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.
Final thoughts...
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.
References
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
