Improving the Quality of Care in Hong Kong

Introduction

In healthcare, clinical governance plays a crucial role in ensuring the delivery of high-quality care. It is the basis of ensuring that patients receive high-end healthcare, and it also promotes the establishment and development of a robust healthcare system in a country. Dwyer (2019) defines clinical governance as the systematic approach that ensures patients receive safe and effective healthcare to improve their quality of life. It encompasses a system of processes, structures and integrated systems that focus on maintaining and improving patient care standards. According to Dwyer (2019), clinical governance integrates various facets, such as continuous quality improvement, risk management, patient safety, and professional growth and development.

In this essay, a comprehensive analysis of a case scenario sectioned under Category 1 of “The Annual Report on Sentinel and Serious Untoward Events (SUEs)” published by the Hong Kong Hospital Authority will be conducted, and strategies to enhance the quality of care in Hong Kong will be proposed. Through applying relevant models and frameworks, underlying issues that might be possible causes of the incident will be assessed, and the potential for change will be explored. In addition, the utilization of a chosen clinical governance strategy and the Audit cycle will be employed to improve the quality of practice in the specific healthcare field.

Case Scenario

“The Annual Report on Sentinel and Serious Untoward Events (SUEs)”, which is published by the Hong Kong Hospital Authority, gives a detailed summary of all Serious Untoward Events (SUEs) and Sentinel Events (S.E.) that occurred in hospital settings (Kong, 2019). Category 1 describes surgery/interventional procedures involving the wrong patient or body part (Kong, 2019). The scenario described in this essay is an interventional procedure involving a wrong patient undergoing the insertion of a nasogastric feeding tube. The error was only identified during the start of the feed when checking the feed prescription regime, and this case raised the alarm for the safety of patients in the acute surgical ward for patients with gastrointestinal (G.I.) diseases.

Analysis of the Healthcare Problem

Quality care refers to delivering healthcare services that meet or exceed established standards, resulting in optimal patient outcomes and experiences. In this scenario, quality care provision for patients with gastrointestinal (G.I.) disease in the acute surgical ward would entail several aspects. Patient safety is crucial in ensuring patients’ physical and psychological well-being as it helps minimize the risk of harm and prevents errors and adverse events (Chan et al., 2023). Standardized procedures are also essential in establishing guidelines and protocols that promote evidence-based practices, reducing variations in care and improving outcomes. Continuity of care ensures the seamless and coordinated transition of care to patients throughout their healthcare journey, from admission to discharge and follow-up (Chan et al., 2023). Finally, effective communication promotes clear and accurate communication among healthcare professionals, patients and their families to facilitate the exchange of important information and avoid any misunderstandings.

The Ishikawa Fishbone Diagram

The Cause-and-effect diagram, often known as the Ishikawa fishbone diagram, is a visual tool for pinpointing the causes of a particular issue. The model was created in the 1960s by a Japanese engineer, Dr Kaoru Ishikawa (Govindarajan et al., 2019). The fishbone model depicts the shape of a fish, with the issue at the fish’s head and potential causes branching out from it like the fish’s bones (See Appendix 1). The Ishikawa fishbone model is essential for clinical governance because it helps identify the various factors that may contribute to a given problem (Govindarajan et al., 2019). For the case scenario, the Ishikawa Fishbone model was used to analyze the incident and conclude on some factors that might have resulted in this problem. They included the following factors;

Human factors

Human factors are a significant contributor to medical errors and unfavourable outcomes. Mistakes can be caused by elements including exhaustion, workload, distractions, insufficient workforce levels, and a lack of proper training or competency (Govindarajan et al., 2019). Human factors may have led to the wrong patient receiving a Naso-gastric feeding tube insertion in the case scenario. This can involve medical staff members needing to be more relaxed, preoccupied, or more information or expertise to verify patient identification effectively.

Breakdown in communication

Clear communication is essential in healthcare to allow accurate information interchange, group decision-making, and safe patient care. Communication breakdowns, including misunderstandings or inadequate handoffs between shifts, can cause mistakes and jeopardize patient safety (Govindarajan et al., 2019). In the case scenario, communication errors could have happened when confirming the proper procedure and the patient’s identity.

Lack of standardized procedures

To guarantee reliable and consistent care delivery, standardized procedures are crucial. There is a higher chance of mistakes and errors from best practices when procedures need to be standardized (Govindarajan et al., 2019). In the case scenario, the occurrence in which the incorrect patient had a Naso-gastric feeding tube inserted might be linked to a lack of clear and consistent protocols for validating the proper procedure and establishing the patient’s identity.

Lewin’s Force Field Model

Change is recognized and implemented successfully when there is a balance of factors that drive and hinder the change from taking place. Lewin’s Force Field Model is a change management problem that was designed by Kurt Lewin in the 1950s and has been widely used in various industries to affect change. According to Shafaghat et al. (2021), change is effected when there is an interplay between driving and restraining forces (See Appendix 2). The driving forces can range from social, economic and psychological factors, and restraining forces hinder change.

From the case scenario above whereby a nasogastric feeding tube was inserted in the wrong patient, the Lewin’s force field model helps to assess driving and restricting force to gain insight on the specific factors influencing the identified healthcare problem and develop strategies to address them effectively (Shafaghat et al., 2021). The driving forces may include the desire for improved communication, employment of standardized procedures and concerns for patient safety (Shafaghat et al., 2021). On the other hand, the restricting forces that may hinder change include the complexity that occurs in the process of implementing new protocols, resource limitations and resistance to change from staff members. The identification of these forces is essential as it enables healthcare professionals to develop targeted interventions and strategies the drive optimizes the driving forces and overcome the restraining forces.

Restricting Forces

Organizational Culture’s Resistance to Change

Some healthcare organizations may have established cultures that are resistant to change, making it challenging to implement change through new processes and protocols. A hierarchical culture is a resisting force as it may discourage open communication and innovative thinking, making it challenging to implement new processes and protocols (Thompson & Reeve, 2022). Hierarchical culture is where decision-making authority is concentrated at the top levels of the organization. Thompson & Reeve (2022) further explain that a traditional-oriented culture can restrict the implementation of change in the healthcare organization. This type of culture ensures that practices and procedures that have existed in the organization are passed on, hence, the establishment of a sense of attachment to how things are done.

Limited Training Staff Opportunities

Lack of training and opportunities for development limit the implementation of change. Healthcare professionals may need more knowledge and skills to implement change or adapt new practices (Thompson & Reeve, 2022). Therefore, providing workshops and comprehensive training programs is essential in mitigating these barriers and ensuring all staff members are well-protected.

Resistance to Change from Staff Members

Existing procedures and practices can foster a risk-averse culture in healthcare organizations. Healthcare professionals accustomed to existing practices may resist change due to fear of the unknown, concerns about increased workload or perceived threats to their professional autonomy (Khan et al., 2020). However, these fears can be addressed through clear communication on the rationale and benefits of change and the opportunities for the healthcare professionals that arise from the change.

Inadequate Resources

Healthcare organizations in Hong Kong and China need more funding due to the high patient population. Therefore, this is a barrier to implementing change as financial resources, inadequate equipment, and staffing impede the change required to prevent a similar incident whereby a nasogastric feeding tube was inserted in the wrong patient from occurring (Vaughn et al., 2019).

Facilitators to Implement Change

Effective Communication Channels

From Lewin’s Force Field Model, one driving force for change is establishing effective communication channels. Open and transparent communication channels facilitate the exchange of information, ideas and feedback among healthcare professionals. For the case scenario described above, transparent and timely communication regarding the purpose, goals and progress of the change initiatives can help build trust and reduce uncertainties associated with the implementation of change required to prevent similar accidents from happening in the future.

Fostering a Culture that Encourages Innovation and Continuous Improvement

Lewin’s Force Field Model highlighted organizational culture as one barrier to change. However, there is a need to cultivate a culture that values innovation, encourages learning from mistakes and creates a conducive environment to change (Correa et al., 2020). In such a culture, professionals, even low-level management, can make decisions and give their opinions regarding matters affecting the healthcare organization.

Involvement of Key Stakeholders

Key stakeholders in a healthcare organization are frontline staff, managers, patients and relevant bodies and associations. Correa et al. (2020) explain that involving these stakeholders in the planning, decision-making and implementation processes fosters ownership, increases the likelihood of successful adoption and ensures that changes align with the needs and values of those directly affected.

Clinical Governance Strategy for Enhancing Improvement in Clinical Practice

Clinical governance is a comprehensive framework comprising various strategies and processes to ensure that high-quality care is accorded to patients (World Health Organization, 2019). It entails using a systematic approach to monitor, improve and maintain the quality and safety of healthcare services. For this case scenario, the most appropriate clinical governance strategy that can be employed to mitigate the risks and prevent future occurrences of a similar incident is the implementation of a Patient Safety Incident Reporting and Learning System. The acute surgical ward’s medical staff could report such accidents quickly if a patient safety incident reporting and learning system were implemented. According to Lansdown (2021), it would make it easier to spot system flaws, encourage people to learn from their mistakes, and allow for targeted interventions to stop such occurrences in the future. Moreover, it would make it easier to spot system flaws, encourage people to learn from their mistakes, and allow for targeted interventions to stop such occurrences in the future.

Benefits of Implementing a Patient Safety Incident Reporting and Learning System

Data Collection and Analysis: The reported incidents will be analyzed systematically. Simamora & Fathi (2019) explain that to identify common root causes contributing to patient safety incidents, data would be categorized, and trends and patterns would be identified. In a case scenario, problems with patient identification protocols, communication issues, or a lack of standardized procedures may emerge in the analysis.

Reporting occurrences: Any occurrences involving patient safety that healthcare personnel witness or are engaged in will be encouraged and given the authority to be reported (Simamora & Fathi, 2019). This covers situations where the wrong patient underwent an operation, such as the one in the case scenario. Staff members can report incidents confidently and without fear of retaliation using a confidential and non-punitive reporting mechanism.

Root Cause Analysis: To better understand the underlying reasons for selected incidents, root cause analysis will be carried out. According to, Simamora & Fathi (2019), this procedure entails determining the incident’s immediate causes, underlying causes, and systemic problems. For instance, a root cause analysis may show that poor communication skills or insufficient training on patient identification processes contributed to the wrong patient receiving the operation.

Interventions and Improvement Strategies: Targeted interventions and improvement strategies would be created and put into action based on the analysis and determined root causes (Simamora & Fathi, 2019). Revision and standardization of patient identification procedures, improved communication techniques, staff training on patient safety, or technical solutions like barcode scanning for patient identification are a few examples.

Steps Involved in Implementing a Patient Safety Incident Reporting and Learning System

1. Establishing Leadership Support: For an implementation to be successful, there must be leadership commitment and support (Carayon et al., 2020). This entails winning the support of senior management, collecting sufficient funding, and appointing a particular team in charge of guiding the implementation procedure.
2. Designing the Reporting System: Create a user-friendly, private incident reporting system that encourages healthcare workers to submit reports of occurrences as soon as possible and offers precise instructions on what incidents to submit.
3. Training and Education: According to, Carayon et al. (2020), holding training sessions and educational activities to introduce personnel to the incident reporting system, stress the value of reporting, and make sure they comprehend the procedure for doing so.
4. Establish a reliable mechanism for gathering data to record occurrences, near-misses, and adverse events. Analyze the information gathered to find patterns, trends, and common reasons contributing to patient safety events.
5. To identify the underlying reasons and systemic problems that contributed to a selection of incidents, do root cause analyses on those incidents (Carayon et al., 2020). This process identifies areas that can be improved and provides information for developing focused treatments.
6. Implementing the intervention: Create and put into action interventions and plans for improvement based on the root reasons that have been identified. These can involve updating procedures and enhancing communication.

Applying the Audit Cycle to Promote Quality Improvement in the Provision of Healthcare Services

The audit cycle is a methodical procedure used to evaluate and enhance the standard of care in healthcare facilities (Alyacoubi et al., 2021). It entails a constant cycle of planning, data collecting, analysis, action, and assessment to pinpoint improvement areas and implement adjustments that improve how care is delivered. Alyacoubi et al. (2021) explain that the audit cycle’s main objectives are to ensure that medical procedures adhere to accepted norms and regulations, increase patient safety, and enhance results. Healthcare companies can adopt the audit cycle to review their performance, spot gaps, and make evidence-based improvements to improve the quality of care.

Stages of the Audit Cycle

The audit cycle has five key stages: planning, data collection, analysis action and evaluation. Each stage is applicable in mitigating the risks associated with inserting a nasogastric tube in the wrong patient.

1. Planning: The audit’s goal is to evaluate and enhance the acute surgical ward’s patient identification and verification procedures (Xiao et al., 2020). The standards include adherence to procedure checklists, accuracy rates for patient identification, and adherence to standard identification processes.
2. Reviewing medical records, monitoring patient identification procedures, and speaking with staff members participating in the procedure would all be used to gather data (Xiao et al., 2020). The information would concentrate on events involving mistakes in patient identification and any underlying causes.
3. Analysis: The obtained data will be examined to determine the underlying reasons for the patient identification errors. This may entail seeing patterns or trends, looking into communication breakdowns, gauging the effect of workload or personnel levels, and reviewing the existence of standard operating procedures (Xiao et al., 2020).
4. Action: Using the analysis as a guide, action plans would be created to address the areas that needed improvement. Xiao, Geng & Yuan (2020) explain that this could entail updating and putting standardized protocols for patient identification, improving communication procedures, giving more patient safety training, or putting technological solutions into practice.
5. Evaluation: Post-intervention data and the initial audit findings will be compared to assess the success of the adopted actions (Xiao et al., 2020). A reduction in patient identification mistakes, enhanced communication, protocol adherence, and staff impression of the modifications made will all be evaluated in this review.

Outcomes that Result from Implementing the Audit Cycle in the Healthcare Organization

• Reduction in patient identification errors (Manita et al., 2020); Patient safety can be enhanced by reducing incidents and addressing the underlying causes of patient identification errors.
• Improved coordination and teamwork among healthcare workers can be achieved by implementing modifications to communication methods and protocols, which will also help to reduce misunderstandings (Manita et al., 2020).
• Procedure standardization; By creating and putting standardized protocols for patient identification and verification, differences in practice can be avoided, resulting in more dependable and consistent care delivery.
• Improved employee competency and training; the audit cycle may reveal areas where staff members need further training or resources (Manita et al., 2020). Filling in these gaps can improve staff competency and ensure they have the abilities and knowledge to deliver high-quality care.
• Culture of continual learning and improvement; Manita et al. (2020) explains that the audit cycle encourages this mindset within the healthcare company. The organization can strive for continuous quality improvement by routinely monitoring performance, implementing changes, and measuring outcomes.

Conclusion

Clinical governance is essential for ensuring high-quality care is delivered in healthcare settings. Healthcare organizations in Hong Kong can promote patient safety by putting the selected clinical governance plan into practice and using the audit cycle. The Patient Safety Incident Reporting and Learning System encourages reporting occurrences and learning from them, which enables the detection of systemic flaws and the development of focused treatments. Similarly, the audit cycle offers a methodical way to evaluate, examine, and enhance healthcare processes.

The significance of these frameworks is essential since they support a culture of safety and quality inside healthcare organizations and help to create a cycle of continuous improvement. Hong Kong may improve the standard of healthcare delivered to its inhabitants, resulting in improved patient outcomes and a safer healthcare environment for all by emphasizing clinical governance, implementing appropriate strategies, and using instruments like the audit cycle.

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