The role of knowledge management in promoting patient safety

1
The role of knowledge management in promoting
patient safety

• Bruce Madge
• Research and Knowledge Manager
• National Patient Safety Agency

2
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

3
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

4
Learning from Bristol

• We are creating a National Knowledge Service for
  the NHSwhich 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)

5
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
• gt400 million clinical negligence
  settlements/year
• hospital acquired infections cost 1 billion/year

6
Water
Lignocaine
7
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

8
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.
9
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 individuals commitment to a specific context.

10
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)

11
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

12
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

13
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

14
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?

15
(No Transcript)
16
Thank you for listening

• bruce_at_britishlibrary.net