The NHS – neither paragon nor villain

Nobody who works in the NHS would claim it is perfect. The more politically active may lay the blame at the current government’s door, or the one before that, or before that… but leaving politics aside, everyone who works in the NHS knows it could be better. We get it wrong. A lot. And patients are harmed, trust is lost, and precious resources are wasted.

We get it wrong for many reasons. Malicious acts do occur but they are thankfully rare. Much more common are the co-incidence of mistakes and misjudgements by front-line staff with a system that fails to prevent or reduce the impact of these errors on that particular day, at that particular time. The whole system can feel like it was designed to be wasteful, bureaucratic and with the needs of the patient at the back of the queue.

We get it right a lot too. Patients receive fantastic care and sometimes cures. Resources are used wisely. Staff, in every layer of the NHS do their best, give their all, catch the errors and make the systems work for our patients. Staff give their energy and time to making little or big changes here and there to make it better next time.

Getting it mostly right is actually the default state of affairs. But you might not believe that if the only story that is told is of the NHS’ failures. Politicians and regulators seem to almost revel in the number of ‘Never Events’ that occur. Sadly, no-one seems in the slightest bit interested in the ‘Never Events’ that never happened, thanks to well-trained, motivated and caring staff.

This blog is not in any way seeking to dismiss or diminish the harms that have occurred. They need to be heard, they need to be part of our DNA. We need to have sorrow that a system that is set up to care and cure, sometimes fails so badly. Instead of care and cure, healthcare can be inhumane and harmful.

But I am increasingly concerned by some of the rhetoric and the hostility, whether in main stream or social media. that seems to exist towards the NHS as a whole and to individuals, inside and outside the NHS, who are trying to make a difference,

This rhetoric, this tone, is, in my view, counter-productive. Others may disagree. That’s fine. But consider that I have pondered writing this blog for some time, but have been unwilling to risk invective, off-hand dismissal and accusations of  ‘typical arrogant doctor’. I’m not sure that’s a healthy state of affairs. I hope everyone wants to make healthcare better – but that involves everyone listening, even to those with whom we disagree.

So what am I worried about?

Why is the NHS so rubbish? It should have copied industry [insert name here] years ago.

Although I don’t have any  issue with the NHS learning from other industries, I do have a problem with this simplistic, and idealistic view of safety. The very industries that the NHS is supposed to be copying are very clear that simply copying a model of working is doomed to failure. Repeating this mantra, worse repeating this mantra even when it is challenged by experts from those industries, just becomes unhelpful noise.

NHS staff aren’t experts, don’t believe them.

NHS staff get it wrong sometimes. With the benefit of hindsight, any decision that leads to a bad outcome can be found wanting. In many cases, patients are far more expert in aspsects of their care than their healthcare professional. I’ve got no shame in using the internet, a patient or a colleague to help me out. But, neither of these mean that the people working in healthcare day in, day out, doing the job they are trained to do, aren’t experts in their field. If you tell me often enough that I’m rubbish at my job, may be one day I’ll believe you. Who does that benefit?

I’ve had a bad experience. Therefore, the whole NHS is delivering the same bad experience.

This is a straightforward fallacy. It would be completely wrong to disregard the hurt that people have suffered. But it is wrong to then extrapolate this to every organisation, every unit, every member of staff working in the health service.

Let me give a clinical analogy. I work as a neuroanaesthetist. A relatively common condition is a bleed around the brain which is made worse by people taking warfarin. Neurosurgeons have been known to grumble about warfarin and the damage it causes.  Their experience is essentially that warfarin is harmful. But, give them a decent night’s sleep and a good coffee, and they will admit, that they never see the patient who didn’t have a stroke thanks to their warfarin.

But somehow, when it comes to commentary about healthcare it is almost unacceptable to point out the good things, even whilst acknowledging the bad.

Doctors / nurses / managers / [insert staff group] only care about their reputation / financial targets. They don’t care about the patients when it goes wrong.

NHS staff, like every other human being on the planet, are… human. They have their strengths, their weaknesses, their foibles, their mixed motives. I can’t speak for every member of NHS staff, and maybe I just work with a fantastic group, but my experience is that the reason I and my colleagues do the jobs we do is because we care. We want to make things better for our patients. Sometimes that’s through direct clinical care, sometimes it’s through the incredibly difficult balancing act of NHS management. Nobody wants to see people not getting good care. Much of the time, most of us are frustrated that we can’t give better care. We undoubtedly need to get better at open dialogue with people when things go wrong, and if you want to hear more on this, try the excellent trilogy of podcasts from @murrayawallace on openness, learning and blame [available from Patient Safety Learning]

This feels like quite a negative blog. Maybe it is. You might not agree with my perceptions – but they are mine to hold.

If even one person pauses and thinks a just a little bit about framing the discussion about how we improve healthcare more constructively, perhaps this blog will have achieved something.

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The problem of two tails – who suffers?

Today is World Sepsis Day. And a good thing too, raising awareness of a ‘silent killer’. There’s loads of fantastic work going on – raising awareness, algorithms for recognition and management. Some of my local colleagues introduced ‘sepsis boxes’ for the wards to get the right kit in the right place. All good stuff.

But…

Here’s the rub. Sepsis is one example of a common problem in healthcare. We don’t currently have a perfect system to diagnose sepsis – either to say someone definitely doesn’t have it, or that they definitely do. We can (probably) say they do or don’t sometime down the line. By that time they will either have been correctly treated (true positive), correctly not treated (true negative), left untreated (false negative) or inappropriately treated (false positive). (Leaving aside the issue of failing to treat when recognised – a different discussion).

Both of these false diagnoses cause harm, at least some of the time. Delayed or no treatment for sepsis may be fatal. Over treating may result in antibiotic overuse (causing individual or societal harm) or other iatrogenic harms and costs. The retrospectoscope (aka the wisdom of hindsight) is cruel and unblinking. Diagnostic or prognostic uncertainty disappears when the outcomes are known.

Consider three possibilities.

First, essentially no-one is being treated for sepsis. Encouraging a more aggressive approach is likely to be of benefit. The harms of over-treating are likely to be outweighed by the benefits (though that will be cold comfort to those so-harmed).

Second, everyone looking the slightest bit peeky is being treated for sepsis. Time to back of a little perhaps? Reduction in harm from over-treatment will outweigh the increase in missed sepsis (again, cold comfort to those coming to harm).

Third, with current diagnostic uncertainty, some are missed, some are over treated. What to do? Status quo? More aggressive, less aggressive? How do we decide?

I genuinely don’t know where we are with sepsis. I suspect different organisations and units are in different places. But the problem remains – if we push too hard in one direction, we risk causing harm somewhere else.

Now replace the word sepsis with another term of your choosing:

• a drug or surgical treatment;
• a mode of care delivery (general vs specialist hospital; childbirth; ward vs intensive care)
• a healthcare process (the push for digital healthcare comes to mind)

Where is healthcare at the moment? What will happen if we push in one direction or the other? Have we ever thought about the other tail – the one that suffers because of our changes?

All actions in healthcare have positive and negative consequences – to deny this is foolhardy, and I would have little faith in anyone – healthcare professional, politician or campaigner – who fails to acknowledge this. Some of these effects are directly visible – inappropriate antibiotic use (too much or too little) is one. Others less so. The impact of diverting resources from an area of high but diffuse impact to a lower one is harder to quantify but no less important. I’m a big fan of protocols and checklists, but there is no doubt that they too have their downsides.

As ever three questions for readers to ponder:

1. When you (healthcare professional, patient, politician) push for your ‘good thing’, have you been upfront about the risks that this entails?
2. When you (healthcare professional, patient, politician) talk about the people saved by your ‘good thing’, are willing to talk about those that will come to harm?
3. Have you done your bit to think about managing sepsis better 😉 ? It really is important!

Thoughts, comments and rebuttals all welcome.

 

Dear healthcare improvement advocate – you’re wrong!

There are many people whose voices can be heard in the drive to improve healthcare.  Many people or groups who can be described as advocates, campaigners or even evangelists.

There are healthcare professionals, particularly those with national reputations, witty repartee on social media or a media friendly image. Politicians always want to be seen and heard – seeking the best for the nation, but perhaps with more than half an eye on the next election. Academics and experts like to weigh in – adding gravitas, or maybe spin, to the debate. Then there are patient voices – experts by accident, and not design – the flaws of healthcare brought into unwelcome relief by personal tragedy. Sometimes they are campaigning for a small change, or for their personal area of legitimate interest, sometimes for system-wide changes.

All of these people want things to be better. Pinning down exactly what better looks like may be difficult, but, at least for the time it takes you to read this blog, let’s agree that at making healthcare better is part of their raison d’être.

But here’s the rub. Each and every one of them – us (I’m included somewhere on that list) – is wrong. I can’t tell you, and it is not my place to tell you, what it is that each one of us has got wrong. But I can guarantee that we have got it wrong. I can guarantee that we are getting it wrong. I can guarantee that we will get it wrong.

Maybe, it is the way we have said things. Maybe it is a failure to really listen to an opposing view point. Maybe it is the belittling of those with whom we disagree.

Maybe it is the extrapolation to all from the actions of one, a few, some. Maybe it is an over or underestimate of the real risks of a procedure or process. Maybe it is a misrepresentation, a spin, of the data to make our point just that bit more. Maybe it is mistaking association for causation.

Maybe it is believing that a simple slogan will make all things better. Maybe it is believing that a solution that works in one part of healthcare will not have potentially detrimental effects elsewhere. Maybe it is not believing that a simple solution might work.

Maybe it is not being prepared to admit that the non-expert is right. Maybe it is not being prepared to admit that experts are just that.

Maybe it is believing that money, politicians, NHS workers or structures are the cause of all problems – or of none.

Maybe it is none of those things, but some other sins of omission or commission.

In case anyone thinks this blog is written in response to any individual, any group or any campaign – that would be a mistake too! It isn’t.

But when was the last time you saw an advocate, a campaigner, an evangelist, tell you they’ve got it wrong. When was the last time you them say, please tell me if I get it wrong, and I’ll listen? When did you last them say – I don’t know?

Increasingly, and rightly, we expect our healthcare practitioners to do this, in their dealings with patients. There are moral, legal and professional obligations to keep. And this makes sense – it is honest, it encourages trust, it enables learning.

So why does it seem to stop when we start campaigning and advocating? Just as trust breaks down between healthcare professional and patient or family when we get it wrong. Perhaps now is a good time to draw breath and think. Surely, breakdown of trust between those whose goal is improving healthcare, is counter-productive. Is that what we want?

As is my wont, here are some challenges for interested readers:

• Whichever of the groups you fall into, think of the ‘opposition’ – what would you like to take from this blog and say to them. Don’t say it! Instead, replace their name, their image, with your own. Look in the mirror first.
• Next time someone criticises your view or actions, try to believe that they may, in part, be right. Does that change the way you respond, or act?
• What can you do to encourage people to challenge you? Each of the groups I mentioned – healthcare practitioners, politicians, academics, and patients – is extremely powerful in it’s own way. Each is much harder to challenge than we care to admit. Can you make that any easier?
• Don’t stop! If you’re reading this far, I’m assuming you want healthcare to be better. Keep going – we might make mistakes, but the biggest mistake of all would be to give up.

Standards, tick-boxes and person-centred care

‘Standardise until you need to improvise’

Healthcare has undoubtedly become more standardised in recent years. There are a plethora of protocols, guidelines, and policies. Throw in a few standard operating procedures and some checklists and it seems as if the individual patient is lost in a morass of unthinking box-ticking.

Along with some colleagues I have been promoting the concept of increasing standardisation of care of patients with hip fracture. But not everyone agrees.  This Twitter response from @EilidhPinkChic perhaps summed up a common sentiment really well.

Why? What happened to patient centredness? And precision medicine specific for that 1 patient?

Away from hip fracture, anaesthetic colleagues @quartered_onion

Also if I’m a patient, I want bespoke, not protocolled, routine care thanks.

and esteemed academics Prof Alison Leary ‏@alisonleary1

I’d prefer clinical acumen & personalised care based on the evidence-not tickbox care

are giving me grief!

So here’s my defence of standardisation in healthcare. You may not agree – and please comment if you don’t – but I thought I’d try to stand up for standards. Going further, I’m going to suggest that properly done standards are a necessary condition for person-centred care. Not having standards is a disservice to our patients. Gulp!

Let’s get a few things out of the way straight away.

First, ticking boxes or filling in forms without understanding their purpose, or engaging with what the questions / answers mean is bad! The culture that leads to individuals believing that this is an appropriate thing to do is bad. The lack of education, training, role-modelling, feedback and time that encourages such behaviour is bad.

The box-ticking is a symptom of an underlying problem. The problems would manifest themselves in different ways if the boxes and forms weren’t there. So don’t blame the boxes – look at the problems.

Second, standards, protocols, checklists etc. never were, are not and never will be the answer to every issue in healthcare. Some stuff we’ve never met, some stuff involves resolving conflicts and competing priorities. We have to have trained, educated, innovative healthcare professionals who have the confidence to go ‘off-piste’. That requires training and experience in knowledge, skills and teamwork.

Third, badly constructed protocols and checklists are at best a nuisance, and worst a safety issue. We don’t tolerate a surgeon who can’t suture properly or a nurse who can’t dress a wound. So why do we tolerate badly produced standards and checklists. There is evidence out there to support their design – use it.

Fourth, standards never, ever, preclude healthcare professionals from talking to their patients, from asking their patients what their needs and desires are.

So, why do I say that standards (and its various siblings, cousins and vaguely related uncles) are a prerequisite for patient-centred care?

First, because if we are to provide patient-centred care we have to get the care right. And the basic stuff, the routine stuff, the lets-face-it-quite-boring stuff needs to be right. It doesn’t need me to make up a new way of doing it every time. It needs me to do some agreed practice the right way every time. If I make it up every time it’s inefficient and chances are that I’ll get it wrong at some point. I’m human after all.

If screening older people for cognitive impairment and risk of delirium before surgery is important (and it is) then my person-centred care should ensure that I do that for every relevant patient. If washing or cleaning my hands before and after patient contact is important, then my person-centred care should ensure that I do that for every patient. To not do these things is an abrogation of my responsibility. To pretend that I will remember every time is foolish and arrogant in equal measure.

But that’s the easy bit – what about clinical protocols? The old ‘my clinical judgement is better than the protocol’ argument. There is probably some truth in that – when things are uncertain, conflicting or unknown. But that isn’t as common as we would like to believe.

Every patient is unique, and every patient deserves the best care we provide, based on their individual needs. But most patients have an awful lot in common with other patients. In my world of perioperative hip fracture care, low blood pressure during surgery is common and associated with poorer outcomes. It probably has many different causes and the treatment will need to be individualised to the patient. But it doesn’t seem unreasonable to me, to set a standard for anaesthetists to attempt to minimise this. Surgical outcomes in hip fracture have improved following the introduction of national standards on the type of operation. Which is person-centred – following the standards or doing it ‘my way’?

At this point, my physician colleagues like to point out my naivety and that even the most holistic orthopaedic surgeon only looks after two bones at a time. Nothing like as complex as a frail older person with multiple medical, psychological and social issues. Possibly, possibly not. But is it person-centred for the geriatrician to believe remember all the possible components of a frailty or comprehensive geriatric assessment without some cognitive aid.

Finally, there’s the human factors bit. In healthcare we need to tailor our care to the individual. But that individualisation is only a small fraction of the care we provide. If we have to concentrate on remembering or recreating the basic, routine stuff for every patient, we will not have the head-room to get the non-routine bits right.

I can already hear the howls of protest from academic colleagues who know far more about this than I do – I have simplified a complex sociological problem. But I hope it has given you food for thought.

Martin Bromiley put it much better than I ever could

‘Standardise until you need to improvise’

Safety in the operating theatre

Key references for my talk at the AAGBI WSM

London 2016

Safety 1 and Safety 2

Hollnagel E (2013) A tale of two safeties. Nuclear Safety and Simulation 4(1): 1–9

A tale of two safeties

Swiss Cheeses

Reason J. Human error: models and management BMJ. 2000 Mar 18; 320(7237): 768–770. 

Not the only description but freely available.

Human error

Drug error in perioperative period

Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016 Jan;124(1):25-34. doi: 10.1097/ALN.0000000000000904.

Rather higher than we would wish to think, but highlights the shifting sands of what error means.

Drug errors

London Protocol

Vincent C. Systems analysis of clinical incidents

London Protocol

Theories to explain how safety works

Mary Dixon-Wood’s excellent paper working through why safety initiatives work (or not)

Explaining Michigan: Developing an Ex Post theory of a quality improvement program

WHO Checklist

Everyone seems to want to knock it, but this stepped-wedge randomised trial is probably the most robust evidence. The effects aren’t confined to the actual items on the checklist though – chiming with the paper above. What happens is not necessarily what we expect.

Haugen AS, Søfteland E, Almeland SK, Sevdalis N, Vonen B, Eide GE, Nortvedt MW, Harthug S. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial.
Ann Surg. 2015 May;261(5):821-8. doi: 10.1097/SLA.0000000000000716.

Haugen paper

National Safety Standards for Invasive Procedures (NatSSIPs)

At first sight these NHS standards seem like a set of protocols and standard operating procedures – very ‘Safety 1’! But read closer and you will see that there is a fair amount of proactive ‘what goes well’ – Safety 2.

NATSSIPS

Speaking up – not easy as it sounds

Sometimes, healthcare goes wrong. Occasionally, it goes horribly wrong. Rarely, the whole system goes off the rails. The UK has been rocked by large scale scandals: Mid-Staffs, Winterbourne View, Morecambe Bay, Bristol Children’s Hear surgery. There are many individual tragedies some of which are well known: Elaine Bromiley, Graham Reeves.*

Why didn’t I know? Why didn’t my advisers know? Why wasn’t I told? Why didn’t I ask? Winston Churchill

In each of these cases, ‘somebody’ knew something wasn’t going right. But crucially, either they didn’t speak up, or they weren’t heard. The current vogue is for politicians, commentators and on-the-ground staff to blame the culture of the health service. ‘Bullying’, ‘toxic’, ‘egotistical’ – these are the words bandied around – and in part they are of course right. Just as in every profession, there are people and structures from the top to the bottom who deliberately, or probably more often unwittingly, create a climate of trepidation, hearing (or appearing to hear) only reassurance.

The safety industry has taken this on board too. Industry realised a long time ago that failure to speak up (or be heard) was too frequent a problem in major accidents. Workers ability to speak up is now viewed as a marker of safety culture. Recent research even validated ‘speaking up climate’ scales: ‘Speaking up’ about patient safety concerns and unprofessional behaviour among residents: validation of two scales .

But here’s the rub. What if it isn’t a ‘bad’ system that is wholly to blame? What if speaking up, in practice, when it really matters, is actually quite difficult?

I’m going to take a wild stab in the dark that most people interested in improving healthcare aren’t that interested in the antics of Canadian anaesthesiology residents. But I think you should be. Here’s why.

Power and conflict: the effect of a superior’s interpersonal behaviour on trainees’ ability to challenge authority during a simulated airway emergency

Anaesthetists are generally regarded as a pretty safety conscious bunch. Especially when it comes to making sure our patients’ airways are looked after properly. Core skill stuff. So, in this study, they got a bunch of trainee anaesthetists to take part in a simulated ‘difficult airway’ situation that a consultant clearly handled dangerously badly. The trainees were observed for their advocacy (speaking up). The result – very few of them really spoke up. (As an aside, the study failed to demonstrate a difference between ‘nice’ and ‘rude’ consultants.) So, we are left with a situation that was clear cut, the trainees knew it was going wrong, but they didn’t speak up. All this despite coming from a safety conscious specialty with fairly flat hierarchies.

Here’s another example, closer to home. I spend most of my clinical time in cases where imaging needs interpretation to ensure the correct operation. A while ago I was unsure of the surgeon’s interpretation – never a good sign, imaging isn’t my strongest suit. So I went and had a look, peered at some other imaging and said to the surgeon words along the lines ‘Are you sure?’ ‘Yes’ came the reply. Another surgeon even came over to show me why I was wrong. The surgeon’s carried on. I felt uncomfortable but said nothing more. I thought about phoning another theatre to ask another surgeon to have a look – but I didn’t. Final outcome – I was right.^ To give the context, this was not a gung-ho egotistical non-communicative surgeon. This was a surgeon who knew his patients, lead and engaged with the pre-list briefing in an exemplary fashion – no toxic atmosphere here. People who know me would probably say I am prepared to speak up – and encourage others to do so. I lead our hospitals Safe Surgery programme!

So what’s going wrong? Am I a bad doctor because I failed to properly speak up? Should those Canadian residents been thrown off their training programme?

Hopefully that’s a rhetorical question, or at least you’ve murmured ‘no’. I like to think that the fundamental ‘issue’ is that I am human. I have my uncertainties, my desire not to cause a fuss, my ‘it’ll be alright if I ignore it’ moments.

Is there a solution? No panaceas I’m afraid. The military, aviation, shipping – they’ve gone a long way to addressing this but don’t claim they are perfect. But there are things we can do.

1. We can train for this. Stop kidding ourselves that speaking up is easy and a natural thing to do.
2. Those of us who are ‘senior’ can go out of our way to seek challenge. To praise those who are brave enough to suggest we might be wrong.
3. Next time we hear of a problem where no-one spoke up we can ask ourselves the question – ‘What would I really have done if I were there?‘

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*In case you think this is an NHS issue it isn’t. See for example the Veteran’s Affairs issues; Tuskegee Syphilis Experiment

^The essential facts are true, but it is a bit more complicated than this might seem. The surgery was correctly performed. The surgeon had pondered the imaging for a long time before making the initial decision.

Complaints, contrition and constructive criticism

I wrote a letter to my MP last week. It’s fair to say that I was unimpressed with the response. There were some good points to be fair – it was sent the day after my email and it was polite. But that’s pretty much where it ends.

In essence my letter to my MP was a letter of complaint about the actions of a senior minister. I tried to keep to the basic rules of complaints – courteous, specific and some clarity over my expectations. The reply – in my view – avoided answering the issues raised, ignored one aspect completely and didn’t contain a hint of apology. I was left feeling cross and that my issues were not being taken seriously.

I’m not writing this to have a go at my MP. My MP is widely respected and rightly so. I suspect any MP of the governing party would have written much the same, and any opposition MP would probably have written a diatribe about the current government. Neither is helpful, but, sadly, that is the nature of politics.

“A complaints system that does not respond flexibly, promptly and effectively to the justifiable concerns of complainants not only allows unacceptable practice to persist, it aggravates the grievance and suffering of the patient and those associated with the complaint, and undermines the public’s trust in the service.” Robert Francis QC

But it got me thinking about how the NHS handles complaints. My experience of my MP’s response doesn’t relate to any physical or psychological distress but it still doesn’t feel right. How much worse must it be when patients feel (rightly or wrongly) that they have been fobbed off.

The media and politicians are constantly on the look out for a new problem but handling of complaints is fundamental to the success of the NHS. Get it wrong and we damage relationships, waste scarce resources on legal argument and perhaps most importantly fail to learn for next time. Thus the cycle continues…

Two years ago Ann Clwyd and Tricia Hart – an MP and hospital CEO – published their report on NHS complaints. (Putting patients back in the picture) It’s a sad and rather depressing read. The themes highlighted weren’t new then and I suspect they still persist.

“Complaints procedure attitude is knee-jerk: deny, defend and delay. We don’t need money to change attitudes. What we need is a compassionate, proactive approach.”

So are we getting any better? I honestly don’t know. Certainly the complaints team where I work try very hard to ensure that the specific questions that people want answered are explicit in the responses. I hope this means that people get the answers they seek.

“I just wanted to make sure no one else suffered in the same way again. Sadly I don’t believe anything at all was done… In the end I simply gave up.”

The experience of Joshua Titcombe’s and Elizabeth Dixon’s families would suggest that the NHS still has some way to go. It really shouldn’t have taken the intervention of the Secretary of State to sort out an appropriate response to the ‘regulatory gap‘  

“We want a sincere and heartfelt ‘sorry’ not just a grudging apology forced upon the person.”

I have a suspicion that we all have a part to play in this though. Whatever the shrill rhetoric might imply, healthcare professionals, and managers in healthcare, don’t come to work to harm people.  We all have our off days, where we don’t do as well as we know we should, but by and large we mean to do the right thing. And we do – most of the time.  But we’re not trained / educated / role-modelled to acknowledge our inevitable failings in public.

So here’s a few thoughts.

I was in conversation with a very experienced non-medical colleague a few weeks ago. Together, we came to the conclusion that perhaps the very first thing healthcare professionals should be taught is how to say sorry – not anatomy or physiology.  Given that making a mistake is one of life certainties, why not learn how to deal with it early on.

That extends to our tribes too.  How often does a specialty or professional group come to a case review, morbidity & mortality meeting, or even a quality improvement process and say, “Here’s what my group could do better? There’s other stuff to do, but let’s start with me and my lot?” 

Let’s stop working in binary. A healthcare professional is extremely unlikely to be all good, or all bad. To acknowledge or raise an issue is not an assault on the person – it should be given, and received as the opportunity to make the good better. The same perhaps is true of our views of politicians. Just because I disagree with something they have said and done, it doesn’t mean everything they say or do is bad.

Finally, let’s learn the habit of acknowledging our mistakes and flaws. I am indebted to John McGarva (@IamChirurgicus) for this one – I’ve nicked his idea.  The senior ones amongst you, try asking your trainees to feedback to you at the end of your clinic / ward round / operating list. What did you do well? (Hopefully something) What could you have done better? (Hopefully not a long list)

Six months of doing this with anaesthetic trainees has taught me a few things:

• They are generally very polite (the authority gradient doesn’t magically disappear)
• They can offer real insights into my practice (not smiling is not conducive to good training…)
• It is difficult to sit in a room waiting for someone to tell you what you have done wrong, but I think I (and my patients) are better for it.

So back to where I started and my politician’s letter. I don’t suppose this blog will be read by many MPs but I’ll take my lead from Robert Francis…

“A complaints system that does not respond flexibly, promptly and effectively to the justifiable concerns of complainants not only allows unacceptable practice to persist, it aggravates the grievance of the constituent and those associated with the complaint, and undermines the public’s trust in the political process.”

A new broom for healthcare

The UK electorate is currently enacting the metaphor of a ‘new broom sweeps clean’. If the polls are to be believed opinions are evenly divided over which way the dirt should be swept.

A traditional broom or besom

This got me to thinking about another broom metaphor – this time related to the rightful tension between standardisation and improvisation. It’s a pictorial metaphor first described as far as I know by Lillrank and Liukko [Standard, routine and non‐routine processes in health care. International J Health Care QA 2004, Jan;17(1):39-46].

Lillrank’s Broom

The concept is refreshingly simple. Consider an old broom (a besom to be precise) lying on its side. The need for variation in practice is shown by the width of the broom, the context of the clinical situation is described by the position along the broom.

So, at the rigid handle end are routine practices which are best served by standardised operating procedures, checklists and protocols. Hand-washing, the process of prescription, drug dispensing – these actions have no need for variation and failure to follow the rules is far more likely to cause harm than not. This is the domain of the run-chart, the narrowing of control limits, identifying ‘special cause variation’.

In the middle the broom starts to widen. Here, clinical variation is needed but within an expected range. Clinical variety in other words – offering acceptable alternatives based on individual patient need or change in circumstances. Surgery or conservative management; medication or time – reasonable (and ideally well-defined) options which match the individual’s needs and desires. Variety helps to drive innovation too – without variety, advances such as laparoscopic (keyhole) surgery would never have happened.

At the far end are the flexible fibres – the times when there is no pre-defined answer. There may be insufficient or contradictory information, time pressure, competing priorities, insufficient resource and so forth. Here we need, we must have, highly trained healthcare workers who have the knowledge, skills and behaviours to think.

There are obvious parallels here to the risk spectrum which can be applied to individuals and organisations: at one end are the risk avoiders, the risk averse in the middle and the risk embracers at the other end.

Metaphors are all very well, but how does this help in practice? Here’s my thoughts.

1. However much we collectively don’t want to admit it, the vast majority of the healthcare process is routine. Therefore, the most of the time we should be constraining ourselves with SOPs, policies and checklists to guard against inevitable human fallibility.
2. A small, but extremely important fraction of healthcare is right at the far end. We must retain and nurture the skills of every healthcare professional to deliver excellence when the rules no longer apply.
3. Each of us has our own broom! In my clinical work as an anaesthetist there are bits of my job which are at the intuitive end – they sometimes coincide with the same ‘critical moments’ for my surgical or theatre staff colleagues, but not often. A key aspect of success at these times is teamwork – but how often do we actually tell our colleagues where we are at?
4. The expert clinician and the standardising manager need to understand the benefits and risks of relying solely on one end of the broom. Healthcare is dynamic and we need both.
5. None of the above precludes highly patient-centred care. Failure to wash my hands properly is not patient-centred; slavishly following rules which do not apply is also a failure to put the patient first.

I’m really interested to hear people’s thoughts – so feel free to comment, tweet (@IainMoppett)etc.

For those of you who whole heartedly disagree just remember that in Scotland, “besom” may be used to refer to a particularly annoying person or naughty child [Wikipedia].

Challenging times

Challenge has come up in different guises in the UK health service this week. Acute hospitals are  struggling with the challenge of how to manage when more people come in the front door than are leaving. Politicians of all political persuasions are being challenged about their role in creating or not preventing these problems. A hospital has this week been challenged over the quality of its care by the UK regulator, the CQC.

The response? Pretty universally it has been to deny responsibility, change the topic and blame someone else. For the acute hospitals (and I work in one) it’s the fault of primary care, social workers, government funding. From the politicians it’s something the other side have or haven’t done, it’s the elderly (becoming demonised as a somehow different species to the rest of us), it’s primary care, it’s too many managers, under performing doctors. The list goes on, but it is never the individual politician’s fault. For Circle, it’s an unfair regulator giving an ‘unbalanced’ report – no mention of any ownership of deficiencies in care.

But I am interested in the parallels with the qualities of a good doctor. One of these is surely a willingness to be challenged. An acceptance that sometimes what we have done, or are going to do, is not as good, not as safe, not as caring as it should be. An understanding that to be better for our patients we must seek to be challenged. Since the medical profession is supposed to embody all that is virtuous we are presumably setting an unimpeachable example to our superiors.

Of course we aren’t. At times we behave exactly the same as those derided politicians and health service managers.

This was summed up by a tweet by a medical student: ‏@mina_el_naguib “Some seniors amenable to challenge/discussion, etc. Some most certainly not.. Advice for the latter?” The twitter advice (from a self-selected group of thoughtful, and perhaps atypical doctors) was variously don’t give up, work with those who are accepting of challenge, set a role model.

But it set me thinking – what is it that stops us (doctors) and others (politicians, managers, companies) from being open to challenge?

Doctors are a strange group of people. By and large we were allowed to enter the medical profession almost exclusively based on exam results aged 18. Our progress is based on knowledge and technical ability. Our ability to listen, to seek and accept challenge don’t really enter the equation.We are used to rarely being wrong. As consultants we are also (thankfully) not often wrong. So a ‘logical’ rule of thumb is that I am more likely to be right than a trainee, nurse, member of the public (and definitely a politician!). We applaud brilliant surgical technique, the innovator, the recherché diagnosis. We rarely recognise those who admit to not knowing – they are derided as indecisive, resource wasting, not quite up to the grade.

The myth of the superhuman individual doctor persists not just inside the medical profession but is perpetuated by society. Doctors (usually individual surgeons) either heroically ‘save lives’ or commit ‘tragic blunders’. Parts of the public still expect the doctor to have an encyclopaedic knowledge of medicine and distrust a doctor using the internet as a memory aid.

(I can hear my educational colleagues telling me how much better things are now – selection is holistic, not based purely on exam results. But consider what really makes us behave the way we do – it is our senior role models. And then consider @mina_el_naguib‘s tweet – how are the senior doctors behaving now?)

Politicians face the same cultural problem. They are not allowed to admit failure or uncertainty. They are most certainly not allowed to ever admit that they are part of the problem. To do so invites mockery, ridicule and political point scoring from the media and political opponents. Politicians, like the monarchs of “1066 and all that” are binary beings – good or bad.

We therefore live in a culture where to be challenged, to show weakness and fallibility is passively  and actively discouraged.

So is there an answer? Can we make doctors and politicians open to challenge? How do we re-educate politicians and the public that the doctor and politician they want is the one who admits their mistakes; the one who reports the incident before they are found out?

Sometime ago, the good Mrs M taught me about the importance of managing upwards. So, here’s my challenge to me, and anyone who cares to read this humble blog.  Set the example to your seniors, your peers and your juniors.

• Consultants – ask your trainees and students to tell you how you could have done better before telling them what they did wrong. Ask the receptionist, the cleaner, the HCA what they thought of your bedside manner.
• Students – favour the consultants who treat you with respect over those who don’t (but love them anyway!). Be brave and explain to those that don’t why their teaching scores poorly.
• College presidents, Medical School Deans, Medical Directors, Chief Execs – be open and honest with the public about your mistakes, your learning. Don’t be content with explaining your organisation’s role – own it.

This isn’t a call for hair-shirt, clothes-rending self-flagellation. We are all part of an imperfect system –  it is just as unlikely to be all my fault as it is for it to be not my fault. Be honest – the truth – nothing more, nothing less!

Maybe then, by setting an example, one step at a time, we will move towards a time when everyone within healthcare, politicians, healthcare organisations, doctors, nurses, managers seeks and respects challenge. Then we might have a healthcare system which listens, learns and improves.

Does patient safety define your medical leader?

The perceived lack of medical leaders vexes those at the top of healthcare organisations such as the NHS.  There are calls for leadership programmes, talent spotting, secondments to industry and the like.  All good, all sensible and all might improve aspects of healthcare management.  They may not do much good at preventing the traditional pre-election management bashing of course. http://www.hsj.co.uk/5077419.article#.VJCa5oiQGrU

The NHS, in common with healthcare systems across the globe, is waking up to the epidemic of harm and failings of care which blight our systems and undo the fantastic work of all those working within healthcare. Rightly, patient safety is heralded as the top priority.

We do already have a plethora of national level medical leaders: national clinical directors, Royal College and Specialty Association Presidents, Council Members and Officers, Regional Network Leads, Clinical Commisioning Group Chairs – the list goes on! No doubt everyone of these women and men has excellent strategic, organisational or political skills.  Almost every one of them is a practicing clinician or has been in the recent past.

Here’s the catch.  What do you – doctor, nurse, employer, commissioner, patient – actually know about the personal safety behaviours of these medical leaders? If you were to go into their hospital would the surgeons and anaesthetists be hailed by ground floor staff as the ones who champion safety practices such as the WHO Safe Surgery Checklist? Would the physicians be known for their diligence in checking inpatient drug charts? How many of these leaders have filed an incident report in the last year? How many have filed an incident report about an error they have made?

This is not to suggest that any of these great and good are not beacons of safety leadership.  Some probably are. We simply don’t know. A quick look at the published biographies doesn’t reveal much. The NHS England Cinical Directors’ page gives far more information about number of papers published than it does about personal involvement and behaviours in patient safety. http://www.england.nhs.uk/about/whos-who/ncd/ A quick (and completely unscientific) sample of Clinical Commissioning Group websites doesn’t look much better.

If we are to have medical leaders let us have ones who lead by example in patient safety. My challenge to every organisation that appoints or elects medical leaders. Make safety your priority – refuse to (re)appoint any doctor who can not openly demonstrate a sustained, personal example of patient safety behaviours in their daily clinical practice.