The role of knowledge management in promoting patient safety Bruce Madge Research and Knowledge Manager National Patient Safety Agency
Outline • Definitions of KM and Patient Safety • How will Knowledge Management help patient safety? • Example: How is the NPSA going about this? • So how can KM help? • What is the role of the Knowledge Manager? • Conclusions
The NHS Plan “The NHS will provide open access to information about services, treatment and performance” (Core principle 10) “ Each week will see millions of hits on the NHS Direct Internet site” (1.9). “Patients will be helped to navigate the maze of health information through the development of NHS Direct Online, digital TV and NHS Direct information points in public places” (10.2) The NHS Plan July 2000
Learning from Bristol “We are creating a National Knowledge Service for the NHS…which will meet the needs of professionals, patients & the public for up to date evidence based information by fully integrating the development of NHS knowledge systems (e.g. NHS Direct, NHS UK, National electronic Library for Health, Department of Health websites)… This is a complex development which will take time and resources” (Learning from Bristol: the Dept of Health response to public inquiry into Bristol Royal Infirmary Jan 2002)
Adverse events in the NHS • adverse events occur in around 11% of admissions, or at a rate of 850,000 per year • adverse events cost approx. £2 billion/year in hospital stay alone – extra 7.5 - 8 extra bed days attributable to incidents • around 1150 people/year in recent contact with mental health services commit suicide • 400 people/year die or are seriously injured in adverse events involving medical devices • >£400 million clinical negligence settlements/year • hospital acquired infections cost £1 billion/year
How will Knowledge Management help? ‘A fluid mix of framed experiences, values, contextual information and expert insight that provides a framework for evaluating and incorporating new experiences and information. It originates and is applied in the minds of knowers’. Davenport and Prusack: Working Knowledge: How Organizations Manage What They Know. Harvard Business School Press 2000
But more than that… Knowledge Management is about what we all do implicitly and that is provide the best possible care through knowledge and learning from other peoples experience.
The two aspects of Knowledge Management • Explicit knowledge is formal and systematic, easily communicated and shared. Examples are: product specifications, scientific formulas, and computer programs. • Tacit knowledge is ‘highly personal’, hard to formalise and therefore difficult to communicate to others. It is deeply rooted in action and in an individual’s commitment to a specific context.
How will Knowledge Management help patient safety? • Explicit knowledge • Embedded in the research literature • Quality web resources i.e. NPSA, NPSF • Tacit knowledge • Experience both from patients and professionals • i.e Improving the Patient Experience programme • Surveys • Complaints • Direct reporting (i.e. NPSA)
Example: How is the NPSA going about this? • Developing a information resource on patient safety • Books, Journals, Leaflets, Web resources • Collecting the patient experience • By E-form, By e-mail, By letter, By telephone • Involving patients in: • Prioritisation • Solutions • Design of the Eform • Ensuring corporate transparency
So how can KM help? • By bringing together explicit and tacit knowledge gained from patients, the public and health professionals • By using this knowledge to improve processes and systems – knowledge into action • To learn from the experience and to work this learning into training • Supporting emerging communities – the “Expert Patient”
What is the role of the Knowledge Manager? • Ensuring quality of literature reviews • i.e Johns Hopkins case • Clinical Librarianship (the “informationist”) • Collecting and making accessible the patient safety literature • i.e ZETOC • Consortium approach? • Creating a taxonomy for patient safety • Starting to collect meaningful figures • Working with PALS and their European equivalents
So what does this mean? • For the organisation • Ensuring the patient experience is heard and acted upon • Tempering the rigor of evidence with patient choice • For us • Promote the idea of working in clinical teams • Working with educational establishments to develop crossover curricula • Illustrating the risks of not getting good literature searches • Start collecting meaningful statistics at a national level • Regulation?
Thank you for listening email@example.com