Quality in healthcare: process

Recent studies have shown startling rates of adverse events and preventable mortality in hospitalised patients around the world. Research using root cause analysis and incident monitoring has improved our understanding of why these errors occur. These approaches are useful in identifying contributing factors and stakeholders involved in adverse and sentinel events. The factors that contribute to these events have been well described, and range from institutional and management decisions down to the individual health care professionals involved and the environment they work in. We discuss healthcare processes, and present a proactive approach of workflow process modelling using sequence diagrams to identify the factors involved. These diagrams can then be used in conjunction with simple calculations for risk analysis to prioritise the value of interventions at different steps of the healthcare process. We discuss how these analyses can be used to plan interventions to improve patient safety and quality of healthcare.