The nuclear power sector might not seem an obvious role model for the NHS but it has made leaps in safety that the health service would do well to adopt for itself, writes Lord Darzi
It is hard to imagine two organisations more unalike than a hospital and a nuclear power plant. While one is revered as a place of healing, the other is feared as a source of potential harm.
We venerate the NHS but we tolerate the nuclear industry – it serves our need for power but has never inspired the affection shown to, for example, the railways.
Yet the nuclear industry and the NHS have something in common: their need for safety. Both require high reliability and have a low tolerance of mistakes.
For the last 25 years the nuclear industry has had a voluntary peer review programme to share best practice, identify safety hazards and improve performance, with remarkable results. There are lessons here for the NHS.
The programme was established in the US following the 1979 Three Mile Island accident in which there was a leak of radioactivity from a nuclear power plant in Pennsylvania. It was later extended globally following the devastating nuclear explosion at Chernobyl, Ukraine, in 1986.
That disaster led to the formation of the World Association of Nuclear Operators (WANO) as the industry recognised its very survival was at stake. WANO now sends teams of experts to peer review nuclear power plants every four years, observing how they operate and making recommendations.
There is a key difference between peer review and regulation. Regulation is compulsory, punitive and blaming. Peer review is about sharing best practice, stimulating professional pride and the desire to improve. It is about doing one’s best rather than settling for the least it is possible to get away with. The process is voluntary, honest and transparent but confidential.
Since WANO was created, productivity in the nuclear industry has risen, reactor shutdowns have been cut and no serious accident had occurred anywhere in the world until a huge earthquake and tsunami destroyed the nuclear plant at Fukushima in Japan in 2011.
Attempts have been made to translate the lessons of the nuclear industry to the healthcare industry. In the UK some royal colleges and specialist societies have moved to introduce peer review. The Society for Cardiothoracic Surgeons has led the way, by publishing their mortality rates for more than a decade, and it was also used in a 2010 project led by the Royal College of Physicians and the British Lung Foundation to improve the care of patients with lung disease in respiratory units.
’I know how a group of individuals performing a complex task can become more effective by working as a team. I know what ‘good’ looks like in the exchange of information’
In the US, nuclear staff have worked alongside medical staff, helping them to conduct reviews in 14 hospitals in Texas and Oklahoma. Among the problems they observed were poor infection control – a nurse who shook hands with a patient’s husband before changing a dressing, without washing her hands, and a patient with MRSA wheeled through the hospital while coughing, without wearing a mask.
These are the sorts of problems a good peer review process can uncover and offer to improve. Riccardo Chiarelli, a senior manager in the nuclear industry, has spent several years conducting peer reviews with organisations around the world.
“I know how a group of individuals performing a complex task can become more effective by working as a team. I know what ‘good’ looks like in the exchange of information. A structured, comprehensive and internally motivated peer review programme could significantly benefit the healthcare industry.”
Mr Chiarelli is now working with Peter Pronovost, a world expert in patient safety, who has pioneered peer review, based on the nuclear industry’s experience. In studying blood stream infections linked with central line catheters, Professor Pronovost was puzzled as to why some hospitals were able to reduce the often fatal infections to zero while others seemed unable to.
He found the successful hospitals were outstanding at communicating their goals from the board to bedside and ensuring everyone understood their role.
There is no equivalent of WANO and no equivalent of its technique of peer review in healthcare. We have relied on regulation instead, which is unequal to the task.
The fundamental purpose of hospital management should be to nurture a professional and organisational culture which puts the needs of patients first, expects the best outcomes, and publishes its results so they are publicly accessible. Peer review would be a powerful aid towards achieving that end.
Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London. He was a Labour health minister from 2007-09.