**1. Introduction**

In this chapter I will explore the under-realized potential of social work leadership as a way of improving the quality and safety of care for patients and clients, and in particular for vulnerable individuals and groups. I begin by briefly examining what we know about patient safety, including the gaps to that understanding. I then explore a new approach to patient safety – one which draws from social epidemiology, ending with several ways in which social work leadership can contribute to increasing the safety and quality of healthcare through specific leadership competencies.

#### **1.1 Patient safety**

Patient safety is an enduring concern in healthcare as evidenced by the wording of the Hippocratic Oath, written in the second half of the fifth century BC, which speaks to the potential for harm caused by healthcare professionals and interventions [1, 2]. Indeed, several 'waves' of concern about the quality and safety of care have been identified over recent centuries, including Ignaz Semmelweis' attempt to reduce hospital

infections in the 19th Century [3], through to the 20th and early 21st centuries [4] and the development of clinical governance and related frameworks.

There is no doubt that the patient safety movement has gained momentum over recent decades, not least of all because of mounting evidence for the persistent rate of errors and adverse events [5]. While estimates vary across countries and service types, it is generally accepted that somewhere between 10 and 12% of people admitted to hospital will experience some form of adverse event [6]. Panagioti, Khan [7] for example found that least one in 20 patients suffer harm that is preventable with around 12% of preventable harm resulting in permanent disability or death.

In recent years the United States the Institute for Health Innovation (IHI) has developed what they originally called the triple aim of healthcare. This framework sought to accelerate the improvement of care by integrating (what were then considered to be the) three most important aspects of healthcare delivery, namely: improving patient experience; improving population health; and lowering per capita costs for healthcare [8].

Over time the IHI have added two more aims for healthcare systems. The first addition was ensuring clinician wellbeing (the quadruple aim) [9]. The most recent addition, in 2021, has been that of health equity move the framework to one of a quintuple aim [10]. Whether or not individual services or systems follow the IHI framework, it provides a useful insight into the nature of healthcare as a complex adaptive system, and the types of organizational and professional relationships that can operate to either facilitate or prevent errors [11, 12].

There are three issues which emerge from the current phase of the patient safety movement which we need to considered relation to the role of social work leadership in patient safety. The first issue is that the rate of adverse events has not decreased significantly despite two decades (and more) of effort around the globe. As Mannion and Braithwaite ([13], p. 685) argue *"… despite extensive efforts by many committed and well-intentioned policy-makers, managers, clinicians, researchers and patient groups, it is disconcerting that improvements in safety have been confined to a few celebrated examples or niche areas …. Where there have been solutions advanced, they have proved difficult to sustain and spread, with recent studies confirming there has been little or no measurable improvement in the overall rates of preventable harm at the systems level."*

The second issue is that errors are categorized in two ways. They are either *"An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome"* ([14], n.p.). Much more is known about errors of commission than errors of omission, although McGlynn, Asch ([15], p. 2635) that in their US study at least *"Participants received 54.9 percent … of recommended care"* meaning that just under a half of all patients were missing out on some type of intervention/assistance they should have received. What we also need to consider is Tudor Hart's inverse care law (after the UK general practitioner who first described this principle) which states that "*The availability of good medical care tends to vary inversely with the need for it in the population served"* ([16], p. 405). Iezzoni ([17], p. 2093) also warns about the particular risk for vulnerable groups, and in particular people with disabilities. She notes *that "People with disability experience health care disparities, including delayed diagnoses … Evidence suggests that these disparities often arise from erroneous assumptions health care providers make about the lives and values of people with disability"* – a perspective that was evidenced throughout the course of the COVID pandemic (as I will discuss later in this chapter).

The final issue is that few, if any, health systems or services collect systematic data on the type of patient who have experienced errors. This means that we do not have

a clear understanding of whether the prevalence or type of errors are the same for different groups, and topic which I will return to later in this chapter.

## **1.2 Leadership and patient safety**

Leadership and patient safety are inextricably linked, particularly but not only, in relation to leaders' role in establishing and maintaining safety cultures [18] and providing oversight of service quality [19]. Our understanding of the type of leadership required to ensure the quality and safety of care has changed over recent years. The Agency for Healthcare Research and Quality ([20], n.p.) states that *"Although the concept of leadership has traditionally been used to refer to the top rungs of an organization, frontline workers and their immediate supervisors play a crucial leadership role in acting as change agents and promoting patient-centered care. As the safety field has evolved, there is a growing recognition of the role that organizational leadership plays in prioritizing safety, through actions such as establishing a culture of safety, responding to patient and staff concerns, supporting efforts to improve safety, and monitoring progress."*

Indeed in recent years, and as a result of numerous public inquiries into various patient safety failures, there has been a decided shift away from the concept of leadership as 'the tope rungs of an organisation' to the idea of distributed or systems leadership. The King's Fund in the UK recommended that "The old model of 'heroic' leadership by individuals needs to adapt to become one that understands other models such as shared leadership both within organisations and across the many organisations with which the NHS has to engage in order to deliver its goals. This requires a focus on developing the organisation and its teams, not just individuals, on leadership across systems of care rather than just institutions, and on followership as well as leadership" ([21], p. ix).
