Patient safety: Errors need to be minimised

The financial, emotional and reputational costs of poor care are considerable. The Mid Staffs scandal was a watershed, not only highlighting appalling care standards at the hospital but also fundamentally changing how patient safety is viewed within the NHS.

In response to the Francis report that was triggered by Mid Staffs, Professor Don Berwick’s review into patient safety called on the NHS to become a “system devoted to continual learning and improvement of patient care, top to bottom and end to end”.

But are the levers in place to enable this to become a reality?

Change in culture

Poor care is expensive and demoralising, both for patients and staff. While the tension between driving efficiencies and ensuring safety of patients – not least with regard to staffing levels – should not be underestimated, it is now clearly understood that ignoring safety to chase financial or other targets is counterproductive in the long run.

Recently NICE’s decision to suspend its work on nurse staffing levels, in a departure from the recommendations of the Francis report, has generated criticism from workforce and safety experts. And reducing harm need not be reliant on increased spend, as experts seem to agree that it is the change in culture – with greater openness and transparency – that is the biggest game changer.

‘Ignoring safety to chase financial or other targets is counterproductive in the long run’

Umesh Prabhu is medical director at Wrightington Wigan and Leigh Foundation Trust, which won last year’s HSJ award for patient safety. Dr Prabhu, along with his team, has been widely credited for turning around the culture of the trust and making patient safety its top most priority.

He is a firm advocate of “value based leadership”, focusing on robust governance and a no-blame culture.

“The trust should define its values – what it stands for and appoint the right people on the board. There should also be leadership training for each and every member of the board, in addition to [training] on patient safety: what is it, how to collect evidence, how to challenge non-executive directors,” Dr Prabhu says.

He also puts equal emphasis on the importance of staff and patient engagement and acting on their feedback. According to Dr Prabhu, the trust’s board team met all the 1,800 staff in small batches, sought their opinion and suggestions and made organisational changes to reflect these, which included empowering the staff, taking on bullying and racist consultants and ousting ineffectual senior leaders.

The trust has 220 patient safety champions – including doctors, nurses, administrative clerks and porters – working on improvement projects, with the help of data from incident reporting systems, investigations, safety surveys and audits.

The approach seems to have worked for the trust as it has seen impressive results. Patient harm has been reduced by 86 per cent (from 516 in 2007-08 to 73 in 2014-15) and the hospital standardised mortality ratio has fallen from 126 (2007-08) to 86.3 (up to February 2014), he points out. It has been reported that 98 per cent of patients are free of hospital-acquired harm, and patient and staff satisfaction has improved.

However, the important question is how to replicate such success – from a single setting to a system-wide perspective. Patient safety cannot be improved in a silo, without looking at quality, clinical effectiveness and a whole system perspective. And it needs a joined up approach.

It is here that campaigns such as Sign Up to Safety can make a difference, taking a bottom-up approach by asking organisations to sign up to a series of pledges and create their own safety improvement plans.

‘Patient safety can’t be improved in a silo, without a whole system perspective’

Suzette Woodward, the campaign director, told HSJ that they don’t want to tell organisations what to do, instead letting frontline teams work on issues that matter to them. “It gives organisations permission to take their time and work on their plans over the next three to five years rather than feel pressured to do something quickly. This is about sustained change rather than transient change.”

Sign Up to Safety leads across the country have created a network of shared learning – essential for improving safety and quality. The campaign has already gathered huge momentum with 260 organisations joining within a year of its launch, which includes mostly acute trusts but also clinical commissioning groups, mental health and community trusts, academic health science networks (AHSNs) and GP surgeries, among many others.

Listening process

The role of patients and staff in improving patient safety can’t be overestimated. Andrew McCulloch, chief executive at Picker Institute Europe, warns that disengaged patients will have a negative impact on safe delivery of care.

“If patients are disempowered, having a negative experience generally, or not speaking up when something goes wrong, they are threatening their own health. [It’s] exactly the same with staff: demoralised staff are less likely to go through staff practices, and are less likely to engage with patients. It’s one big story.”

He highlights that, just like any other industry, consumers or patients have knowledge of the system from a different perspective to the provider and their knowledge can be critical to improvement. “Clinicians dip in and out of patients’ lives so most of the care is provided by other staff, patients themselves and/or their carers. So all these stakeholders should be engaged.”

‘Patients, clinicians and managers have to come together to bring about change’

Mr McCulloch believes that the Francis report has been very helpful in creating awareness of a patient-centred culture, which, he says, can be traced back to Lord Ara Darzi’s review High Quality Care For All in 2008. However much more needs to be done.

“Safety, patient experience, clinical effectiveness are all interrelated – you have to address quality as a whole,” he continues.

“Northumbria is a leader in patient experience and Salford is a leader in clinical engagement. [But] in order to be leaders, they are doing other things well too,” he says – adding that patients, clinicians and managers have to come together to bring about change.

Human factors

The concept of human factors is often cited to understand how healthcare can improve its processes, and learn from other safety critical industries such as aviation and nuclear energy.

Martin Bromiley is an airline pilot and chair of Clinical Human Factors Group, an independent organisation of healthcare professionals, service users, managers and human factors experts from health and other high risk professions. He describes human factors as “all those things that affect our performance when we are at work.

“The variability in output of humans is human factors – the variability in health is around human factors. Anything that affects our performance – [it] can be around environment, cognitive thinking, systems and processes.”

In 2005, Mr Bromiley’s wife Elaine died as a direct result of medical errors during a routine operation. Following her tragic death, Mr Bromiley sought an independent investigation, which revealed she had died due to simple errors and absence of standardised safety procedures – and not because of incompetence of doctors.

Since then he has been a passionate advocate for using human factors in improving safety culture in medicine. He says understanding human factors is about “making it easy to do the right thing”.

But why was healthcare so late in embracing the concept of checklists and standardised protocols, which make it difficult to do the wrong thing? The answer may lie in its history.

Mr Bromiley points out that other high risk industries such as nuclear and aviation are relatively modern, whereas medicine is much older.

He explains: “Two hundred years ago surgeons didn’t need nurses, anaesthetists – they worked on their own. In the last 100 years, healthcare has realised that it is no good performing a brilliant piece of brain surgery if the person is dead a week later because they haven’t been hydrated or they suffered a post-operative infection.

‘You have to assume failure happens’

“Instead of looking at individual component and training for individual component of technical expertise, healthcare needs to focus more broadly. The [main] emphasis is on technical skills, so we haven’t focused on non-technical issues and the whole patient journey and experience.”

Another major difference is a culture of transparency and admitting mistakes openly. Mr Bromiley uses the example of how GP surgeries/hospitals communicate test results to patients to illustrate his point.

“They say if we don’t call you, it’s OK. Any other safety critical industry would say that’s the wrong way to do it. For a fail-safe system, they should call you if everything’s all right and, if they don’t call, please be in touch.

“It might be something is wrong but they might have mislaid the info/file. You have to assume failure happens.

“I have just finished three days flying with a colleague. I’m in command of the aeroplane, I’m the captain, and at numerous points my junior colleague reminded me that I’ve forgotten something or the other. And my response every time was ‘thank you’.

“The way of thinking is that error happens all the time, so we design systems to make it difficult to happen and, if the error does happen, then we have multiple systems to stop it from becoming harm.”

He says healthcare tends to look at what happened but doesn’t understand why. “It gives you victims but not proper answers. In a perfect system if something goes wrong, it must be the doctor’s or someone’s problem.”

‘It is even more important to pay attention to details’

But isn’t healthcare a more complex industry with a wider set of specialities and conditions to deal with? Mr Bromiley agrees unequivocally but says that this makes it even more important to pay attention to details.

“The reality is we won’t improve patient safety until and unless we get to grips with the final frontier of safety in healthcare, which is human factors.”

He adds that healthcare has made great strides in this area in the recent past and perhaps the important thing to learn now is how to get better at assessing individual skills and defining specific good behaviour. “My objective assessment is done both in a simulator as well as during flying on technical and non-technical skills. And those skills are very well defined – it’s not just safely landing a plane.”

Targets versus safety

Besides the obvious, ongoing conflict of staffing levels and safety, there is the added component of time targets too.

Darren Kilroy is clinical head of service for emergency care at East Cheshire Trust. According to him, the challenge lies in how to balance the need for time targets (four hour targets, mainly) in care with the need for absolute safety in care.

“In a situation like urgent care, where you are working against the clock, it is incredibly challenging for clinicians to be able to work efficiently while keeping safety at the forefront of their minds. This is especially true for trainee docs and junior doctors, who are trying to learn the craft, and need good role models.

“It is challenging in modern, urgent care systems to give them good role modelling when they are very conscious of time but want to do work to the best of their abilities.

“We need to think of smarter measures which focus on timeliness but also safety of care. For me one of the best measures of safety and timeliness is time taken for a patient to be seen by a competent and proficient clinical decision maker and not just any practitioner.”

‘The focus should be on raising the bar on quality of care and support from systems and local leadership’

NHS England announced last month that it is dropping admitted and non-admitted elective waiting time targets, as they are creating “perverse incentives”. However the main accident and emergency target – seeing 95 per cent of patients within four hours – will be retained.

But can we do away with time-based targets, which have gone a long way in reducing inefficiency in planning and resources? Dr Kilroy agrees they have been beneficial but says urgent care systems “have reached a pinnacle so there are no more efficiencies to be squeezed, at least here”.

There is also immense concern around staffing deficits, both in terms of nurses and doctors, which he believes will become their main challenge in five years.

“[The] agency staff [issue] tells us where we have gone wrong. We should have a system of rewarding our staff who want to work extra hours without paying agency rates… we should reward them by making their workplaces places to be, [we should] make them happy.

The problem will not be solved by more hirings as it takes years to train clinicians. Rather the focus should be on raising the bar on quality of care and support from systems and local leadership – you should look towards your clinical leadership to support and develop you to raise safety issues,” Dr Kilroy says.

Role of regulation

Regulation plays a very important role in ensuring safety and minimising avoidable harm in any safety critical industry, and healthcare is no exception.

After the Bristol Royal Infirmary scandal, the need for scrutiny, monitoring and regulation of clinicians led to the formation of the Commission for Healthcare Improvement, which was followed by the Healthcare Commission in 2003. However, in order to reduce the number of regulators and cut costs, the Care Quality Commission (CQC) was established, bringing together the Healthcare Commission, Commission for Social Care Inspection and Mental Health Act Commission.

The CQC today is the health and social regulator of all services in England, making sure they provide safe, high quality and effective care to all patients and service users. Despite a troubled past with allegations of bullying, mismanagement and excessive bureaucracy, the NHS watchdog is optimistic that it has a key role to play.

James Titcombe is the national adviser on patient safety, culture and quality at the CQC. A former nuclear engineer, Mr Titcombe’s spirited campaign over the death of his newborn son Joshua in Furness General Hospital in 2008 resulted in the Morecambe Bay inquiry to review the management, delivery and outcomes of care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay Foundation Trust.

He outlines the CQC’s vision and action points, saying the next few years are critical to carry forward the movement around safety. “If you look at CQC’s inspections so far in hospitals, we find safe domain is the area  (the CQC investigates care standards under five domains: safety, effectiveness, caring, responsive and well- led)  that requires most improvement.

“There is a big move towards duty of candour and we would be looking at that. Obviously we’ve got new fundamental standards now for the first time so we can go for prosecution without issuing warning notices. For me there has been a big focus on investigation and quality of learning and that’s where I’d like to see most improvements.”

In March this year, the House of Commons public administration select committee’s report called for a national independent patient safety investigation body, stating that the cost of this body would be relatively small, compared to the costs and liabilities arising from clinical incidents at present.

‘There is a need for an independent body to investigate very big systemic problems’

Mr Titcombe believes the investigation body should be different from the regulator. He says, if we look at evidence and at industries such as aviation, there are powerful reasons why there is a need for an independent body to investigate very big systemic problems.

“The Francis and Kirkup inquiries are big, but started a few years after the incident, and by that stage it’s about 90 per cent looking back and 10 per cent looking forward. We want those investigations to happen sooner,” he continues.

“Too often the response in the past has been defensive. Once there is a complaint, you’re already in the wrong place.

“Safety incidents should be different from complaints. The response should be less adversarial and more working together. Trust breaks down when avoidable harm happens so we need to restore that trust through our response.”

Equally, he calls for a no-blame culture and supports human factors being used in investigation. He cites the open culture in aviation and nuclear industries, where people are “actively rewarded for raising concerns and safety observations”.

He gives the example of Brighton and Sussex University Hospitals, where, under the guidance of their patient safety ombudswoman Delilah Hesling, the trust has given its first award to a member of staff for raising a safety concern. He says commissioners, providers, clinicians and other professionals, regulators and service users need to work together to drive improvement, pointing out the “CQC is part of the system, not the answer on its own”.

“I was there during Morecambe Bay in 2010 and have seen what happens when we don’t have an effective regulator. I still sadly meet families whose loved ones have suffered harm and have had a bad experience. Last week, I met a guy who lost his baby, similar to Joshua. The first two investigations by the trust kept him on the side, treating him as complainant.”

“I passionately believe in the value of robust regulation,” he concludes. “We have started to make a difference.”

IT investment

Kaiser Permanente is frequently invoked as a shining example of a patient-centric, preventive model of care worth emulating by the NHS organisations.

The US healthcare group has been a leading light in integrating patient safety with organisational culture – with its organisations making it their number one priority.

Their track record in reducing newer events, driving rigorous performance improvement and implementing regular system checks have made them the safest care organisations in the world.

However, there are many who argue that the comparison is unfair, as the NHS and its values and structures are different from a fee-paying, market-driven American system. They ask if it is feasible to implement best practice from the US to our publicly funded healthcare.

Dr Prabhu says it’s a “misconception that Kaiser provides safe care at low cost – the US spends 16 per cent of its GDP on health”. However, he can’t praise them enough for having a fantastic IT system.

‘Relevant information about all patients is available to doctors on their iPads’

“They have spent $4bn over a period of 10 years on IT – it is a great system, which has made audits and performance management easy. Say there is a clinical group of 20 doctors and a senior doctor as its head, the system will send automatic reports every month to the head doctor on other clinicians’ performances on a number of criteria – such as number of patients seen, drugs used, investigations done – making it easy to spot the outliers.”

He adds that relevant information about all patients is available to doctors on their iPads, which helps them to monitor their conditions effectively.

Dr Kilroy too rejects the comparison with Kaiser, but calls for greater use of data and technology in improving patient safety.

“Whenever I have gone to the coroner’s court over the years to represent junior staff as a consultant, the things that get flagged up again and again in clinical care are not fancy pathways, brilliant care models or expensive diagnostics but massive gaps in documentation of patient notes and in the diligence with which they are completed. There is something there in the use of technology for smartly capturing data which can be used to drive safety and improvement.”

It often takes a disaster to bring about real change and the NHS is no exception to this. But has there been a seismic shift in priorities, truly placing the need to deliver safe and high quality care above balancing the books? The debate continues.