PERCEPTION OF A MULTIDISCIPLINARY TEAM ON THE FACTORS CONTRIBUTING TO ADVERSE EVENTS AT A UNIVERSITY HOSPITAL

The objectives of this study were: to analyze the perception of a multidisciplinary team of a university hospital on factors contributing to adverse events (AE); to associate such factors to Parasuraman, Berry and Zeilthaml’s dimensions of service quality. This is an exploratory and descriptive study with a quantitative approach and prospective data collection. The population consisted of 98 professionals with a BS in Health. Data was collected from May to June 2010, through a questionnaire with the consent of the Research Ethics Committee of that institution. The research population consisted mostly of young adults; 74.5% were female; 31.6% had a post-graduate degree. The perception of professionals on the factors influencing AE related to dimensions of quality was: responsiveness to customer’s right to refuse procedures; empathy towards customers’ satisfaction and confidence in recommending the institution. Among the participants, pharmacists and nurses conveyed their perception more emphatically. The most cited AEs were: expected or unexpected (according to package insert) pathological effects in medical treatments, medication errors and falls. This research helped to understand the perception of the multidisciplinary team about the factors contributing to the occurrence of adverse events; it supports the redesign of care and management processes focusing on risk management.


INTRODUCTION
Systematic evaluation of work processes in health services aimed at improving quality of care is the guiding principle of health care institutions.Such process involves evaluation, measurement and management of institutional strategies directed to the improvement of care, which benefits both customers and professionals and contributes to the competitiveness of the institutions.
Errors or non-compliance can happen in the care process; they are characterized as failures in action planning or as the wrong execution of a plan to achieve desired goals.It can occur at any phase of the care process, from prevention to treatment. 1 However, customer's dissatisfaction associated to poor service delivery of several organizations demanded the set-up of quality standards such as professional excellence, efficient use of resources, minimal risk to the user, a high level of customer acceptance and positive effect on health. 2 In such context, some governmental and non-governmental initiatives have developed permanent processes for evaluating and certifying the quality of health services, enabling the continuous improvement of attention to the customer, in order to provide quality and humanized medical care. 3t is essential to offer quality care, service evaluations and concern with the prevention of risks inherent to the care process.Identifying risks, developing risk prevention strategies and conveying to the team the importance of recognizing risks are the goals of risk management.
The professionals' perception on quality leads to the need to forecasting, provision, implementation, monitoring and risk prevention; therefore, the quality assessment of an activity is of paramount significance in the work process of health professionals. 4

RISk MANAgEMENT Of ADVERSE EVENTS (AES) AND ITS REPERCUSSIONS IN HEALTH SERVICES
Risk management plays a fundamental role in healthcare organizations by providing support and information to decision makers and offering a safe environment to customers and professionals.
It aims to reduce to an acceptable level, proactively, the identified risks through assessment and prevention rather than reactive actions and remediation.
Health services quality programs strive to promote environmental quality, risk management and adherence to compliance standards, focusing on improving the organization's performance and customer safety. 5isk management is the mapping and the strict control over the flow of activities and the implementation of the culture of shared responsibilities; it aims at achieving the cooperation among teams and an intensive and close attention to customers. 6isk management is the systematic and continuous application of policies, procedures, behaviours and resources in the assessment and control of risks and AEs that threaten safety, human health, professional integrity, the environment and corporate image. 7everal authors state that risk-based auditing complements the set of procedures and evaluation methods in order to estimate the potential damages to organizations and health. 8They mention a number of risk factors which, when detected, reported and treated, avoid AEs.According to these authors, risk management aims to: l reduce the likelihood of actual or potential flaws in their processes; l maximize current process reliability through the analysis of failures; l minimize errors and increase quality in both clinical and administrative procedures.
Risk is classified according to the likelihood of an AEa situation that affects the integrity of health professionals or customers.
AE is an event related to health and/or services provided to customers, it is not consequence of their health condition and it causes an unintentional damage. 9he practice of error reporting is adopted in several countries in order to avoid its frequency; underreporting means that reported errors do not represent the totality of errors occurred during the working process.The purpose of error notification is to find the causes of their occurrence and the failures in the process.After identifying the causes, strategies to correct the processes are implemented to avoid the recurrence of similar errors. 10
attention to customers; it encompasses accessibility, sensitivity and effort in understanding customers' needs.
Reliability can be considered as a result; tangibility, responsiveness, assurance and empathy are structural and procedural dimensions.The use of these dimensions has proved effective to measure customers' perceptions and expectations on quality of service.This evaluation model was chosen here because the quality dimensions related to AEs perceived by health professionals can demonstrate intervening factors linked to customer safety.
Thus, health professionals and internal customers can perceive (or not) the risks to the latter and external users; each quality dimension has a comprehensive view of customers' needs.
The use of the five service quality dimensions gives providers a wide view of the various aspects of customer care; it focuses on situations users are exposed to that may offer some kind of risk.The detection of a health risk or AE enables its investigation, prevention and treatment.
Based on these evidences, this study aimed at analysing the perception of a multidisciplinary team at a university hospital on factors that contribute to the occurrence of adverse events (AEs) and relate them to Parasuraman, Berry and Zeilthaml's quality dimensions.

METHODOLOgY
This is an exploratory and descriptive study with the use of quantitative approach.
It was carried out at a large private tertiary university hospital in Campinas, state of São Paulo (SP).
It was submitted to the institution's Research Ethics Committee; approval was granted in April 2010 under Protocol Nº 0221/10.
The research population consisted of health professionals with university degree who met the following eligibility criteria: l professionals involved in direct customer care; l professionals with at least 12 months experience in the institution.
A total of 241 professionals met the above criteria and agreed to participate in the research; there were six nutritionists, seven pharmacists, ten physiotherapists, fifteen clinical analysts, ninety--seven nurses and a hundred and six physicians.Among these, ninety-eight (41%) returned the data collection instrument and formed the group of research subjects: three nutritionists (50%), four pharmacists (57%); seven physiotherapists (70%), eleven clinical analysts (73%), forty-seven nurses (48%) and twenty-six physicians (24%).After being contacted and the objectives of the study explained, the professionals were invited to participate in the investigation and they were given the Statement of Informed Consent.

THEORETICAL fR AMEwORk Par asur aman, zeithaml and berry's five quality dimensions
Quality is the customer's assessment of overall excellence or superiority of a service.Thus, knowledge on customers' perception is relevant to health services since the gathering of information will benefit service organization.Service quality assessment was defined in the late 1980s as based on three characteristics: a) the first is concerned with the services intangibility, assessed according to the performance and customers' experiences; b) the second, with the heterogeneity of services, with the possibility of different performances and assessments depending on supplier and customer.The latter considers services production and consumption as being inseparable, thus hampering their control and evaluation. 11he belief that the existing knowledge on product quality was insufficient to understand service quality became the starting point to the development of a model for service quality.According to the above authors, failure to understand service quality comes from the way goods are produced, consumed and evaluated.From the moment a service is offered, it is difficult to accurately capture the evaluation criteria used by customer/worker; they usually assess a result and the service delivery process and quality; they consider all other aspects essentially irrelevant. 12ive dimensions of quality were then defined in order to assess customer satisfaction.They are not mutually exclusive, yet provide important subsidies for understanding customer's expectations; they are aspects that delineate the service from the point of view of the customer that is going to assess it.
The five dimensions of quality are as follows: l tangibles: it refers to the appearance of physical facilities, equipment, personnel and communication materials; represents the material aspect of supply that can be perceived by the five human senses.
l reliability: it refers to the supplier's ability to deliver a safe and efficient service; it is the ability to provide the contracted service reliably; it reflects a consistent, flawless performance the customer can trust.The supplier must fulfil expectations, with no possibility of remake; in this dimension, customers' expectations are higher with narrower zones of tolerance than in the others.The data collection tool aimed at evaluating the perception of different professional groups on AEs, relating them to Parasuraman, Zeithaml and Berry's five dimensions of quality: reliability, responsiveness, tangibles, assurance and empathy.Five questions were prepared for each dimension, relating the factors involving the occurrence of AEs and the dimensions of quality.
Table 1 shows the dimensions of quality, number of questions and the researcher's proposed themes.
A pre-test was conducted in order to verify the relevance of the instrument; there was no need to restructure it.

RESULTS AND DISCUSSION
The study findings were analysed and interpreted by the researcher in two parts: a) classification of participants; b) analysis of the relationship between the multidisciplinary team's perception on the factors contributing to adverse events and Parasuraman, Zeithaml and Berry's five dimensions of quality.
The studied institution invests in professional development and training; there is a multidisciplinary residency program, post-graduate incentives and welcoming programs to the newly-graduated.Such policy explains the high number of young adults among its staff.
A total of 73 professionals (74.5%) were female and 25 (25.5%)males: female professionals predominated in all areas.
Time elapsed since graduation varied from one to thirty--two years (average of 11.36 years with a standard deviation of 7.80 years and a median of 9 years).
As the institution is a teaching hospital, there are many professionals -50 (51%) -with up to 10 years of experience: the researchers assumed that the participants were experienced professionals able to recognize and analyse the quality of care delivered.
Although there is a human resources development policy, the number of candidates to post graduation courses is not significant: only six of them obtained a master's degree and four a Ph.D.

Analysis of the multidisciplinary team's perception on factors related to the occurrence of adverse events with Par asur aman, zeithaml and Berry's five dimensions of quality 12
This section presents and analyses data collected through open and closed questions related to the dimensions of quality.Table 2 presents the affirmative and negative responses.
Table 3 presents the results of 98 (100%), since some participants failed to respond.
Table 2 demonstrates that the dimension with more positive answers was responsiveness -94 (95.9%) -for the right to refuse treatment (question 12); followed by 92 (93.9%) in question P23 (empathy) on customers' satisfaction; and 86 (87.8%) in reliability (question P8) regarding the recommendation of the institution.

Tangibles
The tangible aspects addressed in this study are physical facilities and human resources, materials and equipment, representing thus the structure for the provision of health services.
The groups differ in relation to questions 1, 2 and 3, which deal with human, material and physical resources, safety related to equipment and involvement in procurement policies.
Complementing the closed questions, Table 3 displays the open questions; it is possible to infer the concern with the quality of processes related to human resources and direct care to customers.
Regarding knowledge on equipment safety, results demonstrate the need to convey the importance of preventive maintenance and of the involvement of professionals in this process.
The predominant dimensions were related to subjective aspects, being possible to infer the concern with processes and results of services delivered.
The dimension with less prevalence of positive responses was tangibles (risks related to the structure) with 38 respondents (38.8%).It is an alarming result for it raises doubts about strategies employed in risk monitoring and the efficiency of actions against them.
The convergence between this study and the results previously found by Parasuraman, Zeithaml and Berry, in which reliability scored highest and tangibles was the less mentioned for achieving quality of service. 12n order to describe the behaviour of the groups in relation to the 25 questions, the results in Table 1 were subdivided according to the analysis of the responses, as shown in Tables 2, 3, 4, 5 and 6.

Responsiveness relates to the readiness of professionals to courteously, promptly and with precision meet customers
The groups differ in questions 11 and 15 -evaluation of work processes and involvement in protocol development.These themes are relatively new in health area, since they are being discussed after initiatives for quality certification of institutions.
Table 5 explains factors related to responsiveness from the perspective of the participants; most professionals do not know about work processes evaluation, that protocol development is not shared with all groups and that amendments need to be widespread.

Assur ance
Assurance refers to courtesy, knowledge of the needs and expectations of customers and professional ability to convey confidence.
The groups differ in questions 16, 17 and 18 -process monitoring, risk monitoring and the concept of AEs.Such moni-Concerning the participation in procurement policies, centralization can undermine the participation of professionals in the process.
Although most groups have responded affirmatively regarding the quantity of human resources, dissatisfaction with the professional qualification was shown.

Reliability
Questions on the supplier's ability to safely and efficiently perform the service were analysed; it consists of the ability to provide the service agreed upon reliably and faultlessly.
It was observed that the groups differ in questions 6, 8 and 9 -established protocols, recommendation of the institution and involvement, respectively.These themes are related to the staff's commitment, enthusiasm and motivation and are currently one of the biggest challenges to health institutions.
In Table 4 -open questions on reliability -customer safety is one of the main topics.
The need for an ombudsman service for internal users was mentioned, proving to be a vehicle for professionals to express themselves.

Empathy
In this investigation, empathy was characterized by questions that verified the ability of the professional to put him/ herself in the customer's place and to offer an individualized care; it includes accessibility, sensitivity and effort to meet the customer's expectations and needs.The study revealed that the groups did not differ in respect to empathy.The questions dealt with empathic care, customer's expectations and needs, customer satisfaction, professional qualification focussed on the customer, professional skills and empathy.Customer's rights vary according to cultural and socio-political contexts, depending on how they structure, implement and distribute individual, social and political rights in different situations and also how the relationship between health professional and customer was established.
Even so, there is growing international consensus on the following principles: customer's right to privacy, to confidentiality of diagnostic information, to consent to or refuse treatment and to be informed about the procedure's relevant risks. 17able 7 highlights that empathy is directly related to individual profile and to the commitment to adapt environment and devices to customers' needs.From the perspective of the participants, the institution does not promote professional training focusing on empathy and this issue is present neither in training nor in the professional staff's performance evaluation.toring needs well-defined indicators to enable diagnosis and more assertive decision making.
Table 6 reveals that professional groups recognize the tools used by the institution for monitoring care and administrative processes as well as risks; however, they stated that customers are not informed on AEs.
Results highlight the lack of standardization of actions to be taken in case of an AE.
The various professional groups identified ten situations recognised as AEs, cited more than once by the different groups.
The AEs mentioned were: l medication errors: cited only by nurses; a daily practice not less risky to customers.The administration of medicines is a common intervention in hospital environment; recent studies have shown errors in drug treatment that result in patient harm that go from not receiving the needed drug to injuries and death. 13,14  the event of an AE, the doctor's name is revealed and a noncompliance report is submitted and sent to quality service.
The occurrence of an AE prompts changes in protocols, Standard Operating Procedure (SOP), training and guidelines Investigation of the root cause to prevent AE red in process monitoring, risk monitoring and definition of AE; they agreed on information to customers about EA occurrence and actions against EAs.The most cited AEs were: pathological effects expected or unexpected (according to package insert), medication error and fall.
l empathy: highest rates on customer satisfaction -92 (93.9%) -and the lowest -55 (56.1%) -on professional qualification focussing on the customer.There were no differences among the groups in the questions for this dimension.
Regarding the factors influencing AEs related to dimensions of quality, it was observed that:

CONCLUSION
The present study revealed the professionals' perception on factors involving the occurrence of AEs, related to the five dimensions of quality: l tangibles: had the lowest rate -38 (38.8%) -of affirmative answers to risks related to structure.The highest rate -83 (84.7%) -was on human, material and physical resources; the groups differed in the latter as well as in safety related to equipment and participation in procurement policies; they agreed on sizing of human resources and the risks related to structure.The majority of participants -57 (58.2%) -was dissatisfied with the quality of the institution's human resources.l reliability: 86 (87.8%) participants would recommend the institution to relatives and friends.Information to customers on risks had the lowest rate -60 (61.2%).The groups differed in established protocols, recommendation of the institution and professionals' participation; they agreed on the safe implementation of activities and the information to customers about risks.l responsiveness: presented the highest rate of affirmative responses -94 (95.9%) -on customer's right to refuse treatment.The lowest rate -48 (49%) -was on customer guidelines manual.The groups differed in work process assessment and involvement in protocol development.
l assurance: the highest rate was found in risk monitoring -61 (62.2%); the lowest -43 (43.9%) -on information on AEs occurred and actions taken against them.The groups diffe-

l
responsiveness: refers to the provider's readiness to help customers by providing a courteous, precise and fast service.It relates to the willingness of the staff to assist customers and to the promptly delivery of services.l assurance: it is the employees' courtesy, knowledge and ability to convey trust.

l
empathy: it refers to the ability to demonstrate that the organization cares about users and provides personalised Data was collected between May and June 2010, through a questionnaire -after approval by the Research Ethics Committee was received.The data collection instrument consisted of: a) the participants' social and demographic data; b) the professionals' perception on AEs subdivided into open and closed questions.In the open questions, the participants could elaborate on the positivity and negativity of their reply.

4
Lack of professional qualificationMistakes in choosing the professional profile Little training directed to professional qualification 5 Entrance in poor conditions Small sectors with no isolation area Areas and furnishings in need of improvement Failure in access control at the institution Disregard for the guidelines of the Committee on Hospital Infection Control

Table 4 -Responses 6 Failure
Answers to open questions from 6 to 10 on reliability, Campinas, São Paulo -2010 Reliability Question to fill documentation as established in protocol Non-compliance with approved protocol Failure in protocol communication Lack of assessment of existing protocols 7 Guidelines of the Committee on Hospital Infection Control are not always followed The presence of students interferes with customers feelings of safety Work overload conveys no confidence to customers 8 Professionals' relatives are users of the institution Lack of human resources (nutritionists) causes insecurity regarding recommendation of the institution Running of the institution is known 9 Ombudsman for external and not internal users Sector or strategy intended to manifestation is not known Customers voice their dissatisfaction to professionals 10 Customers are informed only in case of an adverse event Information about risks to customers depends on the professionals' discretion Customer ignores the practice of informing on the possible risks of therapy Risks are only informed in case of surgical procedures

l
clinical analysts emphasized tangibles, reliability and responsiveness; l physicians were less perceptive to tangibles, responsiveness and assurance; l nutritionists were less perceptive to reliability; l physiotherapists were less perceptive to empathy; l pharmacists were less perceptive to assurance; l nurses were more perceptive to empathy.

Table 1 -
Dimensions of quality, number of questions and themes, Campinas, São Paulo -2010