The factors in each of the categories of the aspects of the context of care are interrelated; they affect and are affected by the other factors in the specific category. By being interrelated, the factors in each category define the category as a system. These categories of factors are the five systems of the context of care: ambient conditions, physical environment, social environment, organizational factors, and the overarching legal-regulatory-reimbursement-national culture factors represented as the concentric circles in Fig. 1.1. The five systems are interrelated and interdependent and as such define the context of care as a system.
The three systems of the basic care-providing system, the provider, means of providing care, and the care recipient, are embedded in the system of the context of care. Those eight systems of factors are interrelated and interdependent and define the overall context of error as a system. In keeping with the food analogies of error as Swiss cheese (Reason, 1990), and an onion (Moray, 1994), this systems approach to error (Bogner, 2000) is analogous to an artichoke. The leaves of the artichoke are the concentric circles in Fig. 1.1 representing the five contextual systems, with the system of overarching factors being the external leaves and each system of characteristics, the organizational factors, social environment, physical environment, and ambient conditions as concentric rings of leaves surrounding the heart of the artichoke, the basic care providing system.
The concept of the context of error as a system of subsystems is important in considering the impact of factors on provider performance, hence error. Changes in any of the systems of the context of error produce a reverse ripple. Rather than rippling out from the point of impact, as when the surface of a pond
is disturbed by a stone, the impact of a change in any system ripples inward. That is, systems within the circumference of the system with the change are influenced by the change (see Fig. 1.1). For example, changes in the physical environment affect the social environment, ambient conditions, and ultimately the members of the basic care providing system, the care provider, means of providing care, and the patient with little if any impact on the organization and none on the overarching societal level factors.
The greatest impact occurs from a change in the overarching system of legal-regulatory-reimbursement-national culture factors. A change in reimbursement policies that reduces the amount of reimbursement for certain procedures alters the funds available to the organization which necessitates reductions such as the number and educational level of the staff; this affects communication among the staff and with patients' families, building maintenance, purchasing of equipment, and patients who present at more advanced stages of illness—all of which affect the care provider.
Because of the reverse ripple, the origin of a factor that induces error may be other than where the factor impacts the provider, so efforts to change those factors may be applied inappropriately and doomed to failure. For example, a resident's excessive workload although emanating from the organization, the hospital, may be the result of funding limited by reimbursement policies. Directing the hospital to reduce the workload could be ineffective or even counter productive; efforts would be directed more appropriately to those governing reimbursement policies.
In terms of the artichoke model, exerting strong pressure on a leaf in one of the circles of leaves representing systems results in pressure which changes the condition of circles of leaves, the systems, between the ring where the leaf is pressured and the heart of the artichoke. The basic system of care, by being central to the context of care, is affected by a change in any system; the heart of the artichoke is affected by what happens to any of the leaves.
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