thesis can be divided into three parts:

I. A theoretical section, ‘Introduction and methods’. In this section consisting of chapters 1–3, the approach, the methods used and the framework are described. A general introduction to this research is given in this chapter. In chapter 2, the relationship between risk and quality management is discussed. Because the ques- tions of how these incidents occur, of how to learn from them and of how they can be prevented, were underexposed in literature, the development of a risk man- agement framework consisting of models, methods and systems was more or less a requirement and is discussed in chapter 3.

II. A validation section, ‘Results and analysis’, describing how risk management works in practice. This part comprises chapters 4–7 describing the use of risk manage- ment techniques in the OR in chapters 4–6, and in the Haemodialysis department in chapter 7.

24_{E.g. not all incidents are reported, see e.g. [111], and the type of incidents which are reported is very}

1.6 Overview 21

III. A concluding section, ‘Conclusions and recommendations’, consisting of chapter 8 which discusses the conclusions and recommendations as a result of this research. In order to make this research useful and applicable to other health care organisa- tions, the methods and results at both the OR and Haemodialysis departments will be discussed in great detail.

1.6.2 The research path of the thesis

This section briefly describes where and when the research discussed in chapters 4–7 took place, and contains references to reports published earlier on which this thesis is largely based.

Research path The research project started at the end of 1993 with a literature re- view [148], and a second literature review at the beginning of 1994 [150]. In April 1994, the EUT M.Sc. thesis research project in the function group Operating Room started with a process description of the clinical operating rooms. Then an assessment of the pos- sible risks for patients was made by using a Failure Mode and Effects Analysis (FMEA). After this, an assessment of the actual risks for patients was made by conducting twenty Critical Incident Interviews (CIIs). A comparison was made between the results of the forecast (FMEA) and the actual risks (CIIs). One of the conclusions was the need for structural risk management, which evolved into the Incident Reporting and Manage- ment System (IRMS) [151]. This management system was developed and implemented as an EUT M.Sc. thesis research project by Timmermans [140] in May 1995. More than 520 incidents were reported and analysed by the IRMS in the period May 1995 to April 1997 [140, 144, 145]. In June 1997, a risk management project in the Haemodi- alysis department was started: a process model of the Haemodialysis department and PD was created, and twenty-five CIIs were conducted. After this, an FMEA was made (April 1998) [153]. For an overview of the methods, tools and models used in this re- search, see table 1.1 on the following page.

In relating this time path to the chapters 4–7, the following brief outline can be given. Chapters 4 and 5 cover the period February 1994 to April 1997, starting with the pro- cess description of the OR, the FMEA, the CIIs and ending with the analysis of over 520 incidents reported to the IRMS. Chapter 6 is about the period between July 1996 and April 1997 and is based on the results of the first and second analysis of in total 345 incidents reported to the IRMS. The project in the OR ended in April 1997, with the third analysis of the last 178 incidents reported to the IRMS. Chapter 7 covers the period June 1997 to April 1998, starting with the process description of the Haemodial-

Table 1.1. An overview of the methods, tools and models used in this research.

Method Additional tools and/or models used with Used in function group/department

the method concerned

• CII − CTA,a_ECMb _OR

− CTA Haemodialysis

• FMEA − process model,cECM OR

− process model Haemodialysis

• IRMS − (CTA,d_ECM)e _OR

a

CTA stands for ‘Causal Tree Analysis’, see section 3.4.5.

b_{ECM stands for ‘Eindhoven Classification Model’, see section 3.4.6 and appendix E.}

c

See section 3.4.2.

d

Mainly used for the analysis of the first 62 reported incidents of the first/original IRMS, see chapter 5.

e_{Only used for the analysis of the first 62 reported incidents of the first/original IRMS, see chapter 5.}

ysis department, followed by the CIIs, and ending with the FMEA. The larger part of this thesis was written over the period from April 1998 to September 2001. It was not until this period that a number of the publications cited in the thesis became available. This is particularly relevant in the case of the thesis by Koornneef (2000) [80] which deals with a number of issues which overlap with issues discussed in this thesis. Hence the in- sights from these sources could not be used in planning and carrying out the research described in chapters 3–7, but they were useful in providing a better understanding and interpretation of the results of this research.

References to relevant earlier publications The results on which this thesis is based were presented in a number of earlier publications. The literature review was partly presented in two reports, see [148] and [150]. The research in the OR was presented in four re- ports [140, 144, 145, 151] and two articles [147, 152]. The research in the Haemodialysis department was presented in one report [153].

2

Risk and quality management

2.1 Introduction

This chapter describes the relationship between standards, process deviations, risks and process control on the one hand, and the management of care systems, especially qual- ity and risk management systems, on the other. Standards—necessary for providing a fixed frame of reference (both within and outside the organisation) for what is necessary and acceptable, and what is not—are discussed in section 2.2. Section 2.3 is about the ap- proach to risk management this research adopted: the prevention of process deviations in order to reduce risks. The analysis of process deviations, the information resulting from the analysis and the question of how to handle the information are briefly discussed. The control of standards and the risk management information—obtained by analysing process deviations—in care systems are discussed in section 2.4. The question of how risk management and a risk management framework (see also chapter 3) fit into quality management is the subject of section 2.5. Risk management is that part of quality man- agement which is entirely focused on the prevention of process deviations and incidents, and should therefore be integrated into quality management.