**3. How social work leadership can help improve the quality and safety of care: Especially for vulnerable individuals and groups**

Social work leadership is important because if we accept the fact (and I used that phrase advisedly and carefully) that patient safety is about the social as well as the technical dimensions of care, then social workers can provide unique insights and leadership into the risks and responses to those dimensions. In this section I will look at five areas in which social workers can provide leadership in patient safety: clinical governance (and other safety frameworks); understanding the social dimension of risks; advocacy; interprofessional practice; and equity.

### **3.1 Clinical governance**

Clinical governance emerged in the United Kingdom in the late 1990s as an approach to improving the quality and safety of care. It was developed at least in part as a response to major patient safety inquiries, especially the Bristol Royal Infirmary Inquiry into the higher than expected deaths in children who were undergoing operations for cardiac problems at that hospital. That inquiry found, as quoted by the British Medical Journal *"… poor teamwork between professionals, "too much power in too few hands," and surgeons who lacked the insight to see that they were failing and to stop operating"* ([35], p. 181).

Clinical governance was defined as *"a system through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"* ([36], p. 62). Many countries around the world, mostly but not entirely Commonwealth countries, have adopted all or some of the elements under a clinical governance approach. These elements include: *"accountability, vigilant governing boards and bodies, a focus on ethics and regulating qualified privilege. It also includes taking steps to institute measures such as continuous improvement, quality assurance, audit, applying standards and ensuring they are met, using clinical indicators, encouraging clinical effectiveness, promoting evidence-based practice, participating in accreditation processes, managing risk, reporting and managing incidents, focusing on patient safety, improving the sharing of information, supporting open disclosure, managing knowledge effectively, obtaining patient consent, providing feedback on performance, promoting continuous education, dealing with complaints effectively, encouraging consumers to participate in decisions affecting their care and credentialing of medical [and other] practitioners"* ([37], pp. 12-13).

While not all countries' safety systems may include all of these elements, most have adopted at least some of them. Social workers can and should be involved both in ensuring that such systems are in place, and in participating in the review processes to ensure a wider lens is included in activities such a root cause analysis processes [38].

#### **3.2 The social epidemiology of patient safety**

One specific role for social workers to contribute to clinical governance (and related activities) is in explaining and exploring the way in which individual's and group's social characteristics make increase their risk of adverse events and harm. There are multiple examples of this, but I would like to discuss two in particular: the way in which risks do not just start and end with the clinical encounter and what is known as diagnostic overshadowing.

As I discussed earlier in this chapter, relatively little work has been undertaken by patient safety researchers about the way in which a person's social characteristics may increase their risk of harm. This increased risk can occur prior, during or after the medical intervention. Research has shown, for example, that malnutrition increases a person's risk of hospital acquired infection. Yet it is well known both that geriatric patients are more likely to enter hospital with malnutrition and that some patients, including children and older adults, are at risk of developing malnutrition while in hospital [39, 40]. Malnutrition is a pre-operative risk factor [41], but understanding and responding to this risk requires both general clinical knowledge and an understanding of the vulnerability of particular individuals and groups.

#### *Social Work Leadership for Patient Safety DOI: http://dx.doi.org/10.5772/intechopen.105535*

Another example of increased risk is patients discharging themselves against medical advice (DAMA), and therefore missing out on the care they require. It is easy to think 'it's their decision' but the reality is that for many vulnerable groups, the reasons are due to factors such as the affordability of care [42] or in the case of First Nations people, a lack of cultural safety [43].

Another specific risk which social work leadership can address is the effect of diagnostic overshadowing. Molloy, Munro ([44], p. 1363) define diagnostic overshadowing in relation to people with mental illnesses in the following way *"One form of discrimination is diagnostic overshadowing, which is a judgment bias where health care professionals mistakenly attribute clinical manifestations of physical illness (eg, pain, tachycardia, hypertension) to manifestations associated with a pre-existing mental illness … This leads to physical illnesses being underdiagnosed and undertreated … Common causes of diagnostic overshadowing related to health care professionals who care for mental health consumers include fear, avoidance, lack of education, lack of confidence, and lack of clinical assessment, including symptom recognition … and negative unconscious bias".* Cho ([45], p. 1) adds that *"Systematic biases that disproportionately affect historically marginalized groups underlie some of these misdiagnoses."*

It is not only people with mental illnesses who experience diagnostic overshadowing. Evidence of the negative impact of diagnostic overshadowing has been identified, for example, in patients with schizophrenia [46], people with intellectual disabilities [47], people with learning disabilities [48], with physical disabilities [49], children and young people including children with Down's Syndrome [50, 51] and with autism [52].

Cho ([45], p. 1) argues that physicians (and I would add all clinicians) *"… must pay special attention to the ways in which they or their field may be unconsciously biased towards or lack information about certain identity groups."* This is a difficult topic and one which most decidedly requires leadership, including the ability to able to influence and negotiate with all the parties involved [53].

### **3.3 Equity**

One of the underpinning factors in the social epidemiology of patient safety is the equity of care. *"Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided*" ([54], p. 433). This requires that *"… equal access to available care for equal need, equal utilization for equal need, equal quality of care for* all" ([54], p. 434). I would add and equal quality and safety for all.

As noted earlier in this chapter, the Institute for Health Innovation in the USA has included equity as the quintuple aim of healthcare. This, it has been argued, requires that *"… all improvement and innovation efforts a focus on individuals and communities who need them most"* ([10], p. 521). Social work leadership can and should be involved in both identifying those individuals and communities who most need interventions and working to ensure that conscious discrimination or active bias does not occur.

The decisions around medical rationing during the COVID 19 pandemic are a case in point. Chen and McNamara ([55], p. 511) argue that *"The current public health crisis has exposed deep cracks in social equality and justice for marginalised and vulnerable communities around the world."* Lee ([56], p. 1) notes that the pandemic trigged "inequity amplifiers" including *"(1) expansion of riskscape, (2) reduction of social ties, (3) uncertainty of future, (4) losing trust in institutions, (5) coping with new knowledge,* 

*and (6) straining on public spending".* One way the 'straining on public spending' was addressed was through the issuing of treatment guidelines.

One way this played out was through the issuing of guidelines and decision tools around the world which were ageist and or ableist [57–59]. These clinical decisions tools compounded governments' often slow responses to provide the additional care required by these groups [60], even though it was clear from the start of the pandemic that they were at higher risk (as were people from certain ethnic backgrounds – both patients and staff). Discriminatory decisions ranged from the distribution of vaccines [61] to the provision of treatment and care, including *"… reported rise in the number of 'do not resuscitate' orders being imposed on people with disabilities … Vulnerable members of society, including older persons and people with disabilities, were seen as being most at risk, and healthcare professionals were advised to prioritise those who had the best chance of recovery in the event of a mass outbreak*" ([55], p. 1).

From an ethical and human rights perspective these clinical decisions, which would adversely effect some groups in the community and not others, were forms of iatrogenic harm [62]. The fact that these discriminatory guidelines emerged during a pandemic, or crisis, can provide a part explanation, but not an excuse, and they mirrored at a macro level, the decisions made at Memorial Hospital in the US during Hurricane Katrina, where patients were euthanised without their or their family's knowledge or consent [63, 64].

As Marks ([62], p. 104) argues, history *"… calls into question the very idea of the pandemic/non-pandemic distinction. Given the countless failures to heed warnings prior to COVID-19, and the inevitability of future pandemics, we must consider a pandemic as something that is either happening or about to happen. That argument becomes all the more compelling when we recognize that—as COVID-19, Hurricane Katrina, and many other crises periodically remind us—the burden of systemic failures to prepare for public health emergencies falls disproportionately on communities suffering from systemic inequalities."* In short what COVID has done is to show how deeply social attitudes towards the vulnerable can affect clinical decisions. The role of social work leadership? McGuire, Aulisio ([65], p. 23) (as part of the Association of Bioethics Program Directors (ABPD) Task Force) concluded their review of the ethical challenges arising in the COVID-19 Pandemic that *"Even in the face of the terrible burdens of an overstressed healthcare system, disability communities need special consideration to avoid inequities"*.
