Doctors' involvement in a hospital's patient safety drive is bringing about transformation, says Stephen Ramsden

Most in the NHS would agree that for any transformation to occur, any culture change to succeed, doctors need to believe that the change is for the better and that they have a part to play in making it happen.

Doctors certainly have a central role in driving the patient safety agenda. They must see themselves as having a fundamental role in influencing their peers and must work in partnership with managers and other clinicians to achieve transformation.

Talk of 'engaging' doctors is inadequate and risks creating a mindset of unequal partnership between doctors and managers. Both need to drive and lead the safety agenda.

Over the past five years, our work on patient safety has resonated with doctors like no other project, strategy or 'engagement initiative' I have known. Right from the start, a cadre of about 25 consultants was actively involved in leading 29 patient safety improvement projects through the Health Foundation-sponsored safer patients initiative.

Do no harm

So why has it resonated so much with doctors? Perhaps because one of the first things they learn in their training is the philosophy 'do no harm'. Improving safety and reducing error aligns perfectly with this mindset.

But on its own, this happy alignment is not enough. At Luton and Dunstable Hospital foundation trust, we have designed our structures to reflect a partnership approach between clinical leaders and managers. This has been modelled from the senior leadership of the organisation, with myself and the medical director actively and symbolically (joint presentations being the norm) leading the work. This pattern is replicated throughout the organisation. Each directorate is headed by a clinical director and a general manager, who are jointly accountable.

The influence of doctors on other doctors is well-evidenced in the literature. Perhaps less well researched is the impact of doctors who lead work on safety and how that influences the culture of an organisation. Pre-procedural safety briefings in theatre: a five-minute 'huddle' with all staff involved to consider key safety issues before surgery, have become the norm here. This is due in no small part to our medical director modelling this behaviour himself and challenging colleagues who question its validity.

Investment in improvement skills for doctors (among others) has also been a feature of embedding the message that patient safety is our number one strategy. Several of our doctors have undergone the eight-day patient safety officer training at the Institute for Healthcare Improvement inBoston- this has built skills but also generated enthusiasm and changed behaviours. This investment in improvement skills has had a positive impact on doctors' involvement in other work, such as clinical pathway redesign and service changes to meet the 18-week target.

Hard data

Evidence of impact has also helped. Doctors presenting this data to other doctors has proved to be vital in generating the energy and momentum among the consultant body. And it is not just data but individual stories too. It was a consultant anaesthetist presenting data and stories on avoidable mortality to more than 100 peers at the grand round that framed the safety agenda in a way they could all relate to. The shock in the room as he presented case after case of avoidable deaths was the moment that moved the doctors to action.

Continuous feedback on 'the big dots' shows we have now reduced adverse events by 50 per cent and moved our hospital standardised mortality rate from 111 to 90. The data provides the evidence and the stories are so compelling as to move doctors to act in a way that traditional risk management and clinical governance systems often fail to do.

I firmly believe and state regularly that there is nothing more important than patient safety. I then add that we also need to keep our finances in order and meet our key targets.

Doctors respect this, certainly more than in an organisation that emphasises only targets and finance. The NHS needs to do more about improving safety and efficiency and patients' experience simultaneously. Organisational arrangements and strategies that fundamentally reinforce this and have doctors leading and in partnership with managers will be the ones that succeed.

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