Despite major reports calling for an overhaul of safety in the NHS, barriers to effective investigations and an open reporting culture still exist, says James Titcombe
In 2000, Sir Liam Donaldson published his seminal report An organisation with a memory.
It said: “…There is evidence that some specific types of relatively infrequent but very serious adverse events happen time and again over a period of years. Inquiries and incident investigations determine that ‘the lessons must be learned’ but the evidence suggests the NHS as a whole is not good at doing so.”
The report suggested some key areas which the NHS needed to develop to modernise its approach to learning from failure. These included a call for better systems for reporting and analysis when things go wrong, a wider appreciation of the value of a system approach to learning from error and a more open culture which encourages reporting and discussion when things go wrong.
Sir Liam’s report led to the establishment of the National Reporting and Learning System (NRLS) and the National Patient Safety Alert System (NPSAS), which became operational in 2003. Whilst these systems have undoubtedly led to a greater focus on incident reporting and a systematic process for sharing patient safety lessons nationally, a series of major investigations and reports since 2000 suggest that as a whole, the NHS is still poor at learning from error and that too often, the same mistakes are repeated.
In 2001, the Kennedy report recommended that “All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of the individuals, but also the wider contributing factors within the organisation which may have given rise to the event”.
In 2015, the Morecambe Bay Investigation report made a similar recommendation: “Clear standards should be drawn up for incident reporting and investigation… to include a requirement that investigation of these incidents be subject to a standardised process.”
Despite more than 14 years separating these two reports, similar problems and recommendations were identified in both.
The quality of learning
It is apparent that barriers to an open reporting culture still exist and that local systems for investigating incidents, identifying the contributory factors and implementing and embedding learning are sometimes inadequate.
A recent review of 150 cases referred to the Parliamentary and Health Service Ombudsman found that more than a third of NHS investigations relating to allegations of avoidable harm or death were inadequate and failed to identify when something had gone wrong.
A recent report from the Care Quality Commission also raised concerns about the quality of incident investigation and learning in the NHS.
“We have observed a high number of investigations that show a lack of skill and expertise in the methodology used; that do not identify the underlying systems issues that led to the incident; or that leave the reader with unanswered questions.”
There is a lack of clear standards for incident investigations and too often, patients and families aren’t involved in the investigation process in a meaningful way
The evidence suggests a range of shortcomings in the existing response to adverse events across the NHS.
Patient safety investigations are often poorly resourced, with a lack of expertise and skills. There is a lack of clear standards for incident investigations and too often, patients and families aren’t involved in the investigation process in a meaningful way.
Too often, the response to adverse events in the NHS remains defensive and systems and processes for implementing and embedding changes to remove or control risks identified by safety investigations are also variable.
Together, these factors have meant that progress in the key areas identified in ‘An organisation with memory’ has been slow. Indeed, many of the issues and themes identified by that report are still valid today, some 16 years later.
The government has recently announced a range of measures aimed at making further progress to support the development of an open learning culture in the NHS. These include the establishment of a National Freedom to Speak Up Guardian, a new national Healthcare Safety Investigation Branch (HSIB) and confirmation that that a new medical examiners system, a recommendation dating back to the Shipman report (2003), will be fully rolled out across the NHS by April 2018.
However, the common lesson from all major investigations into patient safety failures over the past 20 years, from Bristol to Morecambe Bay, comes back to an evident truth highlighted recently by Don Berwick. Berwick said that all healthcare organisations must choose between safety or fear; that both conditions cannot exist side by side.
Where healthcare professionals perceive a blame-seeking response to incidents and error, the conditions for learning can never exist. It is paramount that the NHS is able to strike the right balance between ensuring there is accountability where appropriate, and fostering a culture where staff can report and openly discuss error with the confidence that they won’t be blamed unfairly. A culture which successfully achieves this balance is often described as a “just culture”.
The concept of a ‘Just Culture’ is also congruent with the notion of ‘psychological safety’, which has been written about by Professor Amy C. Edmondson of Harvard Business School. “In psychologically safe environments, people believe that if they make a mistake others will not penalise or think less of them for it. They also believe that others will not resent or penalise them for asking for help, information or feedback.”
These are not new concepts or ideas and yet the 2015 NHS staff survey found that only 68 per cent of staff felt secure in raising concerns and only 56 per cent felt confident that any concerns they did raise would be addressed. As recently as March this year CQC published an inspection report which found “…a bullying and blame culture” where “…staff did not always report incidents”.
What more can be done?
Whilst the new Healthcare Safety Investigations Branch (HSIB) will be able to carry out a small number of expert safety investigations across the NHS, clearly the vast majority of safety investigations will still need to be carried out locally. Developing expertise, skills, tools and investing in the resources needed to improve the quality of local investigations is vital.
More needs to be done to ensure the concepts of a ‘Just Culture’ and ‘psychological safety’ are embedded across the system as a whole. All parts of the system need to be aligned to achieve this, from providers, professional regulators up to the Department of Health.
The culture of an organisation is strongly influenced by observations of what happens in practice. Feedback should be given to staff following safety incidents, including details of the learning and changes made and importantly, visible demonstration that staff involved have been treated fairly and not unfairly blamed.
Organisations should view reporting concerns and being open about error as a key component of the professionalism of its staff. Annual appraisals should seek to ask staff for examples of safety issues that have been raised and reporting of concerns that lead to positive improvement should be rewarded. New technology and tools can play an important role in making it as easy as possible for healthcare organisations to get this right.
The NHS has a clear choice: safety or fear - an organisation with memory or an organisation with amnesia that continues to miss opportunities to learn and improve.
James Titcombe OBE became involved in patient safety following the loss of his baby son due to failures in his care at Morecambe Bay Trust in 2008. Formerly the national adviser for safety for the Care Quality Commission, he is now a patient safety specialist working for Datix.