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Patient safety and the NHS blame game 

By kate wooland, PA healthcare expert, and elanor bond, PA healthcare expert

Following the publication of the Care Quality Commission review last year, Jeremy Hunt has announced patient safety as a key area of focus. The health secretary’s interest in this area was prompted in 2015, after the Public Administration Select Committee reported that patient safety investigations were focused on blame and avoiding financial liability. From the 31 March 2017, the health secretary introduced new regulations requiring trusts to publish their data on avoidable mortality [1]. The new initiative is part of a plan to force boards to discuss patient safety more transparently and learn from past performance.

The Secretary of State intends to build on best practice in the aviation industry and the US healthcare industry, and provide NHS Staff with a safe space to talk about what’s gone wrong and how to improve. Whilst the mandated publication of such data will certainly provide trusts with a talking point, what is less certain is how NHS leaders will ensure that these conversations yield the positive results needed. The blame culture within the NHS is well documented, with 30% of all UK NHS staff having experienced bullying, harassment or abuse in the last 12 months (NHS Staff Survey 2015). More concerning still is that 55% of those who experienced abuse said that what prompted the abuse was their having raised a concern (The Guardian 2016 anonymous study). If this new initiative is to result in the intended tangible improvements in patient safety, it needs to be accompanied by major cultural change.

Case stories such as the patient safety transformation at Virginia Mason Medical Center in the US demonstrate how such change is possible. In 2004, Virginia Mason had a tragic safety accident in which antiseptic fluid was injected into a patient’s brain, killing her slowly. The hospital used the event to generate momentum and support for radical change, engaging staff at all levels in the process. The hospital’s patient safety programmes underwent complete redesign, implementing systems which encouraged and rewarded staff for admitting mistakes. Not only have Virginia Mason’s outcomes seen significant improvement, increasing productivity by 93% in some targeted areas, their costs have also dropped considerably. The programme has saved the hospital $11m in capital investment and saves $4m per year in reduced supply costs and standardisation efforts [2]. The health secretary has sought to learn from this best practice and awarded Virginia Mason quality improvement contracts with five NHS Trusts in July 2015. The HFMA has reported positively on improved outcomes from the partnership at Leeds Teaching Hospital NHS Trust, where elective orthopaedics were already seeing fewer cancellations and a 20 minute reduction in theatre preparation time by June 2016.

Nevertheless, for many trusts in the UK, current challenges will continue to block NHS progress, unless they can find a way to rapidly embrace radical change. As the Kings Fund has pointed out, in order for structural or systematic changes to succeed, an organisational culture must exist ready to support them [3]. Organisations which invest in employee success help to engineer and develop a collaborative growth mindset which delivers hard results. Where companies have strong engagement efforts, employees take, on average, 57% less sick days (Workplace Research Foundation). In addition, companies with a highly engaged workforce are 50% more productive than those without and display 44% higher retention rates (Weir, 2003 [4]). An example of a highly beneficial cultural shift for the NHS is supporting staff in moving from a “fixed mindset” to a “growth mindset” [5]. These concepts were originally developed to describe two different ways people think about personality, but they can also be used to understand how employees approach the nature of an organisation.

A fixed mindset sees the status quo as indicative of an organisation’s full capability. It is driven by a need to appear to succeed and so is resistant to challenges, effort and criticism. A fixed mindset operates very much inside the box, is mindful of the scope of regulations and generally tries to keep its head beneath the parapet.

By contrast, a growth mindset thrives on challenge and sees failure not as evidence of inadequacy but as an opportunity for progress and innovation. For a fixed mindset, acknowledging failings in a given area is a direct attack on capability and competency. Conversely, a growth mindset regards failing as an opportunity to develop capability and make positive changes for the future. When a growth mindset is adopted across an organisation, everyone feels free to offer critique without fearing that this will reflect badly on them or their ability. This creates valuable psychological security, enabling teams to operate at their best.

In recent years, increasing media scrutiny and financial pressure has generated a culture of self-preservation within much of the NHS, fostering a blame culture and hampering attempts at innovation. There are success stories, such as that of Birmingham Children’s Hospital, which was the first children’s hospital to achieve a rating of ‘outstanding’ from the Care Quality Commission and acknowledged for a culture of support and team work and well respected leadership. In addition, the establishment of the Healthcare Safety Investigation Branch (HSIB) in April last year [6] and the use of the Chief Inspector of the Air Accidents Investigations Branch (AAIB) as one of its expert advisors are positive steps forward. Challenging retributive ways of thinking will be crucial to the success of HSIB and the Secretary of State’s new initiative.

For the new initiative to succeed across the NHS as a whole, it will be important to see more success stories and eliminate any blame culture. This means taking active steps to promote staff engagement and encourage transparency and learning. Without real culture change, driven from the top, publishing avoidable deaths could become yet another aggravating factor in the NHS blame game.

 

[1] http://www.healthcareconferencesuk.co.uk/news/jeremy-hunt-responds-to-cqc-review-of-deaths-of-nhs-patients
[2] https://www.virginiamason.org/workfiles/pdfdocs/press/vmps_fastfacts.pdf
[3] TheKingsFund: Reforming the NHS from Within - https://www.kingsfund.org.uk/time-to-think-differently/publications/reforming-nhs-within/case-study-3-virginia-mason-medical-center
[4] Weir, J. HR.com. 2003. Reporting findings of First, Break All the Rules, by Marcus Buckingham and Curt Coffman (Simon and Schuster, 1999) and Now, Discover Your Strengths, by Marcus Buckingham and Donald Clifton (The Free Press, 2001).
[5] Dweck, C. (2006). Mindset. 1st ed. Random House.
[6] https://www.gov.uk/government/groups/independent-patient-safety-investigation-service-ipsis-expert-advisory-group

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