AnalesdePediatría97(2022)227---228
www.analesdepediatria.org
EDITORIAL
Quality of care and patient safety, key elements of health care
La calidad asistencial y seguridad del paciente, componentes clave en la atención
Aurora Madrid Rodríguez
a,∗, Angel Hernández Borges
b, en representación del Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Espa˜ nola de Pediatría
aUGCdePediatría,HospitalRegionalUniversitario,Málaga,Spain
bUnidaddeNeonatología,HospitalUniversitariodeCanarias,Sta.CruzdeTenerife,Spain
Carequalityandpatientsafetyareessentialprinciplesand keycomponentsofhealthcaredelivery.
Theapproachtohealthcarequalityismoredevelopedin adultcarecomparedtopaediatriccare,yetchildrenhave a uniquesetof qualitycaredemands, andwhile safety is an essential component of health care quality, improving thequalityofthecareweprovideinvolvesalotmorethan merelyguaranteeingsafety.
When tackling safety and quality, we must take into accountthefollowingstatements1:(1)Businessasusualwill nothelpusachievethehealthcaresystemthatourchildren deserve;(2)Everysystemisperfectlydesignedtoachieve exactlytheresultsitgets,and(3)Knowingis notenough;
wemustapply.Willingisnotenough;wemustdo.
Donadebian2 defined quality care as ‘‘care which is expectedtomaximizeaninclusivemeasureofpatientwel- fare,afteronehastakenaccountofthebalanceofexpected gains and lossesthat attend theprocess of care inall its parts’’.ThedefinitionoftheNationalHealthService(NHS)
∗Correspondingauthor.
E-mailaddress:[email protected] (A.MadridRodríguez).
oftheUnitedKingdom3 ismorepragmatic:doingtheright thing(what)totherightindividual(who)attherighttime (when)andintherightwayfromthebeginning(how).The AmericanAcademy ofPediatrics (AAP) considersqualitya keycomponentofpaediatriccare,andissuedrecommenda- tionsin2019toguaranteeaholisticapproachandaccelerate changestowardsaferandhigher-qualitycare.4
Thereisnohealthcarepracticethatiscompletelyfreeof risk,andtherefore,minimisingtherisksassociatedwithcare deliveryshouldalwaysbeakeyobjective.Atpresent,the highcomplexityofcaredeliveryandthehighexpectationsof societyasregardstheoutcomesofhealthcareinterventions requirethat we determine which arethe most effective, efficientand safeproceduresacceptable for patientsand society,beyondhabit, intuition andcustom. All of itin a contextinwhichpatientsmustbeactivelyinvolvedinthe caredeliveryprocess.
Evaluating care quality in paediatric care services is of the essence. This entails comparing what should be donewithwhatisactuallydone,identifyingdiscrepancies, analysingtheircauses, proposingandintroducingthenec- essarychangesand,lastofall,assesstheefficacyofthese changes.5
To this end, we can use quality management systems, whichconsistsimplyoftoolsthathelpimproveperformance 2341-2879/©2022PublishedbyElsevierEspa˜na,S.L.U.onbehalfofAsociaci´onEspa˜noladePediatr´ıa.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.MadridRodríguezandA.HernándezBorges andprovideasolidfoundationforsustainabledevelopment
initiatives.Aglobalvisionofriskmanagementispartofthe healthcarequalitycultureandrequiresallprofessionalsto beinvolvedincaresafety.
Institutionscommittedtohealthcarequality,suchasthe World Health Organization (WHO) and the Joint Commis- siononAccreditationofHealthcareOrganizations(JACHO) recommendtheimplementationof healthcare riskmana- gement programmes. All health care systems should be designedtopreventerrors.Thefirststepistodesignsystems toidentifyandprovidefeedbackonerrorsoradverseevents toreduce or preventtheir occurrence.And paediatricsis preciselyoneofthefieldsinwhichtheknowledgeofadverse events (AEs) is weakest andwiththe fewest strategiesto preventthem.
Oneofthekeypillarsofsafetythatmustbeprioritised is workingonriskmanagementtoincrease patientsafety, understood as the reduction of unnecessary health care- relatedrisktoanacceptableminimum.Themeasurementof theriskassociatedwithhospital-levelproceduresisimpor- tantforthehealthcaresystematthehealthlevelandalso theeconomic,legal,socialandmasscommunicationlevels.
The firststep inrisk management is the prevention of adverse events at three levels: reducing the risk of AEs happening(primaryprevention),earlyinterventiontomin- imisethedamagecausedbyAEs(secondaryprevention)and prevention ofrecurrence toreduce theirimpact(tertiary prevention).
Riskmanagemententailsacombinationoflearningfrom things that have turned out poorly (reactive approach) preventing potential risks to avoid their consequences and impact on the interventions we perform (proac- tive approach). Combining the reactive and proactive approaches, we will consider the phases, techniques and toolsusuallyemployedinriskmanagement.
Risk management is a cycle of phases that resembles theiterativecyclesforimprovementintheplan-do-check- act(PDCA)approach,adaptedtopatientmanagementand safety.
Itisessentialthatstrategiesareimplementedtoadopt andintegrateevidence-basedhealthcareinterventionsand makechangestoclinicalpracticepatterns.
Riskmaps,liketheonepublishedbyMora-Capínetal.,6 areproactivetoolsthatallowthedetectionofcriticalpoints for patient safety during the care delivery process (using thefailuremodeeffectsanalysisapproach,knownasFMEA) in order to anticipate them, implementing improvement actionstominimisetheprobabilityofanAE.Astheseauthors highlighted, periodic implementation of these techniques allowsanoverallreductionintheriskinvolvedinthediffer- entprocessesandsubprocessesthatconstitutecaredelivery
in any health care setting (in this case, a hospitalemer- gencydepartment),especiallyinrelationtothemostsevere failure modes whose correction should be prioritised. In addition,therootcausesofthesefailuresareusuallyshared withother,lessseverefailuremodes,sothattheeffectof improvementsisgeneralised.Needlesstosay,thisrequires considerableeffortfromtheentirehealthcareteamanda strongandcoordinatedleadership, witheffective commu- nicationbetween professionalsthatis notcurrentlyfound acrossallunitsanddepartments.Thesuccessoftheseini- tiatives is not based on chance or an isolated effort at a given time, but rather reflects a culture built through years of recurrent implementation of improvement tech- niquesthroughPDCAcycles,withaninherentcommitment toqualityandsafetyandthepursuitofexcellenceincen- tres,departmentsandunits.Atanyrate,thescarcityofthis typeofstudy,inwhichthepatientisthesettinginwhichwe work,withitsproceduresandprocesses,andthetreatment isourabilitytoimprovethem,isasrelevantasitisinspiring.
Healthcarequalityandpatientsafetymustbeapriority andarequirementinourclinicalpracticeaspaediatricians.
Asprofessionals, we havetoleadthe change inour insti- tutionsand promote strategies,programmes and projects toimprovequalityand safetywithinthem in pursuitof a paediatriccaresettingofferingthequalitythatallchildren deserve.
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