Rationale
Health care providers are one component of a complex adaptive system whose goal is to maintain, enhance, and continuously improve systems of care that support the well-being of the population. Some patients will experience harm from the health care they receive or fail to receive. Health care providers who unwittingly contribute to patient harm may themselves experience psychological harm. Therefore, it is important that health care providers are able to respond effectively to such situations to help patients and their family members, themselves, and other health care providers heal and to contribute to the continuous evaluation and improvement of our health systems.
Key Objectives
Understand that quality and safety are important concepts that are founded upon the following:
- health care is a complex, adaptive system whose primary goal is to keep patients safe by avoiding harm;
- health care systems need to continuously improve to provide optimal outcomes for patients;
- health care providers need to respond effectively if harm occurs.
Enabling Objectives
Given the need to understand health care systems and their role within it, physicians will
- describe approaches to quality management (e.g., identify issues to improve, prioritize issues, test and implement solutions and measure outcomes);
- recognize the central role of patients as members of their health care team and in the design of their health care to most effectively respond to their needs;
- discuss their role as physician relative to other personnel;
- identify other components that influence the delivery of care (e.g., environments, equipment, organizations, regulators);
- understand the common domains of quality (e.g., safety, timeliness, effectiveness, efficiency, equitability, patient centredness);
- understand the role of cognitive bias in diagnostic errors;
- discuss error mitigation strategies (e.g., effective teamwork, identifying best evidence-based practices);
- describe the immediate management following an incident in which harm has occurred (e.g., resuscitation, ensuring a safe environment, securing equipment, protecting others, supporting those impacted, notification and disclosure);
- conduct an effective disclosure conversation with a patient and their family when appropriate;
- offer an appropriate apology (e.g., express remorse for what happened to the patient, accept responsibility when appropriate);
- have the ability to support another health care provider who has contributed to an event where a patient has been harmed;
- describe an effective system analysis that can answer what, why, and how harm happened.
