A lecture by Prof Peter McCulloch, Oxford University
The problem of healthcare safety, and our failure to solve it
Prof McCulloch started his lecture by comparing safety improvements in other industries. In aviation there has been a four-fold decrease in fatalities over the last 30 or so years, whilst in construction, fatalities have dropped by 88%. In healthcare, there has hardly been any improvement. He said that one of the problems is that the profession, as a whole, does not recognise it as a problem, “I see no ships” as Nelson said. This is only overcome when a significant number of deaths raise sufficient concern, à la Shipman or Letby.
Statistics are rarely taken into account mainly due to the lack of numbers making statistical analysis unreliable. If we simplify procedures by repeating operations with the same team, we can statistically assess that team’s proficiency. In Prof McCulloch’s opinion, a team needs to do at least 20 operations before it can start to be assessed on its competency.
Over the years, healthcare has initiated various safety studies. One such study, HRO, reported that the industry was:
- Preoccupied with failure, and constantly averse to risk.
- Reluctant to simplify. They do things the hard way because that is how it had always been done.
- Reluctant to change protected skills and practices.
- Reluctant to let the specialist lead instead of it being based on seniority.
Whilst the industry accepted that these should be changed, it believed, sadly, that they were impossible in the healthcare sector. When asked why not, the responses included that they were dealing with very complex issues, dealing with broken (ill) people, one at a time, and the healthcare machine never stops.
When asked what could work, the survey came up with three factors: resources, senior management change and clinical leadership change.
Do increased resources work, and can we afford them? The Blair-Brown years of investment improved mortality by 26% in the UK, however 70% of nurses said they were understaffed.
The reality of senior management is that Boards are bereft of medical expertise, are forced to focus on finance, regulatory demands and PR/legal threats, and are easily exploited and easily blinded by reality. Clinicians are generally bereft of executive powers. Leadership is not easy to study but can have a striking impact.
None of these factors are susceptible to experiment; hospitals only allow observation.
Can the culture be improved through team training? A teamwork experiment indicated a small improvement although the most likely explanation was that the existing system factors were more powerful and not changeable by personnel. However, promoting both culture and system improvements did produce results. This suggested that increased teamwork training enhanced the efforts of system improvements and made them less inconsistent. However, one of the biggest findings was the enormous effort of getting staff to comply, attend or collect data. It was found that smaller groups worked best.
In a teambuilding seminar, involving the NZ rugby legend, Dan Carter, and Lewis Hamilton’s pitstop captain amongst others, the following key points to achieve improvements emerged:
- Socialise together
- Train frequently and intensively together
- Celebrate success and good performance
- Have a buddy and mentor scheme
- Involve everyone, eradicate cliques
- Look to senior “NCOs” to maintain the culture
- Don’t tolerate misfits and prima donnas
Overall, engagement is the key.
Prof McCulloch went on to talk about the culture in the healthcare sector. There are a number of factors, starting with the desire by its members to do good. Other factors include the professional hierarchy based on an apprenticeship model and social status together with professional and departmental divisions. This can result in poor understanding and cooperation between professions, departments and even wards. And the final factor, especially in the NHS, is a highly emotional and stressful environment.
These factors result in an aspirational culture having to meet impossible demands together with hierarchical pressure.
So how do we move forward?
Start by changing the hospital board structure and its incentives. Involve clinical leaders and external clinical experts. Downgrade the role of Non-Execs, especially non-medical ones. Enhance the Board’s accountability for safety and quality, giving it equal weighting with finance, with consequences for Board members personally.
Future experiments in clinical level changes to be signed off at CEO level, with the Board accountable for local performance, agreed budget, a programme to incentivise compliance together with active monitoring and feedback.
The management structure should give frontline teams more autonomy together with improved communications. The use of independent expert analysis of serious incidents should be widened, and nurse and doctor training changed to improve team cohesion (with possible interchange of roles?). Finally, invest in a National QI and Leadership training for clinical leaders.
The Society’s Vote of Thanks to Prof McCulloch was given by Richard Groome, who has in the past been a non-medical non-executive director in the NHS. Over his 30 years of experience, he has seen a massive increase in bureaucracy and complexity in the NHS, and the fear culture in many health institutions. However, he believed that changes are possible as has been demonstrated in the ambulance service in the UK with improved clinical leadership.
Paul Gerrard