Putting patient safety at the heart of NHS services needs a significant cultural shift. HSJ and Microsoft brought together key leaders to ask how to make this happen
Putting patient safety at the heart of NHS services needs a significant cultural shift. HSJ and Microsoft brought together key leaders to ask how to make this happen
Government, NHS staff and patients agree that patient safety is central to delivering healthcare fit for the 21st century. But driving change has proven challenging and progress is sometimes slow in a system that seems preoccupied with the practice of individual clinicians rather than creating safe systems and organisations. The strengths and weakness of different approaches were debated by our expert panel.
The expert panel included:
- Dr Maureen Baker, clinical lead, patient safety,.NHS Connecting for Health
- Christine Beasley, chief nursing officer, Department of Health
- Harry Cayton,.national director for patients and the public, Department of Health
- John Coulthard, director of healthcare, Microsoft
- Sir Liam Donaldson, chief medical officer, Department of Health
- Martin Fletcher, chief executive, National Patient Safety Agency
- Andrew Foster, chief executive,Wrightington, Wigan & Leigh trust
- Lord Hunt,.then health minister, Department of Health
- Kate Jones, safer care priority programme lead, NHS Institute for Innovation and Improvement
- David Morgan, ENT consultant, Heart of England.foundation trust and founding director of Safe Surgery Systems
- Stephen Ramsden, chief executive, Luton & DunstableHospital.foundation trust
- Keith Ridge, chief pharmaceutical officer, Department of Health
- Stephen Thornton, chief executive, Health Foundation
- Richard Vize, editor, HSJ
Richard Vize: There is a wealth of data to show high error rates and poor safety procedures in many aspects of healthcare and there are many evidence-based interventions that can significantly drive improvements. Chief medical officer Sir Liam Donaldson has recently called for speedier action on patient safety and greater accountability for success and failure. What I would like to do today is discuss what can be done to drive patient safety, including technological innovations to support this.
I would like to begin with national director for patients and the public Harry Cayton. Can you talk us briefly through what you feel are the biggest impediments to embedding patient safety in the NHS?
Harry Cayton: I have to start with the complexity of modern medicine, which presents clinicians with a range of challenges. Then the concentration we have had on the practice of individual clinicians, rather than safe systems and organisations, and the sense in which clinicians are individually responsible and autonomous and hold strongly to that view. And then the lack of public and patient understanding of the nature of risk; we come to believe medicine can be completely safe, and although it can be a lot safer, we need to engage patients and the public as active partners in making it safe rather than as passive recipients.
RV: Martin, as chief executive of the National Patient Safety Agency, can I get your perceptions, particularly about the public's misunderstanding of what constitutes risk and good practice?
Martin Fletcher: The public expects processes of care exist to make sure that risks are managed well, and there is surprise that this does not always happen. But the broader issue, and one of the challenges we face, is how do we implement safer care and safer practices in everyday care? We need to do a lot more to engage frontline clinicians in patient safety and do a lot more around how we position safety as a priority in healthcare organisations at a senior level, as well as what we need to do to support clinical teams with the tools and information to understand where the safety faults are in their practice and what they might need to do to address it.
RV: You make a good point about frontline staff and accountability for change and embedding it. Christine, as chief nursing officer your profession is very much at the frontline of this. What is its perception of the role of patient safety and why are there still concerns and problems with delivering it?
Christine Beasley: All clinicians start off thinking: 'I'm going to give the best and safest possible care going.' But staff are working in an increasingly complex system. You need to wrap around the desire of clinicians to provide the safest care in a system that makes it as easy as possible to do it.
We need to make sure that where it's appropriate we have got the education and training to do it and then the systems need to be linked to what we are doing so it is an important issue and if they are not doing it right - not necessarily a clinician - there is a process of asking: 'Why isn't this working, let's put it right.'
RV: To what extent do you believe that those systems are currently in place?
CB: They are patchy. They are sometimes patchy across an organisation. I do a lot of visiting across the whole of the NHS and there are some organisations where you have systems where everybody is going in the same direction and then in others there are gaps and the challenge for all of us around the table is getting it so that it happens every time for every patient.
RV: Stephen, as chief executive of the Health Foundation, what do you believe differentiates those two types of organisations, the ones where it is absolutely in the DNA of the operation to have patient safety at the forefront and those where it is relegated to the margins?
Stephen Thornton: At a high cultural level it is about recognising that these things are not about blame, they are about help and support. That is fundamental. The second issue is about senior-level commitment: senior clinicians, senior management and the board taking on board the approach: 'This is part of what we do around here, it's not just a project over in a corner.'
Even if you have those two things, this is very hard to do. It requires technical change and focused activity to be planned and implemented. People need to have the tools of the trade and the support to be able to do it.
RV: Sir Liam, this is an issue you have been driving hard on. Can you expand on how you get the whole-system approach to deliver this?
Sir Liam Donaldson: We are assuming that rank and file staff - the nurse on the front line and the junior doctor - understand some of the underlying concepts we are talking about. They need to understand that when things go wrong in healthcare, they are not just one-off events. There is usually an underlying common cause. Ten patients might be killed over a few years due to being given a drug they are allergic to. In the past we would have seen that as a local incident. It would have been investigated and some action put in place but we would not have looked nationwide.
Awareness is growing but it is still not penetrating yet. That is a very simple first base thing that we have to have. That is the head: getting people to understand.
Then there is the heart. Is it a fundamental value? If we compare ourselves to other high-risk industries, such as the airline industry, the pilot and cabin crew really care about safety. Some cynical people might say that is because they go up with the passengers in the plane so they are also at risk.
I think there is more to it than that. I think at this point we are well short of a position where all our staff worry about the safety of their patients. That is not because they are uncaring people but because it has not been one of the traditional values of the NHS.
The third thing is an absence of data showing your problem and pushing it in your face.
RV: Stephen Ramsden, as chief executive of Luton and Dunstable Hospital foundation trust, how does your organisation drive those three aspects of success?
Stephen Ramsden: It starts with leadership. It starts with prioritising the agenda and an interest in the subject from the board, chief executive and medical director. More widely, it starts with the government and the NHS executive showing that this is important. The signs are encouraging.
RV: And how does that then permeate down the organisation?
SR: For us it started with an interest in using improvement science initially, to improve waiting times and redesign services. Then we were impressed by our observations in the US where they were using improvement science to improve patient safety in a transformational, proactive way. You could typify the NHS approach to safety as a bit more reactive in the past. Risk management, quality assurance, governance and regulation are essential, but, in my opinion, not adequate to inspire people to want to improve.
RV: Thank you. Lord Hunt, as [now former] health minister, what is your view of these issues?
Lord Hunt: First, there's the question Liam raised as to whether we are off first base. People are talking about safety much more than they used to. There is much more recognition among people in the service about the issues of safety.
Second, is the architecture in the NHS right in terms of dealing with safety? It can be in that we are moving from a micro-managed, centralised system to one where the role of government is to assure standards of safety and quality and that enough money is going in and appropriate regulation, with the incentives at local level through payment by results, commissioning etc. What we have to ensure is that within that new architecture, safety comes to the fore.
IT can bring many gains in patient safety, so we have to drive on with the national programme because it does bring huge potential. I think Harry would argue that, thanks to some of the changes that have been made - take electronic prescribing, for a start - lives have been saved.
The second is leadership. We need boards talking about safety. Traditionally in the health service boards have shied away from clinical issues. Part of what we have to do is get boards talking safety as something that is a regular item.
The third issue is that, taking Liam's point about looking at the airline industry, there are other sectors that have got their act together in relation to safety. The construction industry, for instance, which traditionally has had a high level of deaths and accidents among its workforce, has made huge advances in the past few years. The main reason is that leaders of the big construction companies decided they were going to do something. It comes back to leadership. If it is seen as an issue [just] for clinicians it is going to be much more difficult.
RV: Andrew, can I bring you in at this point as chief executive of Wrightington, Wigan and Leigh trust and former workforce director at the Department of Health? How do you drive that issue of leadership?
Andrew Foster: I have been interested in the US Institute for Healthcare Improvement 100,000 Lives campaign. It said there are unnecessary deaths happening in your hospital and they are the tip of the iceberg. Then it tapped into the core values of clinicians. Clinicians might not be terribly interested in government access and waiting targets and financial balance, but they are very interested in quality and safety.
Then it put in a methodology so it is measuring the baseline data of the components of quality and safety and publishing them regularly, which stimulates the natural human impulse of competition, which is quite strong. It is actually not difficult to get people incredibly enthusiastic if it is presented in the right way.
Education, education, education
RV: David, as a consultant, what thoughts have you got on the clinician management interface?
Dr David Morgan: We have got great strategic drive coming from Sir Liam and Lord Hunt, but where it starts to fall apart is tactically and operationally. Staff want to do the best for their patients - then it falls apart when they get to work. I think one of the reasons is education. You have got to educate at all levels throughout the health service.
People at the front line need support to guide them through the process. This is where technology comes in. It is the framework to hang off most safety systems. It allows you to verify that steps have been taken. For example, deep vein thrombosis risk assessment. Most hospitals have a paper-based assessment that is never done or people cannot remember where it is. But if you have got a portable device in your hand it is done in about 30 seconds and you can audit it.
If you use technology to guide people down the safety route, as well as educating them, if you put it in their hands they will use it.
RV: Keith, as chief pharmaceutical officer, patient safety is at least as large in your area as any other round this table, but perhaps slightly under-reported or less understood by the public.
Keith Ridge: Medicines are the most common therapeutic intervention and people tend to forget that. Building on what Chris and others have said about looking to the heart of individual clinicians, in my case pharmacists, they want to do a good, safe job. But there are things that can be done to improve. I think there is a gap between where we are in medication safety and what could be achieved. Pharmacists are slightly ahead of the game in trying to introduce technology to help, whether in the pharmacy department or working with others across the hospital in multidisciplinary systems.
I had the pleasure of opening a new pharmacy department at the Royal Lancaster Infirmary recently and it has robotic dispensing. Apart from improving safety by reducing dispensing errors, it has introduced an atmosphere of calm in the dispensary, in the staff and in a more pleasant working environment. The trust has tagged it on to a system to track at ward level where medicines are dispensing and prescriptions are in the system and you can see how it all begins to build together. It has allowed the trust in this case to redeploy pharmacy staff to the front line to improve safety of medicines use.
LH: That emphasises two things. One is the issue of technology. Clearly it has been a pretty tumultuous time for the health service over the past three or four years. But if you go round the NHS you can see how the use of technology is enhancing patient safety.
You have got picture archiving and communications systems [PACS], for instance, in terms of quality and the fact that you are not reliant on trying to find films that have got lost or are not easily obtainable. These are visible signs of enhanced safety.
On medication more generally, there is a lot more that we need to do. There are lots of issues about people not taking all of their medicine. Community pharmacists can be helpful in making sure the medicines they are taking are effective, so we are beginning to see the positive signals of enhanced quality and safety. The question is how do we put our foot on the accelerator?
RV: Kate, as safer care priority programme lead at the NHS Institute, can you put the advances on patient safety, particularly the use of technology, in the context of other NHS objectives?
Kate Jones: It plays a role in staff satisfaction, patient satisfaction, patient experience and efficiency if you're actually getting it right first time, reliably. But do staff really know how they're doing? Technology can help them understand how they are doing. I see safety as a route to delivery improvement.
RV: Do you think that is understood by staff?
KJ: Not at all levels. I have been trying to work with doctors and consultants, particularly, trying to get them skilled up on improvement. Those that are keen to do that find they struggle to get that commitment at organisational level. They feel they are a lone voice.
LH: I attended a Royal College of Nursing conference last week on infection and people were saying they felt they were in a blame culture. We got into a debate about the question of corporate responsibility. While individual professionals do have to accept personal responsibility and they should never run away from that, those people also need to feel that ultimately it is the corporate board that is responsible for the systems.
LD: I strongly agree with that and I have a brief example from one of the visits I did to the US. I happened to be there the day after an incident where a surgeon changed a patient's dressing without scrubbing up or changing gloves. A junior nurse had remonstrated with him, saying 'you can't do that' and he had been rude.
The next day the head of service had a discussion with this surgeon about the unsafe situation he had created. An apology was given to the junior nurse and she was told: 'You have done the right thing'. Basically, the surgeon was told that if anything like that happened again he would not have his admitting rights to that hospital renewed.
I don't know whether that would happen regularly in a hospital in this country. To me that would be a sort of gold standard.
RV: Do you think all members feel empowered in that way, Christine?
CB: No, I don't think they do. Sometimes they don't want to do it because it's a hierarchical thing and they think it will be difficult. Sometimes, you look at someone and think: 'They're very experienced, very skilled, they must be doing the right thing' even though you are not sure.'
ST: I would like to think about Liam's example of the junior nurse and what she did there. How do we make that the norm? While we have talked a lot about culture and top-down and management commitment, what is also needed are systems and processes around that nurse so it happens regularly.
That is part of what we have been doing and in Stephen's hospital they do that, using pre-procedural briefings before any kind of operation. The team, including the more junior members, have a structured discussion about what is going on and what is going to happen. That is the setting in which those conversations can be had without that nurse having to feel she is putting her career on the line and having to be very brave. Ordinary doctors and nurses can feel they can participate in that. And the doctor doesn't see that the nurse is stepping out of their bounds.
We have really got to get it down to that level of putting those things in place and training people and then holding organisations to account for having those processes and systems in place.
KJ: It is not just about doctors against nurses. One of the challenges for organisations is getting consultants to challenge their peers. Once they take that step you can start moving the organisation, but it is a big step to take.
RV: Maureen, as clinical lead at NHS Connecting for Health, can you give your perspective on the role of technology?
Maureen Baker: The national programme is not just an IT programme. It is a patient safety and clinical governance programme. The real benefit from the investment is systems that support clinicians to practise more safely and effectively. We have already seen some of that, but for us to be able to capitalise on this we have to have an expectation from clinicians about what the system can do to help them deliver safe care.
There are good reasons to expect that instituting some IT programmes will deliver a safer outcome. For instance, electronic prescribing: taking out the illegibility issue is a huge step forward and that is just in primary care, where we have virtually 100 per cent electronic prescribing. Illegibility errors vanished overnight.
I do not think we can make the case enough of what the programme can deliver in terms of safety benefits. We need better engagement with colleagues so they have an understanding of what they are going to get in improving care and having safer care for patients.
HC: The patient record is also extremely important. In many circumstances, hospital doctors do not have access to the paper patient record at the time they need it. We know from work by the Royal College of GPs and others that about 25 per cent of GP records contain significant errors and about 25 per cent of those errors are putting patients at risk. So patients having access to their own records, as they will under the new system, and being able to say: 'I don't think that's right on my record', even if it's only: 'I don't think my address is right', is going to be enormously empowering.
On the point about the nurse who says: 'Doctor I don't think your practice is safe', it's even more difficult for a patient. We are asking patients to say 'have you washed your hands?' and 'are you doing that properly?'
RV: John, as director of healthcare at Microsoft, what do you see as the challenges?
John Coulthard: There are a number of stakeholders we may be leaving out. There is the patient. And the employee has some expectations around technology. Technology corrects their insurance statements; they don't have to be taught how to use Amazon, it corrects them as they go. They bring that mentality to work and it doesn't happen. Clinical systems, for example, have eight different date formats. When you present that to the individual they kind of think 'well the leadership, commitment and capability is there, but actually on the ground I just don't see it'.
The third stakeholder is business. It's interesting that Microsoft is working with the NHS around a common user interface programme [the objective is to have a common Windows-based desktop and customised productivity tools. The programme is also delivering a design guide and toolkit components for software suppliers. This should promote increased clinical take-up of systems].
There are 110 items of patient safety data in that. That is fascinating, the fact that we are jointly spending that money and you get a win out of that. We mentioned the aircraft industry earlier and just as it would seem strange to anybody from the outside that Boeing wouldn't have something to do with the way in which cockpits are designed, the same goes for Microsoft because we're talking about information systems as part of the drive to improve patient safety. Somehow we've got to create this sufficient, capable, motivated group of individuals who think of safety at every turn, but initially at the highest level, those 110 items.
MF: The opportunity to harness technology in the interest of patient safety is enormous. But technology also illustrates the complexity and we have got to beware of thinking there is a silver bullet or a single answer that is going to fix the problem. If technology is not well implemented and staff are not well trained and supported in using technology, we can inadvertently introduce new hazards. We have seen examples where over-reliance on technology has eroded human checking and created risk.
MB: We are aware of the possibility that when you introduce any IT it can come with risks. We have a programme to assess what those risks might be and make sure the systems we put in are as safe as the design would allow. There is a whole change-management process about receiving the product into the NHS and making sure it is safely implemented. That has to be part of the process and something the NHS picks up on.
AF: I want to mention the: 'What happens next?' about all this. The DoH is very good at intellectual analysis and this has been a fascinating discussion bringing in leadership, accountability, evidence, IT and countless other things. But what is going to make a difference in the field? I go back to the 100,000 Lives campaign. It didn't produce a philosophical document, it said here are the six most common causes of unnecessary death, here are the six bundles of care that you implement and then it created a mission to get people excited and involved in it. I appreciate mortality is never good, but it was such a simple approach and it worked. It got 3,000 hospitals to sign up to that mission and it really made a difference. In terms of what happens next I would like to see a simple action-based approach rather than philosophical discourse.
SR: I want to build on something Harry said about empowering patients. I have visited many hospitals in the US and all of them market the hospital on the basis of being number one in patient safety, not on waiting times, access or cost. I can't help feeling that we are missing a trick about the NHS system changes, the choice, the market and the ability to use information to help patients choose. And I am sensing that chief executives want to move their organisations forward in patient safety because they will be judged on their safety record.
RV: Sir Liam, can I ask you to pursue that because it is difficult for an organisation, particularly one as politically sensitive as the NHS, to stand up and generate a sense of crisis willingly.
LD: By trying to do it while avoiding the blame culture, patients - particularly victims of medical error and unsafe care - can help. In the work I have been doing with the World Health Organisation we have patient advocates who have risen above their personal tragedy, often a mother who has lost a child, and they are not calling for blame and retribution but for learning.
To put such a person on a platform with a chief executive in front of the media serves a dual purpose. First, it harnesses that patient's experience and exposes it. But having the person there saying: 'I don't want you pursuing blame and retribution, let's talk about how we can make this work as a system' is the virtuous circle.
Coming back to the point about patient involvement, I would take it at two levels. First, in medicine our culture as doctors is very much about data and numerical evidence. Although traditionally you would take an interest in the narrative account of the patient's story, you would say: 'We can't generalise from that.'
The power of the patient's experience has been recognised in other fields of research and you can generalise from it. It tells you something about the wider culture. You may not follow it through linearly, but it does tell you something. So in our medical education system we should be using the patient's experience much more with young doctors and medical students.
Second, there are initiatives around the world where patients are given advice about the changes they can make during their stay in hospital to make their care safer, whether it is asking them to join in the checking of medicines, hand washing, or other things of that sort.
RV: David, it is difficult for many of your clients to feel empowered in the situation they are in. How do you bring them into the discussion about their safety and outcomes?
DM: As a profession we tend to judge our performance by outcomes. Patients often judge our performance by perception and we have to apply our marketing skills, not only at outcomes but at the perception of the healthcare we deliver to patients. There is no doubt we need to work harder at our patient perception of the way we deliver healthcare. We looked at this in greater detail at Heartlands, looking at 200 patients and their perception of coming into a hospital for an operation. It gave them an open question: 'Have you got any particular worries?'
The majority said they didn't have any worries and that they felt quite confident in what was happening. But when you gave them closed questions - are you worrying about hospital infection or having the wrong operation? - the actual concern rocketed up. There are genuine concerns and we can do a lot to help our patients question the way we operate as clinicians and to help us deliver care.
RV: Thank you. I would like to ask Stephen Thornton and then Lord Hunt to sum up.
ST: I want to pick up on Andrew's practical challenge. I don't want to leave here without addressing it. And I think the picture is quite a positive one. From the Health Foundation point of view there are now 24 hospitals across the UK [involved in the Safer Patients Initiative], rather than just the four that we started with. In Scotland they have already launched a campaign with a commitment to take the learning from that kind of work that the IHI have been doing and spread it across the whole of Scotland. Conversations are under way in Wales and Northern Ireland and this week Martin Fletcher met a senior member of my team to take forward something that we might be able to put together in England, which might be some kind of campaign along the lines that Andrew is indicating. If there is as much enthusiasm out there among other chief executives as Andrew has shown today, I think we are well on the way.
RV: Finally, Lord Hunt.
LH: Thank you very much to HSJ and Microsoft for the opportunity to debate patient safety today. It has been interesting and encouraging. Until people recognise that this is a crunch issue for all of us we are not going to get real, rounded action. It seems to me that we are seeing a sea change in understanding and attitude in the health service. As I said earlier we can't be complacent, but we are starting to see some momentum.
The second thing is, coming back to Stephen's point, I would argue that the new architecture of much stronger regulation and the right incentives at local level is a good foundation to make sure safety is the number one issue. We need to work at that because we have to make sure the incentives are towards patient safety.
I think technology, albeit with Martin's caveat that sometimes you can build in failure as well as safety, offers us huge potential.
On public recognition, MRSA and C Difficile are the obvious examples of where the public are and I think that is an issue we have to confront. We recognise that we can use patients' fears as well as their expectations to drive patient safety. Andrew suggested that we need to have a much harder campaigning approach. I am up for this, as long as it can be seen to enhance the service not undermine it. That is not easy, let's be honest, but we should really go for it.
We need to be prepared much more to preach our achievements. We have to cease being precious about being able to quantify the impact of safety achievements. One of my frustrations is that we do not seem to be able to quantify some of the changes in terms of lives saved because of the preciousness of people round this room and elsewhere about having sufficient, robust research to be able to get down to the last dotted 'i' and crossed 't'.
If we are really going to get a campaign going I think we have to be prepared to be brave about being able to tell the public what we have achieved. It is not just the mega stuff, it is about us opening the door to staff to see what has been achieved, perhaps in other hospitals or other parts in the system.
Good practice: key points from the discussion
- Make patient safety a core NHS value and an organisational priority. It requires cultural change, commitment and leadership; safety should be embraced in commissioning strategies.
- Engage clinicians; avoid blame - instil individual responsibility but introduce systems of corporate responsibility; empower clinicians to challenge unsafe practices even when perpetrated by more senior colleagues.
- Design and use technology as a tool to guide staff through safety processes.
- Get evidence of where problems lie and make sure staff are aware; create a sense of urgency or crisis to provoke enthusiasm.
- Engage patients and the public in healthcare safety.