Postcard 4: Safety as a moving target

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The fourth and final postcard has arrived from Maxine Power as she concludes a two week improvement tour of Australia. It’s been quite an adventure!

So it’s my final day here in Sydney and I’ve just met with the teams leading medication safety and VTE prevention at the Clinical Excellence Commission (CEC). Once again I’m struck by the similarities in the work programmes between the UK and Australia but before I go into this I want to tell you about my journey to the CEC.

This morning I left the hotel and jumped in a cab to find my driver was a fabulous Italian called Max. Max has lived in Australia for 12 years and before that he lived in England and France. Max is a trained Chef but here in Australia he drives cabs and entertains people. Max tells me about how he isn’t really supposed to speak to his customers and how his fellow cab drivers fear that the system here is becoming so litigious that they could get sued for ‘saying the wrong thing’ he also describes his sense of joy at being awarded Australian citizenship. He’s an interesting character and full of wonderful observations about people. He describes the variety of people he meets as adding ‘pepper’ to his life! Most interesting is that Max has the ability to comment on the differences between the way society operates in different cultures. Max tells me that when he came to Australia and started working as a taxi driver he got one speeding ticket after another and eventually lost his license! He says that a 60 mile an hour speed limit requires you to drive at 55 and not 61 or 62. He says something quite profound – ‘it’s strange at first but you just get used to it’. He goes on to say how he believes that ultimately everyone benefits and how, when he returns to Europe, he still behaves according to the Australian rules – irritating his family members and friends. I begin to ask myself – could the Australians be onto something?

So why is this important? As I have spoken to people working in healthcare in Australia I’ve been struck by how rule based the whole system appears to be. People in the central government and many in the arms length bodies see their role as ‘setting standards’ and policing them. I’m struck by how people truly believe that the standards and protocols will be adopted and followed. Like all other systems when things go wrong there is a review of standards and a tightening of the grip. I can see now that this is part of the Australian DNA and that application of standards in health is one of many examples of how Australian society is organised.

So, what are the advantages of standards? It’s pretty clear to me that a high performing system or indeed society requires operating norms, standards and structures which describe a minimum expectation. However, the assumption that everyone follows all the time is naïve. The work of Renee Amalberti has shown natural tendency of people to migrate from set norms over time, the enforcement of speed limits is a famous example used often by colleagues working in safety and improvement. How many people drive at 70 miles per hour ALL THE TIME on a UK motorway? Our violation and risk taking is personal, some will go at 70-80 others comfortably travel at 90miles per hour on a regular basis. Risk appetite varies.

In their recent 2015 paper Charles Vincent and Renee Amalberti talk about ‘safety as a moving target’. They elegantly describe how our perceptions of harm have changed over time, from the most serious untoward events in our early days of incident reporting we have added new ‘harms’ as we have tinkered with the margins of avoid ability and the variation that exists between apparently comparable clinical specialities and settings. Our work with the NHS Safety Thermometer here in Haelo has progressed England from a focus on infection prevention and control to a suite of common, largely preventable harms (pressure ulcers, falls, infection in patients with urinary catheters and VTE). Our next generation of NHS Safety Thermometers has seen us extend our definition of harm to include psychological as well as physical harm, being alone during pregnancy at a time when you were anxious or fearing violence and aggression on an in patient mental health ward. All now considered important in the conversation about harm.

So – where am I going with this. I’m interested in how many rules a health system can make about safety before the whole system becomes unworkable and falls over? How are we to stop our natural tendency to build an ever more elaborate policing system? My experience of safety leadership is that we have good people who are simply overwhelmed with the volume of knowledge that they have to assimilate and work with on a daily basis in order to deliver safe care. Let’s never forget that the day to day work of frontline nurses, doctors and healthcare teams is unrelenting. One minute they are making tea for distressed relatives and the next they are handling a central line to administered life saving but potentially lethal drugs.

I don’t have the answers – I wish I did but my time here in Australia has given me opportunity to reflect and here are 5 things that I think we need to consider:

  1. Let’s get governments to decide on the 5 or 6 non negotiable things that we want to monitor, measure and improve. Let’s simplify the system so that policy and payment supports this. Let’s be relentless over more than a political term.
  2. Let’s re-define the role of leaders in healthcare and focus on board level responsibility for quality and safety, in particular for setting the culture of safety. Let’s make continuous professional development and learning of individuals and whole boards part of the statutory requirement for boards.
  3. Let’s measure what matters – a standard set of process and outcome measures and track this over time but let’s use this information to learn and improve. Stop measuring if you aren’t learning. It’s waste. Coach people to use measures intelligently and insist on improvement goals and data being displayed and public.
  4. Respect cultural norms but also consider unique industry, organisational and specialty characteristics. Healthcare is not aviation or engineering or road safety. We need to celebrate our shifting sand and accept complexity rather than lock it down.
  5. Let’s never forget that healthcare is a people business and people are fallible. We need to aggressively adopt technologies to support their decision making, to protect them from error, to remind them when they forget and to make the safe choice the first choice.

What do you think?

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