Does healthcare work like a safety critical industry?

The answer is no.

Too often, individual staff have to deal with variations or minor flaws in the process of care, which they do often and well.  A set of notes may not be available when needed.  The pack of equipment is not the correct pack for a given procedure.  Because of illness among colleagues, temporary staff are on the team who do not know the geography or the operating procedures of the clinical area.  A clinical team member is delayed elsewhere so the ward round must start without them.  A member of staff is asked to deal with a clinical situation of which they have little experience.  One surgeon in a team prefers one set of rules for their patients, another prefers a different way of doing things.  Senior clinicians claim clinical autonomy to decide their own process and practice.

Priorities are set by too many different organisations – by the CQC, by Monitor, by the commissioners, by the provider organisations themselves.  Staff rotations and rosters mean that different people come together as a clinical team.  These continuing variations mean that individual staff must regularly make personal judgements and decisions as to whether to proceed in any given circumstance or not.  They must remember complex instructions of policy and procedure.  They must be aware of the latest incident investigation and its lessons.

In such an environment the safety and success of care depends on the quality and commitment of individual staff.  Their training, their attitude, their care and consideration are the foundations on which the successful care of millions of patients is built on a daily and weekly basis.

If healthcare were run as a safety critical industry, this scenario would not be tolerated.  It would be expected as a matter of course that there was one way and one way only of doing things in any particular hospital.  This would be standard and clear.  Unjustified variations from that way of doing things would not arise.  Staff would not have to make individual assessments of minor changes on a regular basis but would instantly recognise variation and would know that they were right not to accept it.  In particular environments, such as in operating theatres, procedural checklists and team ‘timeouts’ (as recommended by the WHO) would be automatic and unquestioned.  Clinical teams would be well established with continuity of membership to establish familiarity with each other and with the team’s responsibilities.  The level of competence and training of staff would be commensurate with their clinical responsibilities at all times, and each patient would have a single named senior clinician who had overall responsibility for their care.

There are parts of the NHS which already run like this.  Ironically, some of the highest risk units (such as intensive care) provide some of the safest environments because they run on these safety-critical principles.

In his recent report on safety and quality for the NHS in England, Don Berwick emphasised the importance of the NHS becoming, above all things, a learning organisation focused on continual improvement, and an organisation which places the quality and safety of care above all other priorities, at all levels in the organisation.  These things are fundamental to managing healthcare as a safety critical system.

This approach to safety in the delivery of care is not one which calls for yet more safety inspectors.  It is one which requires a further change in culture and approach. One which recognises the high quality of staff across the NHS and supports their individual professionalism with a disciplined approach to process and procedure.  It is one which places maximum emphasis on the coherence and consistency of clinical teams. It is one in which healthcare organisations place the highest priority on unambiguity in their approach to safety and quality.

There are many other safety critical industries in which the routine business of the organisations is potentially dangerous to all involved.  Obvious examples include airlines, construction and mining.

Does healthcare learn and apply the lessons from those other industries in reducing risk and maximising safety?  This is one of several key questions being addressed by a group of clinicians and managers from across North West London. The working group set up by Imperial College Health Partners is developing an approach to the aforementioned issues in which all member organisations will be involved.

A safer system will not be achieved by more regulation and external inspection.  It will be achieved by systematic adoption of an approach to safety which depends on continual learning, clear prioritisation, coherent messages and support for staff, and an appreciation of the fundamental tenets of safety-critical operations.

Posted in:

Leave a Reply

Are you human? *