Lintern's Risk Register: Challenge the narrative of inevitable failure

Mind over experience?

I recently chaired a patient safety symposium with Lord Ara Darzi organised by the Imperial Patient Safety Translational Research Centre, which triggered some reflections.

One of the presentations that struck me was a session led by Wiley “Chip” Souba, professor of surgery at Dartmouth College – an Ivy League university in New Hampshire. He was speaking about being a resilient leader and the leadership capabilities needed to deliver improvements in patient safety.

A line from his presentation was about reframing language. Professor Souba said clinicians and leaders needed to “challenge the narrative” that harm was inevitable in complex healthcare systems. He said there were examples of hospitals in the US that had been able to demonstrate months of zero harm by aiming for such a lofty ambition.

When the first stories emerged from families at Mid Staffordshire Foundation Trust, almost exactly a decade ago (see below), many people dismissed their concerns with variations of an argument that went something like: “That’s awful but bad things happen in healthcare. It’s really complex and people make mistakes.”

None of that is untrue. Bad things do happen – on a frightening scale in the NHS – healthcare is extremely complex and nearly all staff do not go to work to cause harm.

But Professor Souba’s presentation left me wondering whether we lead ourselves into a narrative that normalises error and mistakes – and to accept them as inevitable when we shouldn’t. Not because eliminating all harm from healthcare is achievable, but because by aiming for zero harm we can alter our mindset and approach challenges in new ways that can deliver more than the old ways of thinking ever could.

Professor Souba outlined that staff who believe in the inevitability of harm may dismiss incident reporting and monitoring as unnecessarily time consuming and not their job. They will only begrudgingly make changes that are mandated from above. The result is more of the same.

He argued that when staff accept patient safety is everyone’s problem and zero harm is the goal then monitoring, evaluating and learning from errors is something everyone wants to do. It’s a collective challenge and a collective responsibility; learning becomes real and embedded; errors will reduce.

The professor described people’s approach as viewing the issue through their own “framing lens” so different people see patient safety incidents as an opportunity, a problem or something that is not their issue to tackle. Those with the latter perspective may need to leave the organisation but those who see errors as a problem can, under the right leadership, see an opportunity and be motivated to act.

The key is in the leadership of the organisation. Traditional approaches to leadership have often focused on skills and knowledge – “if only we trained our leaders better and gave them the elusive certificate that would deliver change on the front line”. Consider the amount of money invested in the NHS Leadership Academy.

What Professor Souba suggested instead is that we need to consider a focus on action. Instead of knowing about being a leader, leaders are seen as the people taking action. This can be built from the personality, integrity and consistent messaging of leaders to their staff.

He said: “Better, faster, cheaper is no longer the answer. Transformation is about altering your way of being to create an outcome, which until now hasn’t been possible. It entails a shift in the way you show up each day.”

This is subtle, nuanced stuff but there is a truth here for the NHS and its leaders who face challenges every day. Do you come to work thinking breaches in safety are inevitable? That regulations are a nuisance? Monitoring is a waste of time? Other places have a problem, but we’re OK?

Perhaps some new mantras are needed. Professor Souba suggested: lapses in safety can be eliminated; everyone can improve the care they provide as individuals and teams; standards are necessary to create a culture of safety; measurement is the only way to improve performance; together we will create a culture where people speak up; constructive criticism will be designed to learn not punish.

A decade on from Mid Staffs

Ten years ago, this month, Bella Bailey died at the Mid Staffordshire FT. Her daughter Julie was so concerned about the care her mother and other patients on the ward received that she spoke out about it. I wrote my first article with her a few weeks later, which began a long campaign that resulted in the Francis report in February 2013.

Ms Bailey, founder of the Cure the NHS campaign group, remembers her mother Bella and has written an excellent summary of where the NHS is today on improving care for patients.