Examination of Witnesses (Question 622-639)
DR JO
BIBBY, DR
OLGA KOSTOPOULOU
AND CAPTAIN
GUY HIRST
5 FEBRUARY 2009
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
practiceand most of my work is being done in secondary
care, in the hospitalsso 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
organisationso 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 carenot 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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