Transform the culture of fear into a culture of learning

Recently I enjoyed an evening meal with group of young and very bright clinicians.

During the evening I was asked about my experience of safety culture. In my response I talked about the reporting culture in my former job as a project manager in the nuclear industry. On the last project I worked on we ran a scheme to incentivise the reporting of any observed safety issues.

Providing the number of reported issues was more than 100 each month, one report would be chosen by the safety team and the person who raised it given an iPad.

‘They understood that highlighting potential safety issues enabled problems to be addressed as soon as possible’

There was nothing unusual about this. It was just one example of an approach to safety culture that was embedded from my first day on a nuclear site.

Incentives like this were a helpful signal to staff that reporting safety concerns would always be welcomed, but the reason people routinely used this reporting system wasn’t because of the chance they might win an iPad. It was because they genuinely understood that highlighting potential safety issues (no matter how minor) enabled problems to be addressed as soon as possible, hopefully before resulting in any harm.

Nothing was seen as being more important than working as safely as possible to avoid harm to ourselves, our colleagues or the general public.

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Culture of fear

The group I was with responded with enthusiasm and agreement that this is the kind of culture they would like to see in healthcare, but I was told a rather depressing anecdote which suggests how far some parts of the NHS have to go.

A very common IT system used to report safety concerns in the NHS is Datix. I was told that a phrase which has now emerged is “I’ll Datix you”, used as a kind of threat in argumentative situations where there is some disagreement or heated discussion.

Datix’s chief executive, Jonathan Hazan, is just as dismayed by this phrase as I am.

Mr Hazan says: “I’ve seen this issue being raised repeatedly on social media and it now seems to be recognised at the highest levels of NHS trust management.

“The purpose of an incident reporting system is to learn from the incidents to prevent them from happening again.

‘A climate of fear will prevent people from reporting, and serves to drive issues underground’

“A climate of fear will prevent people from reporting, and serves to drive issues underground. Everyone in healthcare needs to understand the negative effect on patient safety that comes from punishing those who make genuine mistakes.”

How has this culture arisen?

In part, it’s basic human behaviour in hierarchical organisations.

But other industries have successfully overcome this behaviour. The airline industry managed to transform itself from a culture where no one dared challenge the captain to one where even the most junior member of cabin crew can report an incident without fear of reprisal.

But this change didn’t happen overnight and took a number of horrific accidents with major loss of life to spur the transformation.

Threats are powerful

Where there is pressure to conform to numerical targets and directives from above, a culture of fear can also flourish. This can flow down through the entire organisation.

The desire to suppress bad news means incident reporting may be actively discouraged, and I’ve heard a number of examples where nurses have been told not to submit reports on short staffing by their managers. In these circumstances, staff can get into real trouble for being seen to make mistakes and the threat “I’m going to Datix you” becomes a very powerful and frightening one.

Conversely, some of the safest trusts I’ve seen have senior managers who are not afraid to challenge decisions from above when they see them as being unsafe. They also welcome concerns being raised by the staff who report to them.

They recognise that the frontline staff hold the key to patient safety and actively encourage them to make their voices heard when it comes to suggestions for improvement.

The issues affecting culture in the NHS are complex and difficult. But the starting point should be to think about the reasons why reporting concerns or safety issues is so important.

‘Some of the safest trusts I’ve seen have senior managers who are not afraid to challenge decisions’

No one goes to work to cause harm, yet if staff are aware of issues that have the potential to cause harm and do nothing about it, the end result can be exactly that. My plea is for all NHS staff to reflect on this.

The phrase “I’ll Datix you” is surely one that most people can recognise is not conducive to a culture of learning and safety. As Mr Hazan says: “Wouldn’t it be good if ‘I’ll Datix you’ could be banished from the NHS’s vocabulary once and for all?”

James Titcombe is national adviser on safety for the Care Quality Commission and the father of Joshua, who died as a result of preventable errors during his care in 2008. Jonathan Hazan, chief executive of patient safety software company Datix, also assisted with this piece