James Titcombe lessons learned

“Lessons have been learned”

Whenever there is a story in the news about a serious NHS failure involving avoidable harm or death, the phrase ‘lessons have been learned’ is invariably included as part of the organisation’s media response. It’s a phrase that I know can grate with patients and relatives who have been directly affected by such events. In recent years I’ve come to know the tragic stories of many people who have been affected by avoidable harm from healthcare and in my experience, the most important factor for the families involved is to know that changes have been made to prevent the same things happening to others in the future; to truly know that lessons have been learned. So why has this phrase become one that many people dislike and distrust?

Looking back on my own experience, losing a baby boy due to avoidable failures in care at Furness General Hospital (FGH) in 2008, I know that on many occasions we were told that lessons had been learned. In January 2010, more than a year after what happened, the chief executive at the time wrote the following in response to an article in the local paper about ongoing problems at the FGH unit: “Latest statistics show that FGH is among the safest places in England to have a baby… Today, FGH is a safer place as a result of the lessons learned…”

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Florence Nightingale – “Authentic Leadership” for Patient Safety

War is a terrible, horrible thing. As a former military physician, I have been to war and have seen the mayhem inflicted by the mechanics and methodologies of modern warfare, alarming and sobering stuff, indeed. It ain’t pretty and it sticks with you, forever!

Having said this, it remains a fact that many great advances in health care have resulted from the experiences of doctors and nurses serving in war zones and treating medical, surgical and psychological casualties of both military and civilian victims – resulting from the destruction and chaos of conflict.

It should not surprise any of us involved in healthcare professions that amidst all this havoc, individuals with great compassion and even greater insight and awareness often arise. The collective adrenaline of our medical culture, functioning under duress, often fosters brilliance and innovation. Good stuff and good people percolate upwards.

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Why every Datix is a GREATix

Why every Datix is a GREATix

Here at the Datix HQ in Wimbledon, we’ve been learning about and discussing recent initiatives to report and learn from ‘excellence incidents’. There are a number of compelling reasons why reporting and learning from examples of good practice and excellence in healthcare are valuable. By sharing examples of outstanding care or improvement initiatives that have been shown to result in tangible benefits, this learning can be shared and emulated by others. The very act of recognising examples of excellence is also something that can greatly improve morale and help foster a supportive and positive culture.

There is also real value in looking in detail at specific incidents of excellence. A recent paper describes a process where such reports are given detailed consideration at an ‘IRIS’ (Improving Resilience, Inspiring Success) or reverse SIRI (Serious Incident Report Investigation). The paper describes the positive benefits derived from the process, including empowering front line staff to share ideas and innovation.

It is encouraging to learn that some organisations are starting to use Datix as a means of reporting ‘excellent incidents’ and we’ve even seen the term “GREATix” coined to describe such reports. We are currently working to see how we might be able to support such initiatives.

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Leadership and Management – It’s all about clarity

Leadership often is viewed as something emanating from the top and filtering downward. However, effective leadership is more about colleagues working together, buy-in and bottom-up implementation than anything else. For a leader to be effective, a culture of collegial buy-in must be present, and there must be reasons for followers to follow, to sustain a safety culture and to align their daily work efforts and patterns with clearly stated goals of the institution. Themes, goals and mission statements may emanate from the top, but their achievement depends on the efforts of subordinate levels of leadership and, ultimately, to those on the front-line.

In “closed” systems where members of staff are salaried employees, it may be easier to implement and sustain a culture of safety and to develop strategies to achieve institutional goals. In more “open” systems, where some doctors and nurses are employees and others are self-employed or working under contracts, especially agency staff, it may be more difficult for leadership to be effective. If leaders and front-line stakeholders are not aligned and working together to achieve the same outcomes, then safety and highest quality cannot be assured.

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Leadership and the Just Culture – Holding the Keys to Safety, Joy and Meaning

Leaders are responsible for establishing and sustaining the culture of an institution. They are accountable for monitoring the institution’s cultural rhythm. With strong leadership, that rhythm should vacillate only slightly, rather like the variations on a barometer as compared to those on a thermometer. The rhythm must be stable or else turbulence sets in, with associated disruptions and hazards. Safety degrades under such circumstances and patients and staff can be harmed.

A key strategy for success is for leaders to recognize vulnerabilities that may affect staff performance and to address them specifically. This is accomplished by sustaining a culture where just treatment, e.g., the Just Culture, is the norm. The Just Culture consists of two dimensions, related but also unique in character.

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Why rigorous investigations matter

Advancements made in the healthcare industry over the years have been truly crucial in how we value and regard medicine. Technologies have been developed to perform surgeries and procedures not thought possible prior to their creation. Revelations have been made in the treatment of diseases once believed to be incurable, such as Malaria, Tuberculosis, and Measles, all of which are now perfectly treatable through proper care and medicine. It has not even been a hundred years since the advent of penicillin, which is unparalleled to any other discovery in modern medicine and responsible for saving untold lives since its introduction.

Due to these improvements and the results they have brought to patients throughout the world, the perception of healthcare has changed drastically. We often view healthcare as infallible, placing our trust entirely in a system dedicated to making us well. However, healthcare is not an absolute science and due to the complexity of individual health issues, hospital stays, and the number of medical professionals involved in a patient’s care, mistakes are bound to occur. When a mistake does occur, it falls on the responsibility of those involved to investigate the underlying causes.

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Why has root cause analysis not led to broad-based improvements in patient safety?

As its name would suggest, root cause analysis is the process by which teams of individuals assess and identify the underlying issues and factors that lead to unintended outcomes. In theory, root cause analysis is an investigative tool aimed at eliminating errors and improving the outcome of specific situations. If, for instance, treatment X results in unintended outcome Y, then one must merely identify and eliminate the root cause of errors in order to ensure the intended result.

Here is a simple illustration of root cause analysis, using a common tool known as the “5 Whys,” in which the question, “Why,” is asked five times to get to the originating cause of the problem. In this example, the “5 Whys” is applied to a flat tire.

  1. Why did the tire go flat? Because I ran over a nail in the driveway?
  2. Why was there a nail in the driveway? Because I failed to clean up the area after doing a home improvement project there.
  3. Why did you fail to clean up the area? Because I didn’t allow adequate time for the project and had to leave for week.
  4. Why did you not allow adequate time for the project? Because I had no idea it would take as long as it did.
  5. Why did you not know how long the project would take? Because I had never done a project like this before.

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Plane taking off

From ‘no blame’ to a ‘just culture’

Last month, the Parliamentary and Health Service Ombudsman (PHSO) published a report relating to the tragic death of 3 year old Sam Morrish. Sam died in 2010 from sepsis. In 2014, the PHSO published a report that found Sam would have survived had he received appropriate care and treatment. However, whilst the 2014 report confirmed that Sam’s death was avoidable, it didn’t provide a satisfactory explanation as why it was that the local NHS failed to uncover what happened and therefore couldn’t ensure that necessary learning took place. At the request of Sam’s parents, the PHSO undertook a new investigation to look at why.

The report found that the local investigation process was not fit for purpose, was not sufficiency independent, inquisitive, open or transparent and that the people carrying out the investigation were not sufficiently trained. It’s a hard hitting, compelling document that builds on the now strong evidence base that tells us there is an urgent need for change in the way the NHS responds and learns from mistakes. Sam’s father, Scott Morrish said:

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