How transparent incident investigations are helping to develop better care

National, regional and local initiatives have all served to increase the emphasis placed by the NHS on patient safety. Projects such as Patient Safety First and the Scottish Patient Safety Programme have reinforced the importance of developing safer clinical systems to reduce avoidable death and harm.

In addition, as a result of the systems failures at Mid Staffordshire Foundation Trust, there has been an increasing awareness that people can be harmed by unreliable and unsafe health systems. The focus on rates of hospital acquired infection and medication errors have also served to enhance awareness of the harms associated with delivery of healthcare. 

This heightened awareness has occurred against a backdrop of increased expectations, regulation and scrutiny in general, as well as an emphasis on the importance of accountability and of open and transparent approaches to the delivery of healthcare.

NHS Ayrshire and Arran provides healthcare services to approximately 400,000 people in south west Scotland, is one of 14 territorial NHS boards in Scotland and has an annual budget of £683.7m.

Following internal reviews and some critical reports from external regulators such as the Mental Welfare Commission, NHS Ayrshire and Arran decided to review the way in which it approached adverse event investigation.

As part of this initiative, the executive medical and nurse directors and their assistant directors committed to learning from the Institute for Healthcare Improvement’s board development programmes.

The publication of the NHS Scotland Healthcare Quality Strategy focused boards on the following three quality ambitions and provided further impetus to make changes:

• There will be mutually beneficial partnerships between patients, their families and those delivering healthcare services, which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision making.
• The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
• There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.

The significant harm that can be caused to staff when reviews become focused on blame and individual conduct had become very apparent in some clinical directorates. This had resulted in a “them” and “us” mindset and concerns that reporting of near misses and adverse events would lead to unnecessary scrutiny and review focused on individual conduct and performance. 

Coordination and support

NHS Ayrshire and Arran developed the role of investigatory support coordinator to ensure a standardised approach to the implementation and coordination of activities in support of adverse event reviews. This also enabled links to be made across complaints, clinical improvement, health and safety, litigation and claims and incident reporting support teams. 

New arrangements to ensure more effective coordination were implemented, using a secure SharePoint collaboration website to manage and document the flow of information for review teams in relation to staff statements, clinical records, meetings, protocols, family and staff liaison.

All reviews are now led by clinical leaders from outside of the operational areas in which the events occurred. At least two team members are trained in root causes analysis (promoted by a corporately supported initiative to increase staff trained in this analysis) and there are team members specifically nominated to act as subject matter experts and to link with staff in operational directorates where events occurred. Directorates are asked to nominate relevant medical and nursing staff to become involved and subject matter experts as required.

Increased transparency

Board governance committee minutes are now much more transparent in outlining the details of adverse event reviews. The following extracts from minutes in 2008 and more recent ones from 2011 outline the differences in approach:

2008: “Dr Masterton introduced a report which outlined an incident in the intensive psychiatric care unit and subsequent completed action plan, including various service improvements. Mrs McQueen noted that concerns/issues in respect of individual unit staff are being progressed.”

2011: “The patient made a call to the ambulance service at 04.13 hours on 31 August 2010 complaining of suffering from depression and stating that he tried to slash his wrists and hang himself and had Stanley knives in front of him. The presenting problem in the ambulance handover was cluster headaches, depression and a subsequent statement that he had tried to hang himself in his garage. He was subsequently triaged as yellow (to be seen within one hour) and allocated to room one, which is used for “mental health” patients, with the door open. He was seen on two occasions in the room by nursing staff after making banging noises and the patient requested oxygen for his headaches. On noting the door was closed, at 06.00 hours, a staff nurse entered the room and found him hanging by his jumper from a door at the rear of the room. He was resuscitated at this point, but died on 3 September 2010 at 16.00 hours.”

Resisting opposition

Anonymisation or confirmation of consent from next of kin have not always been sufficient to prevent concerns being expressed that this level of detail in board documents constitutes a breach of data protection legislation and the Caldicott principles regarding use of patient information. This “pushback” – objection from within the organisation – is likely to be a reflection of custom and practice that serves to maintain the status quo or historical tendency to avoid disclosure.

We now publish learning summary reports on our public website, outlining details of recommendations resulting from adverse events and providing a point of contact for members of the public wishing to learn more about work on making our healthcare systems safer.

The external review of minutes has received positive feedback from Jim Conway, adjunct lecturer at the Harvard school of public health, principal of the governance and leadership group of Pascal Metrics, and a senior fellow at the Institute for Healthcare Improvement.

Mr Conway commented: “These are probably the most transparent meeting minutes that I have seen in the NHS or another organisation around cases. I can understand the pushback – culturally it is not where people have been. That said, we won’t get the outcomes we want based on the way we used to do things. You are right to push this approach, and based on the root causes analysis, it sounds like the organisation is taking the journey with you.” 

Family members are now invited to contribute to the terms of reference for significant adverse event reviews, ensuring their specific questions are considered and responded to. Examples of the types of questions that arise include:

• Why were his medicines not given?
• What did the nurses know about his condition?
• What was done after my telephone call about her state of mind?

We have found that this approach has resulted in some senior staff experiencing higher levels of discomfort than anticipated.

The following remarks illustrate initial reactions when board governance and improvement processes featured family involvement, photographs from the former lives of people killed by unsafe systems and descriptions of the impact on families.

• ‘Stop using these pictures – it makes the staff uncomfortable.”
• ‘“Beware of aligning yourself with patients and families.”
• ‘“These people need to take responsibility for killing themselves.”
• ‘“That is not statistically significant.”
• “It was only five cases and she was 78 years old.”

We are also now more focused on acknowledging in our media releases the harm, impact and distress of an event. There has been a noticeable change in content of releases, with words such as hurt, harm, pain, distress and suffering appearing more. People’s names are also being used more openly to emphasise the personal cost of harm.

Board governance committees are also presented with direct quotes from the families of patients who have died, including phrases such as: “we can’t get her back,” “He came to the hospital looking for hope, comfort, help and treatment. He found none of these things.”

This is an area associated with strong emotions among all of those involved and affected. Some staff have said that they find it refreshing and empowering that they are able to be more open.

Others have now openly shared their discomfort at having to personally revisit long held beliefs, behaviours and ideas, acknowledging that the process of change has been personally challenging.

More people are talking and thinking about the safety of our healthcare system and doing so openly, honestly and with a commitment to support families and staff to deliver safer and more reliable systems of care in the future.