Institute for Healthcare Improvement president and chief executive Donald Berwick talks to Stockport foundation trust chair Robina Shah about the role of NHS boards in improving patient safety and quality of care
RS - What is the best approach to improving safety and quality performance in a complex system?
DB - This doesn’t just involve simple projects. There are overriding organisational issues that affect improvement - preconditions of resource allocation, transparency, support for risk taking, and teamwork, as well as issues of reliability and commitment. The clinical workforce can help make the changes, sometimes even organise them, but they can’t arrange for the preconditions to exist. It all goes back to the boardroom, the place where the conditions for improvement are going to be set. Boards are stewards of resources, and they also need to be stewards of the primary quality and safety goals of the organisation.
RS - Who is responsible for stewardship and leadership - the board, the organisation, everybody?
DB - Ultimately, the board is responsible for the achievements of the organisation, clarifying what success is and ensuring it happens. That responsibility cannot be delegated. In a social enterprise like healthcare, the board speaks for the hearts and spirits of the workforce. What the board wants to accomplish is no different from what most of the entire workforce seeks to achieve; it is a purpose everyone shares. Priorities need to be set, though, and that job is one aspect of governance - an important duty of the board.
RS - How do you define quality as a corporate measure?
DB - Quality means meeting the needs of the people you serve. The organisation exists to match its work to those needs. Ensuring people are not being injured by care means delivering scientifically grounded, technically correct care. The healthcare system is a guest in the life of the patient and needs to act that way. Timeliness - avoiding waits and delays - is a primary aim. So is the reduction of waste. Equity is also important in healthcare. When there are racial, socio-economic, cultural, or ethnic differences impinging on standards of healthcare, removing them brings an improvement in quality. Care must be safe, effective, patient-centred, timely, efficient and equitable - an important list of aims for improvement established in the US Institute of Medicine 2001 report, Crossing the Quality Chasm.
RS - What should the board be asking itself?
DB - The highest level question for a board is: “Why should this trust or hospital exist, what is the social need?” It is important for senior managers to explore and agree on organisational values as they underpin efforts to improve and should direct the way the organisation operates. The board should also seek integrated ways of working that are part of a larger system. Can we demonstrate behaviour and thinking without boundaries or silos that keeps us agile and responsive to technology, society and the needs of patients and families?
RS - What are the most important skills for non-executive directors to have?
DB - It seems sensible that all directors should understand and be trained to feel comfortable with asking good questions about patient care and issues of safety. Competence in financial management is crucial, but to say that stewardship of the healthcare system is stewardship of its money instead of its outcomes is neither proper nor wise. It leaves us with board members who are perhaps frightened of getting more involved in understanding and addressing care and safety issues.
RS - How would you know that the board is doing its job properly?
DB - It’s all about the effect the board has on patients. That said, boards need help to ask the right questions about how they are doing, to inquire in a way that deepens their understanding of the organisational story rather than just ticking boxes. Patients should be invited to board meetings, to talk about their care experience and what could be better. The board itself should investigate the case study of an injury or error that occurred in the hospital so they can understand, in detail, the things that happen in such instances.
RS - What role does standardisation play and what are the challenges in implementing it successfully?
DB - Excellence in any industry involves reliability - the ability to deliver what you intend to deliver every single time. If we are to prevent complications from heart attacks, there are certain medications to give and protocols to follow, and it is important for us to agree what those are. So, standardisation is a very important part of any scientifically grounded industry. Ultimately, though, the person doing the work is the protector of excellence, not the standard. People have to be free to use their knowledge. A smart approach is to work to agreed standards and whenever there is a violation of that standard, treat the violation as an opportunity to learn and improve the process, making it more reliable. Learning needs to be part of the process that creates the standards, and sometimes what is learned is that the standard doesn’t apply in every circumstance.
Tools of the trade
RS - If you had a toolkit of quality and safety, what would it contain?
DB - Reading several wonderful publications would make for some beneficial conversations in the organisation. For example, The Design of Everyday Things by Donald Norman is very readable and there are some wonderful books and papers on human error such as James Reason’s Human Error. There are also tools available to help hospitals measure patient injury and error rates, such as the Institute for Healthcare Improvement’s global trigger tool. Boards should view the improvement of safety and quality as a continual learning process.
RS - What are the key barriers that organisations face when trying to implement a culture of quality and safety?
DB - Ignorance is one. Many doctors, nurses and managers don’t believe people are getting injured. It is helpful to have ways to open their eyes. Visiting other organisations already on the journey is helpful. Fear is another barrier - the fear of embarrassment, reprisal or feeling guilty. Have these and you don’t have a safe organisation. This leads to other dysfunctional barriers like finger-pointing. That is, if something goes wrong, it is always someone else who is responsible. We have to recognise we are all in this together.
RS - What does success look like?
DB - The continual improvement of results that you have agreed to work on is success. So, for instance, if one goal is to reduce infection rates, watching those rates go down is success, but improvement is never-ending. More and more important for me, though, is joy. The workforce should be joyous in pursuit of excellence. When that happens, you are on the right path. Ultimately, patients and families will know it. Maybe not at first, but later on you will begin to hear the acknowledgement of your work.
World class care
RS - Is the NHS aspiration to be world class in everything realistic?
DB - I am a huge fan of the NHS. It is one of the great human endeavours of my time. I think that it can be world class. The circumstances are right. The NHS has consolidated funding, has the potential for strong leadership, and offers services that are free at the point of entry. The missing element is the integration of care between hospitals, primary care offices, laboratories, etc. From the patient’s point of view, they journey through one system. The healthcare system, however, carves up care and creates walls between entities. Integrating the vision, design, even management of the system as a whole is, I think, the next great challenge.
RS - What are the key headlines for boards to be aware of and to work with?
DB - Trust the workforce. You will not get very far if you don’t. Become systems thinkers and learn more about the system so you can more carefully support the improvement of what matters, including bringing in the patient to tell the story of his or her care experience and how it could be better.