In search of that illusive beast: a culture of safety
It is World Patient Safety Day. What does that mean?
We all know that culture eats strategy for breakfast.
Depending on the teller, culture will also happily snack on performance, tactics and all manner of other subjects beloved of MBA students.
Given that it’s World Patient Safety Day, I thought I would ask what is this monstrous thing and how it creates its effect.
There’s been a lot of research on the subject, but the answer is best illustrated by a story.
Reporting failure
Many years ago, I once raised an incident on my hospital’s patient safety reporting system because a patient had turned up in our emergency department with a near-fatal pulmonary embolus, caused by an overdose of a drug that stimulates the production of red cells (he was suffering from too few such cells prior to treatment, as a result of a bone-marrow cancer). It’s true that this was a known potential complication of his treatment, but it did seem to me that the safety of the patient had been compromised and that he should probably
I was taken aside in the corridor a few days later by a colleague and given a ticking-off for having interfered with a senior doctor’s plan. Apparently that doctor now had to account for his patient’s condition to a bunch of ‘quality people’ who didn’t understand medicine and would now hound him for investigation reports, explanations that could be shared with the family. I had, in short, caused trouble.
More particularly, it seemed that by reporting the fact that we - as a hospital - had nearly killed a patient, I had brought into question the competence of the haematology consultant, and their wider team.
I didn’t raise another safety report. Ever.
Such is the power of shame.
The sum of every conversation
A short and pithy definition of culture is ‘the sum of every conversation in an organisation’. I like this because it brings culture down to the personal, and the human. It also means you can see and hear it. You just have to look and listen.
It also helps to explain, as my story suggests, why you can have the greatest reporting systems and the best-staffed quality departments and the greatest … ahem … strategy, and still deliver lacklustre patient safety numbers.
It also helps to explain why culture is difficult to shift. The conversations people have with each other are determined by many things, many of them conflicting and difficult to change: hierarchy, history, rectitude, received wisdom, values … however you cut it, conversations are channeled by almost everything apart from strategy.
But this pithy definition doesn’t really help to unpick which conversations you want to change. For that, we can think about the cycle that creates better safety.
STEP-up to a culture of safety
Here is a mnemonic of my own devising that helps to unpick how to make patient safety better:
SPOT the problem: you don’t get far unless you can see there is a problem. A patient with a near-fatal PE is a problem, but so is a trailing wire in a corridor, so is a patient whose call-bell remains unanswered. So are most complaints.
TALK about it openly: without a fear-free and shame-free discussion of the problem, things remain at least partially hidden. This, of course, includes ‘speaking-up’ (some might say whistleblowing, although that is a loaded term). But it’s also about just having a conversation that doesn’t create shame or anger. Without open conversations, hierarchies remain; egos are protected.
EXAMINE the system: without a systemic view, all error is human. And yet it’s not. Humans work in context. Their team-mates, their working environment, their training, the characteristics of the task at hand and even patient all contribute to the chances of error. Indeed, the same error can happen time-and-again without consequence, but when combined with other flaws in the system, can cause unexpected harm. This counter-intuitive idea that harm is not someone’s fault is so important, and so difficult to assume, that its understanding represents - IMHO - the greatest barrier to patient safety improvement.
For instance, if you think you are being blamed when a pipsqueak junior doctor dobs-you-in about a near fatal complication in one of your patients, you’re missing the point. Which is that we need to try and ….PREVENT it happening again: which is, at the heart of the matter, the primary point. Changing our systems and processes is the only way to stop recurrence. This includes addressing our working environment, our training regimes, our shift patterns, our patient-mix, our recruitment, and - very often - our computer systems.
Would it not be better to use a means of monitoring of at-risk patients in order to catch near-fatal changes in a patient’s blood earlier — rather than simply saying ‘that's a known complication’?
All you need to do is repeat these steps, until you have a high-reliability organisation.
Addressing culture head-on
Which, of course, is easier said than done. If it were easy, everyone would do it.
But these four steps give you targets for the types of conversations that need to be addressed to shift the culture.
Do we talk about problems simply as ‘how things happen around here’? Or do we have conversations about the prevalence of error?
Do we speak-up, openly, about risks and problems that we see? Or do we think that’s someone else’s job?
Do we talk about systems, processes and inter-connections? Or do we talk about people and blame?
Do we talk about what needs to change to make things better? Or do we insist on everyone following current procedure?
What next?
All this is possible, as my colleague Judi Ingram and I tried to prove a few years ago.
Our paper - showing extraordinary results - is here
For more information on STEP-up, and other aspects of clinical leadership, you’re welcome to download the book “CAREFUL Leadership” here.
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