'Accounts of long and complex journeys give a sense of inevitability of error'
One of the few irritating moments at June's NHS Confederation Conference came during chief medical officer Sir Liam Donaldson's session on patient safety.
There was nothing wrong with what Sir Liam was saying. The trouble was it was being said to a half-empty auditorium - until a few minutes before the end, when he was partly drowned out by the arrival of scores of delegates trooping in to hear David Cameron. I was impressed by Sir Liam's calm professionalism. In the same position I would have found it very easy to get cross. And in case you think I'm exempting King's from this criticism I can assure you I have raised this with members of my board who were at the conference.
What does this episode say about the worth we place on patient safety? Not enough frankly (with all due respect to Mr Cameron). I was heartened later in the day by a contrasting quote from a fellow foundation trust chief executive: 'It's about time the NHS took this agenda more seriously. There should be nothing more important to a CEO than saving lives.'
We have work to do, but we aren't alone. The Institute for Healthcare Improvement in the US continues to advertise events on the role of the board in quality and safety, for which the first two questions are:
- Does your board of directors discuss finances in more detail than issues of quality and safety?
- Could your board send a stronger signal to the organisation that it really is serious about achieving quality and safety aims?
'Hang on a minute!', you may say. 'We receive our risk and clinical governance reports! We're doing all we need to for infection control! We're good against the Standards for Better Health!' That would be fine if it was the last word. Research suggests otherwise. Sari et al found that critical incident reporting picks up only 5 per cent of incidents that cause harm. It sometimes takes detailed casenote audits to know where we really are. An expert working group on venous thrombosis identified the numbers of deaths in hospital from these conditions to be five times greater than for infection with some 70 per cent considered preventable.
The more we look the more we find. It will surface uncomfortable truths about how acute services are organised. Hence the strong safety theme in Lord Darzi's London review.
Happily, other emerging evidence suggests a strong association of safe care (as measured by mortality), with efficiency and sound operational performance. Trusts working with the NHS Institute for Innovation and Improvement for instance have observed improvements in mortality when medical outliers are reduced, when length of stay is reduced, and when outreach teams provide early warning of patient deterioration. We should be following these developments carefully.
At King's this understanding has had big implications for the construction and use of the risk register, including in the business planning process. It has also influenced our daily information reporting and key indicators for performance scorecards.
Raising our game here gives some challenges. It's one thing to talk about high-reliability organisations. It's another to welcome in management consultants bearing slogans like 'right first time' and 'zero defects'. This is the stuff of manufacturing processes. Clinical colleagues do not enjoy identification with the manufacture of ball bearings. Theirs is a culture of individualised judgement based on training and experience.
But it's becoming clearer that for patients to be best served clinical work has to be done on a more programmed basis. For example, the key to eliminating the medical outlier issue at King's was the streaming of acute patients into two categories - simple and complex needs - and to group resources accordingly. There is a clinical and corporate leadership need here. Clinical and medical directors and chief executives have to step forward and take their boards with them. I sense an opportunity to release new energy and excitement.
Tackling safety will help us catch up with our patients and public. On social occasions it doesn't take long before conversation gets round to problems of infection in hospitals or to personal or family experiences.
Many of these stories are wonderful, others are hair-raising. The accounts of long and complex journeys give a sense of inevitability of error, of a link in the chain being broken. Why aren't we more on top of this? I wonder how much we on the inside use the NHS.
Five years ago I asked a group of consultants what happened when they were ill. Did they book an appointment with a GP? Then wait for the outpatient appointment? Then wait, see the consultant, wait for tests?
No-one could claim experience of the full process. Senior NHS employees know enough to short-circuit most of this - a sort of ad hoc process redesign (of course, emergency care is an exception, and that's when professionals raise issues about service delivery. Sooner or later one of our kids ends up in accident and emergency).
If we don't understand the public and patient perspective we won't 'get' public anger about infection or the differences in safety and quality of services between hospitals as these become ever clearer. We struggle with this just as we once struggled with public anger over A&E waits. Boards and their clinical and managerial professionals have a common agenda, a unifying opportunity even.
If we get this right we will create what NHS Institute senior associate Hugh Rogers would call synergy for quality, where reliability, safety and mortality and lean processes are brought together. We have moved a long way from the days when data did not distinguish between discharge and death.
We now have a chance to develop into a modern, responsive and robust service industry.
Malcolm Lowe-Lauri is chief executive of King's College Hospital foundation trust.