Patient Safety - Health Committee Contents

Examination of Witnesses (Question 622-639)



  Q622 Chairman: Good morning. Welcome to our fifth session on our inquiry into patient safety. For the record, could you please introduce yourself and the current position you hold.

  Dr Bibby: I am Dr Jo Bibby. I am the Director of Improvement Programmes at The Health Foundation.

  Dr Kostopoulou: I am Dr Olga Kostopoulou. I am a research fellow at the University of Birmingham.

  Captain Hirst: I am Guy Hirst. I run a consultancy for research and training in medicine called Atrainability. I was for 34 years an airline pilot involved in training pilots, mainly technical training but also, for the last 15 years, human factors training. I was involved during the transition, from before we had human factors training until after. I retired two years ago.

  Q623  Chairman: I will ask a general question to all of you and then there will be specific questions from individual members of the Committee. Which three changes do you think would make the biggest difference in improving safety culture inside the National Health Service?

  Dr Bibby: The first of the three things we would advocate in The Health Foundation is that there needs to be a greater awareness around the avoidable harm that arises from routine clinical care. We also feel that there needs to be a building of the belief that this harm can be avoided if clinical teams have the right skills to address patient safety issues. We feel there needs to be a much greater culture of openness and learning by looking at the reliability of routine clinical care, so that clinical teams can engage in that and the defects that are arising. In the organisations we have worked with in our programme Safer Patients, we feel that all those three culture changes have played a part as a result of the programme.

  Dr Kostopoulou: Since most of the NHS consultations take place in primary care, I think that any improvement in safety in primary care is likely to have a large impact on patients. One thing we have been ignoring or under-researching is the importance of prompt and accurate diagnosis of serious conditions in primary care. GPs, as the first point of contact, are very well placed to catch these conditions early. Conditions like the cancers that we talked about earlier, rapidly evolving infections, ischemic heart disease can really benefit from early detection and treatment. It is a very difficult job and sometimes it is not done well. We know that it is not done well because patients complain. More than 60% of claims against GPs are about diagnostic errors. The way we can support a diagnosis in primary care is through medical education, through training of doctors and, also, through the improvement of the electronic health record to include things like diagnostic support or other types of support during the consultation.

  Captain Hirst: These are all small ideas, things could be done on a day-to-day basis. First, accept that error is normal. It is ubiquitous. We all make errors. Good, successful team working can avoid, trap and mitigate the consequences of those errors. Second, a bit of discipline in procedure and practice—and most of my work is being done in secondary care, in the hospitals—so that all the team can take individual responsibility for safety. That can be done quite easily by having a decent briefing before the day starts and a debriefing afterwards to learn from it. Third, general human factors training and coaching. A study in Boston showed, for instance, where they had a major situation there, that just training the entire team on communication protocols made a huge difference to safety. They went from almost becoming a failing hospital to a superb hospital. This is Boston in America, by the way, in case any of you are from Lincolnshire.

  Chairman: Thank you.

  Q624  Dr Taylor: Dr Bibby, your foundation is running the Safer Patients Initiative and Safer Clinical Systems programme. Can you tell us a bit about these and what they have achieved?

  Dr Bibby: A little background on The Health Foundation. We are an independent charity. We have been working on patient safety for the last five years and we have invested upwards of £10 million on these programmes and other work. Perhaps I could give you an overview of the Safer Patients Initiative, which is our longest running programme and then move on to the Safer Clinical Systems. Safer Patients started over four years ago with four hospitals, working with the Institute for Healthcare Improvement in Boston in the United States. It was the first exercise of its kind, in that it was trying to look systematically across an organisation at how you can routinely and reliably implement evidence-based practices to improve patient safety and how you can create the right leadership framework to ensure patient safety. About three-quarters of the way into our first programme we extended that to a further 20 hospitals and they have just finished their phase of working. We are now keeping these organisations going in the form of a network. The work that we have done in safer patients was very much around acute care. We are now starting to ask if we can we transfer some of these approaches into mental health community-based services, and we hope other sectors later this year. One of the things we learned when we were doing Safer Patients was that individual clinicians wanted to provide reliable care, they knew what they needed to do, but often the system they worked in did not support the delivery of that care. It might be that they did not have the supply of the right equipment, not the right clinical information, there might be issues around prescribing and medication systems. From that learning, we decided to set up a further programme of work that started just last October that focuses much more on these systems of care that provide the platform. Perhaps I could talk about some of the achievements. At a broad level I think we have demonstrated some quantifiable improvements in the reliability of care and the reduction of harm. We have seen the approaches in this programme being adopted across the four UK countries. Wales, Northern Ireland, Scotland all have national programmes going on using these approaches. In England there is the National Patient Safety campaign and we are working with some specific strategic health authorities to adopt similar approaches across their patch. In the organisations we have worked with we see a shift in the safety culture and something that can be sustained. What has been provided to clinical teams and those organisations is a set of skills. They say to us: "Now we know how we can tackle safety issues beyond that which was in the original programme."

  Q625  Dr Taylor: I think you tell us that under Phase 1 there were impressive safety improvements at the four hospitals. After just two years they had on average halved their number of medical mistakes. That is really very impressive. Then you have added another 20. What are the initial results there?

  Dr Bibby: There were five work streams within the programmes, so I could give you some examples, a flavour, of some of the results that have been achieved there. One of the work streams was around safety on the general ward and we mentioned in our submission around the reduction in cardiac arrests at Luton and Dunstable Hospital that were achieved by a system of an approach that ensured that they were monitoring the condition of patients much more reliably, carrying out key clinical observations on a reliable basis, making sure they were detecting any deterioration and acting on that earlier, so that patients were not deteriorating to a point that they might—

  Q626  Dr Taylor: So you really did reduce crash calls by 30%?

  Dr Bibby: The reduction in crash calls was around six fewer crash calls a month at Luton and Dunstable.

  Q627  Dr Taylor: We have a list of the targets you set and the target for crash calls was a 30% reduction. Did you achieve that?

  Dr Bibby: I would say that the targets were not necessarily uniformly achieved but we would say that the purpose of putting targets in to this programme was to set something to aspire to rather than saying this is a success or fail. We then looked at what was achieved in the individual organisation—so we can say, yes, that there was a significant reduction, six fewer cardiac arrests a month at Luton and Dunstable. There were other sorts or reductions that we saw. For instance, we had a work stream around critical care, where we wanted to reduce infections around critical care. An example there is at the Royal Free Hospital in London. At the start of the programme they were having 18 infections per thousand bed days within their critical care unit. They reduced that to nought by August 2007, so about a year into the programme, and they have sustained that. By introducing what we call a care bundle around the management of central lines, they have been able to eliminate central line infections from their programme. Going back to some of the evidence earlier, another area that the hospitals worked on was around adverse drug events, around anticoagulation. Again one of the hospitals that we were working with was able to achieve a 40% reduction in adverse events associated with anticoagulation. The programme set out a set of targets and goals that it wanted to achieve which it believed was possible. Some hospitals achieved some of those. All hospitals made significant improvements in their patient safety.

  Q628  Dr Taylor: That is pretty impressive. Did the Safer Patients Initiative go on to other safety issues like slips and patients falling out of bed and the feeding of vulnerable patients?

  Dr Bibby: In Safer Patients we were interested in looking at the clinical aspects of care rather than necessarily the physical environment of care—not that that is not important but that is just what we chose to focus on for the programme. Obviously with some of the work around medications we would expect to see impact on falls, because better medication, better prescribing leads to less confused patients and less risk of falls, but we were trying to approach it from a clinical perspective rather than, as I say, the environment of care.

  Q629  Dr Taylor: I think you said you were going to extend into mental health and community. What about into primary care? We have already heard that this is the great big gap.

  Dr Bibby: We would like to do that and we are having discussions with Professor Esmail and others around that. The reason we started with mental health and community is that it is easy to see the transferability of some of the approaches we have used in the acute sector into those sectors. Because of some of the discussions we have heard this morning, primary care is a different beast, in a sense, and we need different approaches, so we do not want to rush into trying to transfer something without properly thinking through what we are doing.

  Dr Taylor: Thank you.

  Q630  Charlotte Atkins: Dr Bibby, following on from the Safer Patients Initiative, was there measurable improvement in all the targeted areas that you selected? Or were there areas where there was not measurable improvement?

  Dr Bibby: One of the areas that was probably harder to track improvement was around surgical site infections. Some of the reason for that is not necessarily that there was not improvement, but it was harder to measure, because obviously we were having to look at infections post discharge and it is not necessarily easy for hospitals to track what happens to patients once they are discharged, particularly because there is much earlier discharge nowadays. That is an area where we perhaps have not been able to quantify the improvements as clearly as we would have liked, but that is not to say there have not been improvements. The approach that Safer Patients took was to say that there is evidence in the literature that if you implement, say around surgical site infections, a care bundle, so five key steps around management of a patient pre and post operatively, there is evidence that it will lead to a reduction in infection. We were able to say that, yes, theatres are now reliably implementing those components of the care bundle, but, as I say, it is sometimes harder to transfer that into outcomes.

  Q631  Charlotte Atkins: But you are happy that broadly you achieved measurable improvements right across the board.

  Dr Bibby: Yes.

  Q632  Charlotte Atkins: Did you encounter barriers of any sorts in the pilot sites? To introduce this new system you must have seen some barriers.

  Dr Bibby: There are probably three barriers I would identify. First, I think there was an issue around a recognition of avoidable harm Working in a clinical setting people often normalise harm and it becomes something that it is felt is unavoidable in the context of working with very ill people. First of all, there was something about raising the awareness that harm could be avoided. People having got that awareness, it is then: "What do we do about it?" and having the skills set to know how you can improve systems of care so that you can improve the safety and the outcomes. A lot of the programme support was around building those skills. Looking forward, we are hoping that we are able to use the hospitals we have worked with as mentor sites for the wider NHS. The third area is that, inevitably when you bring in something new to a clinical setting where clinicians have ways of working, there can be, appropriately, questioning and challenge to that. The approach we would take is that, rather than saying, "You are going to do this and you are going to do it across the board," we would start with an enthusiast, somebody who was keen to test and develop, and allow experimentation in the local theatre, in the ward or wherever it started, and prove that it worked there before we tried to spread it further within the hospital, and so it would build up ownership and belief that it was worth doing.

  Q633  Charlotte Atkins: I am sure there were many success stories but are there any in particular that you would like to share with us?

  Dr Bibby: I have talked about some of the improvements we have seen around crash calls, central* line infections, medication. The other thing is around the change in culture. One of the approaches that the hospitals that we worked with used was called Leadership WalkRounds. The idea of that would be that usually two members of the board would visit an area in the hospital on a weekly basis, different members of the board. These were not spot checks, so it was not about trying to find things that were wrong, it would be planned ahead, the team would know they were coming. The idea of that would be to start to have a conversation about issues around patient safety in this organisation, the directors might say, "What was the last safety issue that happened? Tell us about it so we can understand how we would prevent that again. What could be the risk that it could happen next?" When you go into the organisations where they have been doing this, you get a real sense of recognition that patient safety is something that the senior leadership are paying attention to and that they are willing to act on system practice to improve patient safety.

  Charlotte Atkins: Thank you.

  Q634  Dr Naysmith: Dr Bibby, you have just talked about good practice with boards and whether boards took it seriously. In general, do you think NHS boards prioritise safety now? Do they take it seriously?

  Dr Bibby: Obviously all NHS organisations are concerned with ensuring the safety of patients. I think we would accept that. In a sense, the question is really about where the focus is.

  Q635  Dr Naysmith: It is about prioritising safety, is it not? You have chief executives and boards and they have so many different responsibilities. We obviously think in this inquiry that they should place safety quite highly, but in your experience what do you think happens?

  Dr Bibby: We work with over 20 organisations. We have networks of other organisations we work with where we see safety being put, quite literally, at the top of the agenda. For instance, at Torbay Hospital, one of the hospitals we worked with, they will start every board meeting with an item on patient safety, so it is sending some very visible signals there that this is something that is a priority for the leadership of the organisation. There will be a whole group of organisations in the NHS that know safety is important but do not necessarily have the ideas, the approaches, to tackle that.

  Q636  Dr Naysmith: What can we do about boards like that?

  Dr Bibby: I think there needs to be more board development. There needs to be the sharing and development of the sorts of techniques we have used in safer patients to enable boards to engage in the safety agenda more effectively.

  Q637  Dr Naysmith: Does having a "no blame" or "fair" culture that we have talked a bit about this morning mean that boards and chief executives have an excuse, so they do not have to take safety seriously?

  Dr Bibby: No. We would not say that at all. We would say it is the board's responsibility to ensure that clinicians can practice in a safe environment. It is essential that boards are understanding the clinical business of their organisation and they are able to look at how they can ensure the right systems are in place to support safe care.

  Q638  Dr Naysmith: You say in your memorandum to us that ministers in top NHS management need to ensure " ... a co-ordinated use of managerial commissioning and regulatory levers" in order to make patient safety the top priority in the NHS. Why do think these levers are not being properly used now?

  Dr Bibby: I do not think we are saying they are not being properly used, but if you look at the patient safety agenda at the moment, quite rightly it is a complex agenda: there is a number of different levers being used, with different lines of responsibility to different agencies that have a role in patient safety. The responsibility for those different areas and those agencies is spread across the Department of Health, so what is important is that there is effective co-ordination. We would want to see that that co-ordination is taking place at the NHS management board, so that we ensure we are not getting duplication of effort, that we are not having conflicting messages going out to the NHS. The NHS finds it very difficult if it is getting different messages about how it should be addressing issues.

  Q639  Dr Naysmith: You have seen areas where the practice is good and the co-ordination does take place, it does happen. Have you seen examples of good practice?

  Dr Bibby: Of good co-ordination?

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