Managing risk around upstream services
Those who clean, sterilise, transport patients and provide administrative support within hospitals and health services are often left out of meaningful participation in multidisciplinary care teams, ward management and other ‘clinical’ operation — to the detriment of safety service standards.
Those who are concerned with the quality and safety of health care know all too well about the ‘systems approach’.
Thinking about quality, safety and risk management from this ‘systems perspective’ is to acknowledge that error and harm in health care are influenced by a variety of ‘upstream factors’ located in the wider system of care.
In this way of thinking, safe care is not just about what happens on the ward, or between practitioner and patient. Instead, thinking about safety means thinking about how upstream factors influence patient care in either a ‘more safe’ or ‘less safe’ direction.
Managing upstream factors
These upstream factors are well known. They include quality of teamwork, communication, the allocation of tasks, workload scheduling, equipment and resource management, and broader service cultures.
Whilst this ‘upstream’ impacts the quality and safety of the work and care of all participants in health care, it is ‘peopled’ particularly by the ancillary staff of hospitals and healthcare services: the clerks, cleaners, sterilisation technicians, porters and maintenance staff who schedule and timetable; who administer and operate communication systems; who purchase, store, provision and maintain equipment; and who physically clean, sterilise and transport patients and provisions.
Given the importance of upstream factors in our understanding and response to healthcare quality and safety risk and failure, this diverse group of staff should be by now a key asset in efforts to improve quality and safety. However, they are not.
Impact on infection control
Take the challenge of environmental cleaning. Effective environmental cleaning is absolutely central to maintaining high-quality and safety hospital-based care. And the news that the multidrug-resistant bacterium Enterococcus faecium is becoming increasingly tolerant to alcohol-based disinfectants and hand rubs commonly relied upon in our infection control regimes means we are entering an age where hospital cleaning practice and process must become more rigorous and well-managed.
Yet results of the recently concluded REACH study into hospital cleaning undertaken by QUT and Wesley Medical Research mapped considerable variation in the auditing process used to evaluate environmental cleanliness, cleaning practices, product use, training and communication pathways available to cleaning staff across 11 hospitals in Australia.
Service standard failure
So too is this the case with sterilisation services. In recent memory, Fiona Stanley Hospital in Perth witnessed the complex mix of an outsourcing strategy and serious failures in service standards in relation to its sterilisation services. In that instance, the state government stepped in and took over the management of the formerly outsourced sterilisation services after human tissue was discovered on sterilised equipment.
Two years on, both the health service and the contractor remain in negotiations regarding cost recovery from the removal of sterilisation from contracted services, with the WA Auditor General noting that contract disputes continue, with an estimated $6–7 million in dispute.
Integrating upstream into mainstream
Both of these challenges of environmental cleaning and sterilisation are ‘core business’ for delivering safe and high-quality hospital services. For this reason, those who work in cleaning, sterilisation services and other parts of our health services must become an integrated part of our efforts to increase quality, reduce harm and manage risk. More than integrated, they must become core to our efforts, and so too must their skills and valuable craft-based knowledge that is built up over years of working in their roles.
Empowering those who work in often forgotten parts of our hospitals with training and recognition of existing skills and knowledge, alongside new forms of formal certification, is one path that will likely support high-quality services. Sterilisation technicians have been engaged in this approach, with the emergence of the Certificate III in Sterilisation Services now fast becoming a prerequisite for employment.
This journey towards professionalising and certification will hopefully lead to enhanced service standards and professional skill. It may also result in those working in sterilisation and infection control being recognised for their expertise, borne from both theoretical and practical experience.
All this notwithstanding, if healthcare facilities are serious about ensuring patient safety and managing risk, incorporating those who work in upstream roles into mainstream safety and quality processes is essential.
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