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Replying to @doctorcaldwell @KenZeroHarm and
Gordon, can you elaborate on why you haven’t defined any deaths as ‘Avoidable’ in the reviews you have done? Is it the term? The lack of definition? Or another factor?
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Replying to @Cjw450Cathy @doctorcaldwell and
It is possible to identify care that could have been better (although with hindsight bias) - but this can only be confidently seen as an association. Causation is very difficult to attribute in most cases. Learning comes from how we can improve care & not from definition IMV.
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Replying to @pkakodkar001 @doctorcaldwell and
Awareness of hindsight bias, limitations of ‘causation’ very important. How can ensure appropriate training and interpretation? as could easily be used as another tool of diversion and blame
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Replying to @Cjw450Cathy @doctorcaldwell and
If I understand you rightly you are saying ‘never events’ ‘ZHH’ are nirvana. The data will perhaps unfortunately prove you right - may be for decades. If we aspire for something big than not we are more likely to have a greater impact on reducing harm suffered in healthcare.
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Replying to @pkakodkar001 @doctorcaldwell and
There is a lot of background and reasoning to why ‘zero’ is a false panacea, and potentially harmful in itself, from wider Safety work in other industries... a great introductory video, lots to make you think...https://youtu.be/moh4QN4IAPg
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Replying to @Cjw450Cathy @pkakodkar001 and
ZHH I ask you to reflect on what you’re promoting
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Replying to @KenZeroHarm @pkakodkar001 and
I reflect on it every day, Ken. And I see less an less value in target-based improvement goals every time I look. Take some time to look at the texts I have attached.
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Replying to @Cjw450Cathy @KenZeroHarm and
Targets sometimes scare me too. Because it can lead to a tick box culture without listening. Equality matters, in terms of listening & treating people equally kindly. Observed-disparity in access to quality social healthcare really concerns me. I see a lot of divisive inequality.
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Replying to @kateheydonorg @Cjw450Cathy and
Targets are also counter to continuous quality improvement because once the target is met the implication is that the job is done and no further improvement needed
3 replies 3 retweets 4 likes
A target has to continue to be met each and every time, when measured as a %.
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Replying to @C7RKY @doctorcaldwell and
In theory that is all very sensible. But what it does not account for is human psychology. When targets become a big focus, standardisation of processes, etc, then the targets/processes pull cognitive focus away from the intended outcome.
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