Clinical governance is built on the concept of continuous quality improvement, which is also the key concept of TQM or Total Quality Management. Clinical governance procedure should be aligned as a TQM system as that would help in the creation of high quality procedures and will aim at continuous improvement of such. This will also ascertain maximum value creation, reduction of wastage and errors to a great extent and will uplift the quality of healthcare for the maximum benefit of the patients (Devettere, 2009). Clinical governance received significance in the Hong Kong’s Hospital Authorities Annual Plan for 2017 – 2018 and as a part of it, the authority is determined to improve the status of healthcare services through aligning the system with effective procedures of quality control. Offering high quality healthcare services to patients is the main agenda for the hospital. This paper would be divided into three core segments – the introduction which presented the rationale of the paper and its background, the main body would delve into the chosen situation of incidence and commonality of needle stick injuries in healthcare settings to be analyzed on the basis of Ishikawa’s Fish Bone model and Lewin’s Force Field Analysis and finally the third segment which will summarize the key findings and present the scope for this paper.
Ishikawa’s Fish Bone Model
The main strengths of Fish Bone Diagram are that it accurately identifies the cause and effect aspects in a specific situational problem; it helps in creation of brainstorming of ideas and helps in identifying out of the box ideas; it displays the causal effects clearly and very logically and simultaneously depicts all the related causes; it stimulates problem solving and also aids the team to maintain its focus on the issue (McSherry & Pearce, 2011). On the other hand, the Fish Bone Diagram also has some key limitations. These are – the brainstorming often leads to identification of causes which are irrelevant along with the relevant ones, resulting in loss of energy and time; there is no means of understanding which cause is more important than the other ones through the diagram as all the causes are given the same importance in it; the complex interaction and relationships of a large number of factors are difficult to be depicted in a fish bone diagram and lastly, the diagram is not subjective (Breathnach & Lane, 2017). The situational analysis of Needle Stick Injuries is presented in a Fish Bone Diagram in later segments of this paper.
Needle-stick injuries or a percutaneous injury is an injury occurring from accidental penetration of the skin by a sharp object or generally needle, which has previously been in contact with tissue, blood or other body fluids (Muralidhar, Singh, Malhotra, & Bala, 2010). As per WHO’s World Health Report in 2002, out of 35 million health workers worldwide, 2 million of them experience such needle-stick injuries and get exposed to infectious diseases every year. 37.6% of the Hepatitis B, 4.4% of HIV/AIDs and 39 % of the Hepatitis C occurrence in healthcare workers around the globe is due to the needle-stick injuries (WHO, 2018). Hence, the gravity of the situation can be well understood from the statistics provided and it is of crucial importance that the causes be identified of such occurrence so that corrective strategies can be taken to reduce the occurrence of needle-stick injuries.
The main causes which result in the occurrence of needle-stick injuries are when healthcare staff draws blood, or administers the application of an IM (Intramuscular) or IV (Intravenous) drug, or performs a procedure which involves handling of sharp tools, accidents can occur and result in the transmission of blood borne diseases. These injuries can also occur during the recapping of needles, or the improper disposal of such in a poorly located container for used sharps or when such is overfilled. Lack of protective gear or lack of access to such, or the failure of an employee to use such equipment also increases risk of such occurrences (Devettere, 2009). Injuries pertaining from needle-sticks commonly occur when needles are passed in between personnel or when sutures are sown while being connected to the needles. It has also been witnessed that human factors, of exhaustion, fatigue and sleeplessness for long also has resulted in the occurrence of needle-stick injuries (Siegrist & Rodel, 2006). Chaotic environment in the Operation Theatre often disrupts the concentration of highly trained personnel and can lead to the occurrence of such injuries. High work pressure, low perception of risk, ill trained people etc all result in the high probability of needle stick injuries (Cousins, Mackay, Clarke, Kelly, Kelly, & McCaig, 2004). Lack of awareness about the gravity of the situation is also another aspect which can lead to serious outcome of needle-stick injuries. Hence, the key causes can be identified as follows;
-Ill managed workplaces, improper hospital management ( no provision for protective gear / ill placed protective gear which cannot be accessed on need )
-Ill trained staff ( do not know the use of protective gear / does not understand the gravity of such a situation / is not trained to handle sharp objects carefully)
-Improper manpower planning ( permitting low trained staff to administer drugs / assist in surgeries / to draw blood )
-Human Factors ( Fatigue / Exhaustion ) and chaotic environment in the OT can result in such occurrences
-Improper scheduling of work hours (which result in stress / high work pressure )
Therefore the Fish Bone Diagram which can be construed from the above mentioned causes are as follows;
Strategies to reduce the Occurrence
As there were six causes identified which leads to the occurrence of NSI, we would identify specific six strategies which will help in counter these causes. Primarily, NSI is a resultant of accidents which occur in hospitals. Though being cautious and careful and taking care of the other five causes will reduce the occurrence of a large number of these accidents, a portion of such can always occur as accidents are beyond anyone’s control. However, attempts should be made by the hospital management as well as the healthcare staff to reduce the chances of occurrences of such accidents to the minimal (Alli, 2008). Secondly, improper equipment placement by the hospital management can also act as a leading cause. To counter this, hospital management should refocus its attention of equipment placements in different parts of the floor, so that in times of need the staff can get hold of the specific protective gear and conduct their work safely (Champoux & Brun, 2003). And care must be taken in repeated servicing and maintenance of such equipments as well so that they are fit to use and do not have any quality issues when handled by trained staff (Champoux & Brun, 2003). Thirdly, ill trained staff is a big issue for the occurrence of NSI. Staff members who do not have expertise in handling sharp objects, who do not understand the gravity of the situation resulting from a NSI on their health and who due to poor knowledge bring about NSIs in their working partners, all need to be trained effectively by the management. Handling of sharp objects when the patient is around, is a very minute and accurate job and should be handles by individuals who have steady hands and strong expertise. Therefore, effective training would help in reducing the risks which arise from low confidence regarding the procedure and lack of effective knowledge about the safe practices. Improper manpower planning basically consists of two causes - which involves in assigning ill trained staff for operations or complicated drug administrations and in assigning more work- hours to the same individuals, resulting in extreme pressure and stress (Healy & Dugdale, 2009). Therefore, job assignment and personnel assignment are tasks which hospital management should do with care to avoid wrong assignments to wrong people, and to lower the build up of stress and pressure. Lastly human factors like fatigue and exhaustion plays is role in the occurrence of NSI. Human resource management of hospitals, must take care that the highly stressed individuals are not assigned tasks regularly and every staff must get free time to de-stress. Also the stressful environment in the operation theatre though is highly probable, but still management should take active efforts to assign only highly skilled staff so that they can better handle such stressful situations. Management can also assign a backup of skilled staff in case of taking care on wrong turn of events. Therefore after analyzing the individual strategies of the NSI causes, it can be said that instead of making individual changes, a holistic change has to be brought about by the hospital management which will ensure significant reduction of such cases. Therefore, the need for Clinical Governance can be felt which will help improvement of such situation comprehensively.
Lewin’s Force Field Analysis(FFA)
One uses the FFA, by defining the change one wants to see; mind map the resistors and the drivers; evaluate the drivers and resisters; review the forces; strategize and prioritize. The main advantages of the FFA are that a visual summary of all the forces for and against can be identified and it also helps in identifying potential obstacles. FFA can be used as a visual aid and can thereby simplify the communication and assist a group in developing a common understanding. The key disadvantages of FFA are it requires every individual in the group to participate which will help in better analysis but it is a difficult task to achieve and required time; it is difficult to obtain the complete picture and lastly, this FFA can have a negative influence on team work as this leads to identifying individuals who promote and who resist change and this leads to division in the group. For this specific situation of NSI, the drivers are – need to reduce the occurrence of NSI; need for improvement of the quality; more resources in terms of funding and manpower; improved human resource management; pro-change top management and clinical governance. The resistors of this situation are – aging manpower ; lack of interest and motivation ; high work pressure and low skilled manpower ; low funding and lack of resources ; unconvinced top management ; human nature etc.
Clinical Governance Strategies
Strategy 1 - Integrated Care Pathways
Strategy 2 - Risk Management
Strategy 1 – By the end of 2018, ICPs must be in operation regarding all the leading infectious diseases which patients bring in the hospital and every staff members and job allocation team must be made knowledgeable about the ICPs and provide training.
Strategy 3 – By the end of 2018, risk management teams will ascertain proper floor management and job allocation/ manpower training to reduce the NSI occurrences stemming from poor management and poor training.
Strategy 3 – Audit
A typical audit cycle is divided into five sub-stages : preparation stage, which is concerned with choosing a relevant high priority topic and identify the associated available resources; criterion selection, where standard or target is identified; measuring the present level of performance; making improvements and lastly, maintaining improvements (Kaynak, Toklu, Elci, & Toklu, 2016). For Scenario 3, the audit would be conducted in, firstly by gathering information regarding the occurrences of NSIs in specific hospital setting and understanding which diseases were involved when NSIs had occurred; secondly, identifying the reasons which have led to the NSIs – that is, identification of personnel who were involved and the reasons which resulted in such NSIs, that is, lack of protective gear, lack of skills, human issues etc ; developing a standard that 50% of such cases need to be eradicated by the end of this year ; taking strategies like changing the equipment plan per floor, conducting training and skill tests, allocation of more humane work pressure and establishing ICPs and lastly, conducting analysis of whether the standard has been achieved at the end of the audit session. Audit is an ongoing process so the second cycle of audit can being at the end of the first cycle and so on and so forth.
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