In our last post, we talked about our experience with audiences after screenings of Falling Through The Cracks: Greg’s Story. It is common for people to share their own stories about the impersonal character of interactions with the “system”. It is not just a local, or provincial, or even a national problem but a worldwide one in the areas of system/provider culture, communication, and needed collaboration, partnering with patients in their/our care.
Perhaps we have been thinking about this in a way that doesn’t really get at the heart of the problem. Perhaps it would help to go back to when our family was developing the short description of what care really should look and feel like and we were told that we were missing a keyword. One that we had been taking for granted. We took that advice and added SAFE, to the description of continuous, collaborative, patient partnered care.
Safety is not automatic or something that happens on its own. Nor is it something that can be looked at, or effectively addressed occasionally, or when convenient. Everyone has a role to play. To create a safe environment, or a safe system, safety has to be top of mind all of the time for absolutely everyone. It must be clearly demonstrated from senior leadership in an organization and run all the way through it. Everyone has to think of safety first in everything they do for themselves and with everyone else. The team must know and truly believe that it is their responsibility to identify any condition or action that may impact negatively on the safety of anyone and everyone. Organizations and industries that have achieved the highest safety standards are ones that recognize and celebrate the contributions of individuals who raise the alarm in order to make things safer. For example, people involved in the food industry must be vigilant and follow the processes in place that eliminate risk and maintain food safety. Aviation investigations are made public and lessons and recommendations are widely circulated. When there has been a loss of life regulations and laws change to ensure the safety of all involved. This doesn’t happen in the health system.
A true safety culture not only prioritizes being watchful and aware but also ensures everyone is open to learn and continuously improve. This culture must include how patients and families themselves think about what they can and should say and do in the situations they find themselves.
Last time we spoke of the need for the public to become involved and to help support the great people working inside and that are doing their best to improve “the system”. But there are a lot of assumptions made about the system – including how safe it is (or isn’t). One way to inform the public is to encourage conversations between providers and the public. The purpose is to listen and learn through questions and discussion. It is not to drive a certain narrow agenda but to build everyone’s understanding of the current reality, and to discuss what could be better and how.
We believe that going back to that very early advice we received is the right thing. We need to focus on Safety.Will a decision or proposed action impact safety? Safety for patients? Safety for their providers? Safety for the public involved?
When a patient is harmed, or continuity of care breaks down, is it because the safety was not paramount but became a lower priority than some other task or political priority? A true safety culture would ensure that together, everyone’s actions are built on striving for the safest path. No buts or other priorities
A strong safety culture also is one that has a continuous evaluation and learning character. Just because something was decided to be safe today, doesn’t mean that it will continue to be the safest choice tomorrow. We must also embrace the opportunity to learn from failures (or near misses) and to share what has been learned in order to prevent it from happening again.
We all have a role, as patients, as families, as friends, as providers, as leaders and as the healthy public, in always considering future decisions, futures steps, future policies, working from this fundamental lens of s
In our next post we will try to look at what we believe this means for these different roles and perspectives.