Improving Patient Safety - How to Use Service Modularity in Healthcare Processes to Manage Systemic Errors

Abstract

Complexity in healthcare processes stems from the diversity of the components of the service in terms of activities, personnel, resources needed, organizational practices, patient complications and types of services. Current organizational practices have not tackled complexity adequately, allowing for unacceptable levels of errors leading to patient harm. This study suggests firstly at study processes as complex adaptive systems by using the Healthcare Error Proliferation Model, and secondly by using the concept of service modularity in this model in order to redesign the architecture of the processes. For this purpose, 5 healthcare processes from the surgical ward of a UK hospital are analysed through FMEAs, Root Cause Analysis and expert interviews; and their defence layers are used as interfaces where the process components can be reconfigured. The study also uses 5 industrial examples (rail, marine, chemicals, construction, and animal hospital) to show how this is applicable in other settings.