Putting patient safety first: how long will it take before the NHS learns from its mistakes?

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One of the most powerful contributions to our Annual Conference was a presentation by James Titcombe, the father of Joshua, a baby boy who died aged only nine days after signs of his deteriorating condition were missed by the staff at Morecombe Bay NHS Trust. What was remarkable about James’s story is that he was able to draw valuable lessons from it about how the NHS could improve patient safety by learning from mistakes. 

James presented data from a regional confidential inquiry into 25 cases of perinatal death. Only 24 per cent of the 140 possible contributory factors identified by the inquiry team had been identified in local investigations at the time of the incidents. So 76 per cent of the learning from the incidents had been missed; a situation that there is an urgent need to improve.

James said that we would only achieve Don Berwick’s ambition for the NHS to ‘place the quality of patient care, especially patient safety, above all other aims’ if we have candour when mistakes happen and acknowledge all medical errors. All mistakes/serious incidents must be properly investigated, with audited action plans that address the root causes. James said that if an NHS organisation makes a mistake that causes preventable harm to patients for a second time, it should be regarded as a ‘never event’. James also argued for the Care Quality Commission (CQC) to make greater use of investigations into serious untoward incidents in its assessments. 

Since James presented to us, the government has issued its response to the Francis Inquiry report. But to what degree does this response address James’s recommendations? There is a lot that is relevant – as well as the new statutory duty of candour, the ‘cultural aspects of care’ will now form part of CQC’s inspection regime. Greater use will be made of incident data, including a commitment for CQC to consider each hospital’s review of serious untoward incidents as part of its pre-inspection activity. NHS England will also launch a programme of new patient safety collaboratives, which will be expected to provide expertise on learning from mistakes and help to provide a ‘rigorous approach to transforming patient safety’.

The key to success will be the degree to which these national aspirations are owned and adopted at local level, to create a culture that rigorously uses data to monitor quality and progress. Immediately before James spoke at our Annual Conference, we heard an inspirational speech from Dr Brent James, who talked about the systemic approach to quality improvement at Intermountain Healthcare and gave examples of initiatives that had made significant improvements in survival rates. At Intermountain all senior clinical and administrative staff are expected to be skilled in quality improvement. Brent stressed that ‘We count our successes in lives’.

How far is the NHS from this culture? In places like Salford Royal NHS Foundation Trust it feels not far. The trust has worked hard to skill clinical and non-clinical staff, specifically in quality improvement, systematically reviews its quality performance data and has managed to significantly reduce the incidence of avoidable harm. Sadly, this is a long way from the position in many trusts.  

I spent yesterday at an event called Medicine Unboxed. It was a fascinating day. One of the most startling presentations was from Professor Roger Kneebone, a trained surgeon, who showed an anonymised film of an operating theatre. Loud music was being played, so much so that the words of those conducting the operation were not being heard or properly understood, a sharp contrast to the requirement for aircraft cockpits to be silent at take-off and landing. To me this exemplified a culture that does not put patient safety above all else. A graphic example of the distance the NHS has to travel before we see making the same mistake twice as a ‘never event’.

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Consultant Neurologist,
Plymouth Hospitals trust
Comment date
02 December 2013

This reminds me of attending Global Lean Conference. I attended with a team of 6 from my Trust, as we were all passionate about improving quality and reducing cost within the health sector more widely and our organisation specifically. At that conference, a different parent of another boy called Josh told his story. I wrote an almost identical blog to this at that time.

It is now 2013 and all 6 of us have left our roles in service improvement within our Trust. For each, the root cause of the decision to leave was frustration with the difficulty of creating authentic change. I have documented my experience during that time in about 20 articles published in two online journals (The Consultant and Clinical Business Excellence). I have attached a link http://www.clinicalbusinessexcellence.co.uk/issue/10/index.html

You are right when in your blog you state - nothing is changing. I could list many more examples that confirm your assertion; perhaps the most stark is the work of Keith Grint. I give a workshop on the Top Leaders programme, which always follows Keith's talk. In essence, he describes 60 years of impressive NHS inertia...

It is exactly this conundrum I have investigated for the past 5 years. To make any sense of this I have had to dive deeply into the organisational learning literature from other sectors. I provide an overview of those conclusions below. They are described from a NHS perspective, but I believe the conclusion are applicable to all healthcare systems across the developed world.

It is absolutely clear to me everyone involved in healthcare passionately wants to do the right thing. However, the brutal facts are, only a tiny pockets are currently authentically improving quality and reducing cost. The Kings Fund is doing a pretty good job of making those examples visible (e.g. Intermountain Health, Kaiser, Veterans Affairs, the work on value by Richard Bohmer). My investigation of those systems is that the approach used is same in all cases. Richard's two NEJM editorials document those characteristics pretty succinctly.

Sadly, these characteristics seem to be extremely rare in the NHS. During the period of implementing the NHS Plan, we did improve aspects of quality but it was at a huge cost. Mid Staffs was also able to happen during this time. The true impact of the reduction in NHS funding, firstly post the NHS Plan and secondly following the credit crunch, is now starting to show at an aggregate level. It has been obvious at a micro level for 2 years. This would be OK if these symptoms were driving the system to analyse this reality in a systematic way that led to an actionable diagnosis. I don't believe we are on that path at the moment but I do believe the knowledge we need does exist. I desperately want to get into a dialogue with people such as yourself about the knowledge that could help, and how it could be shared and actioned.

A systematic analysis of our reality could be described using the value based principles advocated by Michael Porter. With time this could be combined with additional strategic principles advocated by Clayton Christensen. Both would have to be adapted for an NHS starting point. What I mean by an NHS starting point is this; my improvement work has helped me see our systems have three types of demand stream:

1. Recognised value demand - 70 year old man with MI (15%)
2. Unrecognised value demand - 95 year old lady, very frail with UTI (35%)
3. Failure demand - chaotic alcoholic with multiple admits (50%)

This distinction is vital because the relative resource consumption of each stream (included in brackets) is very different. If we don't directly address the improvement opportunities in demand stream 2 and 3 first, we can never sort out stream 1. Furthermore, all the horror stories occur in streams 2 and 3.

But I still don't think this would get to the root cause of our problem. The most fundamental problem is that to advocate and deploy such a strategy also requires a huge cultural transformation. The characteristics of high performing culture are well described - Michael West is doing a good job in this space. However, moving from a prevailing defensive culture (current day NHS) to productive culture (where the NHS needs to be) is an extremely rare event. The reason why it is a rare event can be determined by reviewing four separate streams of work undertaken by the following thinkers: Chris Arygris, Bob Kegan, Bill Torbert, and Rob Cooke. In a nutshell, the answer is defensive reasoning. The work of these thinkers suggests that the only way to impact on defensive reasoning is through the senior leaders changing. Such changes would require specific interventions.

I believe, the most compelling and actionable results come from Peter Fuda's adaption of Rob Cooke's method. a link to a recent webinar. You will see that the key facet, is helping senior leaders overcome the inevitable disconnect that exists between their intention and impact, this challenging but vital


I paasionately believe, if we are to see actual change this is where senior NHS leadership needs to go in the future

Jeremy Butler

Public Governor Royal Berks FT,
Comment date
02 December 2013
As a former operational General Manager in aviation I know the value of reporting and the necessary culture. The key to improving the reporting culture is confidence by staff that they wil not be subjected to disciplinary action for reporting safety incidents. It
must be understood that, at times, errors will be made and we must learn from them. Exceptions are if there are wilful violations of Standard Operating Procedures or evidence of negligence. In these cases disciplinary action is appropriate and should be taken. The principles of this culture must be laid out in the policies and procedures af the NHS organizations to which they apply and clearly understood by all staff.

Aidan Ward

Organisational systems consultant,
Comment date
04 December 2013
I'd like to just make some comments from what for most people is left field. There are other ways of describing the behaviour of organisations that do not depend so heavily on the self-reporting and tendentious statistics of senior management.
A good place to start is POSIWID: the Purpose Of a System Is What It Does. Certain things in an organisational system (not the same thing as an organisation) stay alarmingly constant or trend consistently no matter what anyone tries to do to shift them. These invariants are in general a better basis for understanding what the system is actually doing than management claims of cause and effect.
So when we can show conclusively that some things don't change "60 years of inertia" then we have the beginnings of a model of how things actually work. A systems law called Conant-Ashby states the blindingly obvious that you can't manage a system when you don't have a model of how it works. Unfortunately, in a political system dogma about what everyone knows about how things work trumps having a realistic model.
I have been discussing with Steve Allder and others how the life and intelligence of an organisation depends critically on the ability to sense and adapt to a complex environment. You will notice that we design health organisations to discount input from their clients except when professionals agree with it ...
Truly from a systems perspective we could not be further from the truth, and each reform takes us further from being able to listen.

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