Mastering Patient Safety: Navigating Healthcare System Dynamics

Eva Ferlez's 15-year journey within the NHS weaves a rich tapestry of commitment to change. Navigating the NHS's intricate framework, she seamlessly transitioned between trusts, specializing in acute and integrated care, mental health services, and commissioning. Starting in a legal role, Eva supported clinical care processes, from coronial inquiries to clinical negligence cases. Her journey evolved into patient safety investigations, governance, and quality assurance. Her influence extends to developing robust incident systems that fortify patient safety. In her commissioning role, Eva orchestrated healthcare with a holistic view, meticulously monitoring performance and ensuring quality outcomes. As a patient safety specialist, in her current role Eva guides teams through complex investigations, and fostering safety and learning cultures across the organisation.

In an interview with Healthcare Tech Outlook Europe magazine, Ferlez shares her insights on the challenges and emerging trends in the patient monitoring industry and the experience she has gathered in the domain.

What challenges have you seen in achieving quality improvement and maintaining patient safety within healthcare systems? How do you approach overcoming these types of challenges?

My expertise lies in clinical governance, overseeing clinical safety rather than direct care. This offers a unique perspective on patient safety.

The NHS's current trajectory, outlined in the new patient safety framework, strongly emphasizes human factors and systemic learning to enhance patient safety. This approach, while present before, is now reinforced. This direction resonates with me and my colleagues dedicated to patient safety. Core learning consistently emphasizes human factors and system dynamics as pivotal to improvement.

This learning doesn't rely on intricate knowledge of specific clinical areas, although these can be relevant in some cases, but centers on understanding how care providers operate in their working environments. Key themes encompass communication, patient engagement, collaboration, and teamwork. Challenges include working conditions, staffing, and complexities of effectively using the various electronic systems in use to manage patient records, particularly in high-pressure situations or when navigating complex interfaces with other NHS Trusts and agencies.

Persistent issues have long been recognized, yet full comprehension and resolution remain challenging. The NHS grapples with intricate systems underlying healthcare operations. While these challenges are identified, effectively addressing them within the complex healthcare ecosystem is an ongoing endeavor.

What are some of the emerging technologies that are influencing the landscape of patient safety and quality? As a leader in this space, how do you believe any certain technological trends would shape the future of patient safety and effective practice?

In the technological realm, it's acknowledged that healthcare faces challenges integrating disparate IT systems. Assembled piece by piece, these systems often operate in silos, lacking cohesion. Bridging these gaps is complex, requiring more than a "band-aid" approach.

The evolution of these systems yields a mosaic of technologies from various sources, complicating seamless integration. This presents a significant challenge, particularly in patient safety. For clinicians, handling diverse systems is onerous and counterproductive. A better approach arises from technology development itself, embracing user-centered design. Instead of expecting users to to train and adapt to the IT systems in use, create intuitive, user-friendly technologies.

"We apply human factors methodologies to investigate incidents and extract key insights and learning, employing tools that guide investigators in scrutinizing the interplay between individuals and their working conditions and environment"

Patient safety learning offers valuable insights that underscore a crucial point—increasing training to navigate technology often doesn’t yield the desired outcomes. By incorporating these insights, we reshape the role of technology in healthcare, bridging the gap between philosophy and technology. This transformation ensures that systems align seamlessly with user needs and capabilities.

Could you provide your insights into how you integrate human factor principles into your leadership approach?

Human factors have emerged as a pivotal paradigm in patient safety, enhancing methodologies like root cause analysis. Our approach involves applying human factor methodologies to investigate incidents and extract key insights and learning. This entails employing tools that guide investigators in scrutinizing the interplay between individuals and their working conditions and environment, illuminating human factor elements, and conducting effective actions.

Service delivery aligns with information pathways. Whether face-to-face or remote communication, our focus remains on understanding these dynamics. In process improvement, these factors wield considerable influence. Human factors acknowledge the difference between ‘work-as-imagined’ and ‘work-as-done’– policies and processes versus day-to-day reality.

We learn by recognizing this divergence. Policies may not align with real-world scenarios, but understanding drives us to acknowledge unaccounted elements. Analyzing the environment and conditions within which care is delivered empowers frontline caregivers to align actions with established procedures, and to improve the processes and procedures to make it easier for clinicians to ‘do the right thing’.

Drawing from your journey and experience, what primary advice would you offer to those aiming to create a substantial influence within this domain?

For those aspiring to a patient safety career, my advice centers on fostering courage and curiosity. This journey demands continuous education, training, and skill refinement. Staying attuned to emerging developments bolsters confidence to translate insights into actionable improvements in our work environments.

Courage involves raising concerns effectively. Human factors extend beyond patient safety, they permeate our organizations. Cognitive biases from can cloud perception at all levels from minor incidents to major organizational challenges.

By championing self-awareness and decisiveness, we empower ourselves to highlight concerns and elevate them to leadership candidly. This is not to imply lack of willingness by leaders to hear the concerns, but simply acknowledges an overwhelming array of responsibilities within healthcare leadership. The role of patient safety professionals is to offer clarity amidst the information overload, which is pivotal in propelling solutions forward.