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First do no harm

October 4, 2014

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I had the privilege yesterday of joining a discussion with David Dalton, Chief Executive of Salford Royal Hospital, in particular focusing on the inspiring work he has led around improving patient safety and quality.

I was really struck by what David said about the start of his journey, that you cannot really improve safety if you are not honest and transparent in the first place about the current state of affairs and the intrinsically risky nature of healthcare.  Given the number of patients seen by the NHS, harm whether avoidable or otherwise, is inevitable and as the providers of care we must be honest with the public about that fact.

There is a growing and welcome move in the NHS towards greater transparency which I fully support.  Initially organisations and individual teams and practitioners are very nervous about publishing data about performance and, in particular, safety and data can always be misinterpreted and used out of context.  However in general, as I once heard it put very eloquently, publish and be damned is the right approach and the more you publish the less you will be damned as commentators and the public become better educated about the context from which to judge individual performance and events.

Transparency also helps at the local level so again I was impressed with what David said about the fact that individual wards in the hospital will post data about the most recent incidents and other aspects of performance.  There is an example to follow here from food hygiene.  The practice of requiring restaurants and other food outlets to publish their food hygiene ratings prominently where customers enter the premise normalises the issue and creates an important pressure on those who are not complying with standards.  Done appropriately the same approach can work in healthcare normalising the general run of performance and creating an incentive on those who have issues to address to do so.

A second theme of the discussion was about learning.    My experience of healthcare is that when things do go publicly wrong considerable effort is put into investigating what happened, establishing root causes and identifying lessons learnt.  Such investigations can often be quite emotional searing for those involved and that, if an avoidable fault is discovered, my experience is that there is a genuine desire for making sure that it doesn’t happen again. Yet in large complex organisations with a constant turnover of staff and leadership those lessons can easily be lost.  A learning culture is an easy aspiration to make but one which is difficult to deliver in reality.

There are two approaches which I believe can help.

First is the use of decision support.  While I was at NHS Direct, which used decision support routinely in the delivery of real time clinical care, I was struck by how powerful the system could be in helping to disseminate lessons from those cases where things had gone wrong.  15 years later the use of decision support in clinical is still relatively uncommon and I wonder how many lives might have been saved if it had been adopted more widely.

Critics will of course say that medicine does not always lend itself to computerised algorithms and that may to some extent be true.  However the clue is in the name, decision support is there to support the clinician not take their place. However there must be advantages in bringing to the clinicians attention, at the point of a decision, key information including any factors from adverse events which might impact on what they do.

The second strategy rests in the power of stories.  My time as the leader of a patient organisation convinced me of the power of stories as a vehicle for changing attitudes or behaviour in healthcare.  Personal stories not only convey the facts of a situation they also connect us with the emotions of those who were involved.  That emotion can be the most powerful factor in getting us to engage with what has happened and what it might mean for our future actions.  While circulars and guidelines and more factual  presentations are important , stories and their emotional impact are a relatively untapped approach to help us understand and disseminate the consequences of when things go wrong in healthcare.

The final point at the end of our conversation was a sense that this was the right conversation for us, as a group of health care leaders, to be having.  All of us had some personal experience of what happens when things go wrong.  We could have been talking about money or structures or integration or whole load of other issues which impact on the working life of a NHS Chief Executive.  However if we did n’t feel strongly about safety and the avoidance of harm and were n’t interested in what we could do differently to address those issues you could argue we were in the wrong business.

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