What went wrong with the quality and safety agenda?
This is the title of an essay by Michael Buist and Sarah Middleton published in the BMJ in October 2013 (1). Why after the wake-up call of “To Err is Human” (2) have we made so little progress? What we need, these authors conclude, is a culture change. We know what our existing healthcare culture is like but what should the new culture look like and how could we get there? Answers are provided by two works of fiction from John J. Nance: “Why Hospitals Should Fly” and “Charting the Course”. So it seems a good time to review these two books and address how they might impact on those of us who are involved in the development and delivery of simulation-based courses in healthcare.
Who are these books for?
With any book review there are two questions – who should read this? What might you gain from it? Well, anyone involved in the quality and safety agenda will benefit from reading these books. The author has a credible background – pilot involved in the early days of CRM training, involvement with the patient safety movement, published author of fiction and married to an ex-nurse with expertise in business studies. What this means is that these books are readable, populated with recognisable characters from healthcare world, and have something to say that is made explicit and reinforced without being too much like a lecture or sermon. It may not rival Moby Dick as a work of literature but it is not intended to. What might you gain? In addition to the vision Nance provides access to a lot of relevant evidence and lays out some of the key steps that need to be taken. What he is good at doing is providing some very useful, practical tips that individuals can adopt without losing sense of the larger picture.
The plot (no spoiler alert required):
Will Jenkins, a former physician and CEO of a hospital in Oregon is visiting St. Michaels Hospital on the outskirts of Denver Colorado to observe a success story. Over the course of few days Will takes his own personal journey and discovers why he has not been able to implement the quality and healthcare agenda in his former institution. At the end of the first book Will is asked by the CEO to consider applying for the post of CEO in a hospital in Las Vegas. The second book describes the early part of Will’s arrival and attempts to apply the lessons he learned from St Michaels. Will is married to a former nurse and head of a business school, who helps him apply sound business theory to help him manage change effectively. At the end of the second book Nance provides notes and questions similar to those found for book groups.
What is good about these books?
The main strength is the clarity of vision that Nance conveys. Through Will’s experiences Nance provides details of how healthcare staff members deal with their day to day challenges within an overall framework that supports their activities. The use of particular examples brings it to life. One example is a description of how the intensive care staff looking after neurosurgical patients with dural leaks have modified the ventilator acquired pneumonia bundle to deal with this specific problem. This illustrates the point that staff members have to work with these initiatives and make them work. The CEO of St Michaels uses a comparison between James T. Kirk and Jean-Luc Picard to illustrate different leadership styles and you don’t have to be a trekkie to get the point that a didactic ‘do as I tell you’ approach works less well than ‘I would appreciate your input into this before I make a final decision’ collaborative approach. In the second book I liked the two converging stories – Will’s experiences at board and senior management level and the experiences of staff on the front line of Las Vegas Memorial. This illustrated the culture that Will was trying to change. So how did change come about? Nance pulls no punches; there is no quick fix but he makes his points through Will via the discussions between Will and his Wife. The application of Maslow’s hierarchy pyramid in not conventional fiction pillow-talk (unless Maslow’s pyramid means something different from what I understand) but it allows Nance and his wife to introduce good practical applications from business management and psychology. So what are the key points?
1. Have a clear sense of purpose that you can articulate – missions and values that mean something to whole workforce.
2. Invest in strong leadership – the leaders at all different levels are there to facilitate conditions that allow the front line staff to get on with their jobs, which includes reflecting on their performance and making changes to the system as appropriate to improve the system. Strong leadership is about setting standards, making them explicit and not tolerating performance below those standards.
3. Staff can only perform in this way if they are prepared for their new roles. This requires a significant investment in time and training resources.
4. Unnecessary variation is not tolerated – this does not mean applying rigid protocols to the treatment of patients but means consistent use of checklists, sepsis bundles etc.
5. Strong sanctions have to be applied when appropriate – if staff who do not comply with the new way fail to respond to further training then they have to go. This applies irrespective of their rank or position.
6. This is always work in progress because the aim is to continually improve and adapt to new challenges. A successful culture change is defined in terms of no-one being able to remember what it used to be like.
7. Increase the involvement of patients in forcing the pace of change.
I was impressed by the high standards set and expected. This is articulated as no unnecessary patient deaths or harmful events. This contrasts with the present culture and was nicely illustrated in Buist and Middleton’s essay when Buist describes his CEOs response to a series of disasters in the ITU as “we don’t appear to be worse than the other hospitals in our area”. In terms of the simulation-based education does he mention us? Does he say nice things about us? Yes, of course he does but places more emphasis on in-situ work for career grade staff.
What could be improved?
So what could be changed? Nance deals with the culture in the US and that has its own hurdles to overcome. Nevertheless, I found it an interesting exercise to think about where the challenges arise in the devolved healthcare systems of the UK. Nance highlights the need to reassure Chief Financial Officers that those initial heavy investments will pay off by reducing the fiscal costs of patient harm, reduce turnover in staff, fewer sick days with a more contented workforce and so on. These are relevant in the UK but involve political will because most of healthcare is government funded. Can politicians be persuaded to take a longer term view? If I were still active in clinical practice I would be recommending these books to the patient representatives and encouraging them to share the vision.
I took early retirement for many reasons but I recognised that sense of demoralisation that Nance captured in the front line work force. Would I have retired early if my hospital had been a St Michaels’ type of hospital – I suspect not.
1) Buist M, Middleton S. What went wrong with the quality and safety agenda? British Medical Journal 2013: 347; October 5th, 20-21
2) Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000