At a recent meeting, a colleague likened the current welter of initiatives on quality to being “tied down like Gulliver”. It’s not that I argue with the importance of providing safe, high quality care - far from it - but I have some sympathy with the view that there is a danger of drowning in the tsunami of system and regulatory activity in this area.
As the deaths at Mid Staffordshire foundation trust have shown us, no amount of external focus can necessarily identify problems inside an organisation - real change has to come from within.
Henry Ford said: “Quality means doing it right when no one is looking.” I’m grappling with this question in my own organisation and I guess I’m not alone. While my trust has a good track record in providing high quality services, we also have some significant challenges: despite Herculean efforts, we have been held to account by Monitor for our poor performance last year on healthcare acquired infections.
Reflections on this experience, one which I would not relish repeating, tell me there is always something more you can do even though you believe you are doing everything you possibly can to succeed. Moreover, we need to deliver breakthrough performance in patient safety and quality in an economic climate that grows uglier by the minute. As NHS chief executive David Nicholson pointed out last week, the value for money challenge will be met through delivering High Quality Care for All, not instead of it.
This is why I’m enthusiastically supporting NHS Quest, a membership collaborative and the brainchild of Salford Royal foundation trust chief executive David Dalton. It will bring together managers and clinicians from like-minded organisations to drive forward a plan to achieve unprecedented levels of quality improvement. Our collective ambition is for all members to be in the top 10 per cent of all NHS trusts within the next three years for five targeted domains: reducing mortality, reducing harm, delivering evidence based care, improving patient experience and improving productivity.
Of course, this is easy to say, but much more difficult to do and will require discipline in traditionally challenging areas like transferring knowledge, collaborative learning, sustaining and embedding improvement and most of all ensuring every patient gets the best quality care every time.
My involvement in NHS Quest has exposed me to a powerful guide called Becoming a High Reliability Organization, which was produced for the US Department of Health and Human Services last year and gives new insights into how some hospitals across the water are collaborating with each other to tackle these challenges. It draws on experience in the aviation and nuclear industries, which are known for their high reliability in safety and quality.
I emphasise that this is not an improvement methodology like Lean or Six Sigma; it’s about introducing an organisational mindset that creates a culture that systematically identifies weak danger signals and responds swiftly and strongly so catastrophes are avoided and safe, consistent high quality care is provided to patients.
The report contends that for any improvement initiatives to succeed five forces need to be in place:
- A sensitivity to operations, thereby ensuring leaders and staff are constantly aware of the state of systems and processes that affect patient care.
- A reluctance to simplify by recognising that while simple processes are good, simple explanations for why things work or fail are risky. In my experience serious failures are often attributed to simple things like communications failure or inadequate training, but these are rarely the full and detailed explanation for why patients are placed at risk.
- A preoccupation with failure so the mindset is viewing near misses as evidence that systems should be improved to reduce potential harm to patients, rather than viewing near misses as proof that the system has effective safeguards.
- A deference to expertise so leaders, managers and supervisors are willing to listen to frontline staff who know how the processes really work and the risks patients face.
- An in-built resilience by ensuring leaders and staff are trained and prepared to know how to respond when system failures occur.
I’m not offering this as a blueprint as it is clearly a way of thinking. Making this work, as with all these things, is down to organisational leadership, commitment, strategies that are tuned into the local environment and the skills of leaders and staff to adapt these ideas to suit their own particular situation. The beauty of this approach though is that it costs little to implement and does not depend on a plethora of external sources or resources to succeed.
Our experience in failing our infections targets has certainly taught me that the systematic application of knowledge transfer, rapid improvement and constant focus are the basic ingredients of success, but it has also taught me that on their own these measures are not enough. Forcing the pace and becoming a high reliability organisation as quickly as possible will help us to make sure we continue to provide the high quality services that patients and the public expect. As Aristotle said: “Quality is not an act, it is a habit.”