A change of culture, but how?
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1152 (Published 20 February 2013) Cite this as: BMJ 2013;346:f1152
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Godlee's editorial asks ‘A change of culture, but how?’(1). The answer is that it is not easy, but is also not that difficult.
Culture is variously defined but is most strongly expressed in shared expectations of which attitudes and behaviours are desirable, acceptable or tolerable. Many of us will have had the experience of joining an organisation and having to revise our expectations according to the prevailing norms. If standards and expectations are high, we will strive to do better. If not, we may have to bend or change our expectations accordingly and, if the organisation makes unclear, unrealistic or conflicting demands of us, the result is fear, uncertainty, and erratic outcomes, which may be relevant to events at Stafford Hospital.
Reliable organisations need a coherent set of rules and standards, together with clear accountabilities. Hudson describes how this – in the form of a Safety Management System (SMS) –was a necessary first step in achieving a safety culture in the oil and gas industry(2,3). From my own experience in aviation, I am convinced that the regulatory framework, although in itself not sufficient, is a key driver in creating and sustaining a safe culture (4,5). A Safety Management System (including Quality Assurance) has been mandatory for airlines for several years (6). Whatever you may believe about governance in the NHS, we do not have this or anything resembling it at present - now is the time to take action.
Every NHS organisation should be required to have a SMS, with a requirement that Trust boards should have a director of Safety and a director of Quality - roles which may be combined (but only with each other). Safety management and monitoring should be independent of the operational and other functions of the organisation. The structure and function of the organisation should be made explicit in the form of an organisational manual, which should provide staff with instruction, guidance and information, and rationalise and replace the thousands of documents typically found in many Trusts.
With this framework in place, organisations will need to look again at their processes and how they are managed: do they fit with the way people actually are, what can reasonably be standardised, and how can resilience be achieved when faced with unexpected events? Human factors science will have a major role to play in this.
To be effective nationally on the scale demanded by Francis, change will need to be supported and facilitated by the Department of Health, whose managers themselves will need a clear vision. Support must include a simpler regulatory structure, with effective reporting and learning, and provision for rapid and independent investigation of serious accidents. It must also include a review of service and financial arrangements in the NHS. It is perhaps not a coincidence that managers at Stafford were reported as being preoccupied with financial management and targets. Unrealistic or conflicting demands are not only generated internally.
1)Godlee F. A change of culture, but how? BMJ 2013;346:f1152.
2)Hudson PTW. Safety management and safety culture: the long, hard and winding road. In: Pearse W, Gallagher C, Bluff L, eds. Occupational health and safety management systems. Melbourne: Crown Content, 2001:3–32.
3)Hudson P. Applying the lessons of high risk industries to health care. Qual Saf Health Care 2003;12(Suppl 1):i7–i12
4)Toff NJ. We need a safety system (and an operations manual). BMJ 2010;340:c917
5)Toff NJ. Human factors in anaesthesia: lessons from aviation. BJA 2010; 105(1):21-5
6)Safety Management Manual (SMM). 3rd Edition. ICAO 2012.
Competing interests: No competing interests
No. Dismiss. Deny further employment. Deprive pension. Gag him. Blow his whistle.
Guy Harris
Retired Bevan boy
Competing interests: Health and decay.
The focus on the future of David Nicholson misses the heart of the problem which is the political consensus over more than two decades that health services are best organised through market mechanisms. These intrinsically involve targets, the pursuit of which must ignore any measures not defined in the market agreements. Politicians need these targets to be achieved, because that is how their success is measured. Civil servants and senior managers are there to make that happen.
We will not change the culture of the NHS without changing this political mindset, which pervades all three main parties.
Competing interests: No competing interests
Beyond all 290 recommendations made in the Francis report, one word appears to have been deployed to encapsulate the crisis-"candour."
In an era of "gagging clauses" and scant protection for so-called 'whistleblowers,' how can a culture of candour flourish in a meaningful and realistic way? In reality, doctors and allied healthcare professionals work in an atmosphere of veiled or covert threats, where they are made to fear for their livelihoods should they dare to 'step out of line.' As humans, self-preservation inevitably kicks in at some point, and whilst we continue to feel threatened by the powers that be, it actually takes some courage to speak the truth. It is an act of self-sacrifice, for in reality, simply being open and honest can end up costing us our jobs.
Consequently, doctors need real protection from potential recrimination to empower us to speak out when we feel things are going wrong. In an ideal world, doctors who openly express their concerns would be lauded and embraced for their honesty, in which case courage would not have to factor into the equation.
What kind of environment do we work in when well-intentioned openness and honesty can be perceived as acts of heresy by our employers? This is the calculated and very deliberate climate of fear and recrimination which prevails throughout the NHS. And whilst we continue to work under such psychological conditions, many of us will continue to "keep our heads down," in the words of Robert Francis QC. And the NHS will continue to operate with an endemic culture of secrecy and non-transparency.
Whilst the patients who suffered and died are undoubtedly the real victims here, doctors are also victims of a pro-conformist regime whose modus operandi is to rule through fear.
In the wake of the Mid Staffs scandal, the GMC issued guidance which advised that doctors were duty-bound to take action should they believe that patients are being denied basic care. And now we learn from the GMC's Chief Executive Naill Dickson, that some doctors may be referred to the GMC for failing to raise concerns by "not reporting what they saw" (Clare Dyer, BMJ 16th Feb 2013, page 2). At complete odds with this are the much-maligned "gagging clauses," specifically designed to prevent us from reporting such concerns. Am i the only one who can see the obvious incompatibility and mutual exclusivity between such legislations?!
Whilst there is no doubt that many doctors at Mid Staffs have clearly failed in their duty of care towards their patients, they must in turn feel that they have been failed by a system which failed to protect them from being punished by their employers. Alas, it seems, we are faced with a catch 22 situation: on one hand, we may be punished by our employers for blowing the proverbial whistle, whilst on the other, we may be struck off by the GMC for failing to do so. We can only endeavour to do the right thing by our own consciences.
Quite rightly, David Cameron has asked why no doctors or nurses have yet to be struck off in the wake of the investigations conducted thus far, despite the fact that the GMC had opened investigations on 42 doctors. I believe there are a few uncomfortable truths at play here. I feel that doctors and nurses perceive that the likelihood of actually being struck off for failing to draw attention to deficiencies in patient care is extremely low, in reality. It seems that acts of omission (e.g. gross neglect) are perceived as being easier to avoid addressing pro-actively than those of commission (e.g. gross clinical incompetence). We all know that it would be seen as unforgivable to consciously avoid drawing attention to an act of clinical incompetence leading to a death, and that we would definitely face severe punitive measures should we be found guilty of such. By contrast, i do not believe that the same attitudes apply for not reporting acts of neglect or other deficiencies of care. Consequently, we do not fear being punished for such inaction, irrespective of GMC guidance making it incumbent upon us to report such incidents. Indeed, the fact that no doctors have been struck off despite all the GMC investigations conducted thus far, will only serve to further perpetuate this perception amongst the profession. Perhaps a firm approach by our regulators would send out a clear message to doctors, and make us think twice next time we consider ignoring what is not occurring around us. Francis states that "show trials can serve only limited ends, and to place too much emphasis on individual blame is to risk perpetuating the illusion that the removal of particular individuals is all that is necessary." I agree that apportioning blame to a few individuals detracts from the fact that the problem is clearly one of a deeply-entrenched and systemic nature, and would be a form of scapegoating. However, a strong counter-argument may be that making an example of a few would serve to scare the rest of us in to changing our behaviour and attitudes to acts of omission in the future. After all, it seems that fear of recrimination serves as the deciding factor in the decisions we make-that is how our employers exert such control over us, isn't it?
The fact of the matter is that it is extremely difficult to prove beyond doubt that a doctor or nurse consciously and deliberately decided not to disclose concerns relating to poor patient care and neglect. The sheer magnitude of neglect not reported in the Mid Staffs case, suggests that the majority of staff working there believed they would not face serious repercussions to their careers by their regulatory bodies for choosing to ignore the situation. By contrast, these same individuals must have felt sufficiently intimidated by their employers to simply 'turn a blind eye' to an appalling situation. I strongly believe that it is this potent combination of 1) not fearing punishment by their regulatory bodies, whilst 2) simultaneously fearing recrimination at the hands of their employers, that has surely lead to so many staff making a conscious decision to 'look away.' It is this imbalance of power between regulators and employers which has lead to this disaster.
And what of this notion of changing the culture within which we work, and which places an emphasis on candour and honesty? Call me a pessimist, but i find myself agreeing with Tony Delamonthe's editorial statement: "easy to recommend; almost impossible to implement" (BMJ 16 Feb 2013). How exactly do we instil these moralistic qualities in all individuals working within the NHS? To a large extent, surely these qualities are deeply-ingrained character traits, moral codes of conduct and personal attitudes which are the result of a complex admixture of innate character, parental beliefs, childhood upbringing and much, much more. Is it really possible to change the behaviours of those who may be more naturally predisposed to dishonesty and disingenuousness? I have my doubts. Perhaps we should consider conducting validated personality rating scales on potential medical and nursing students, to complement tests of their academic abilities? Perhaps then we would stand a greater chance of having a workforce which is capable AND compassionate in equal measure. After all, some of the most intelligent, driven to succeed business leaders have been shown to score highly on core psychopathic traits such as lack of empathy, remorse or guilt-exactly the kind of traits which are not conducive to the culture of candour we would expect to course through the veins of the NHS (The Psychopath Test by Jon Ronson). Perhaps the same deeply-flawed but successful characters are leading the NHS? And if so, is it any surprise that similar malevolent traits may have crept in to the moral fabric of the organisation as a whole?
Competing interests: No competing interests
Firstly - Thanks Iona for all your contributions.
Secondly - One of the key changes which might bring constructive change about is a form of organisational quantum entanglement or shared jeopardy.
Suppose that, say, 50% of top managers (from Nicholson down to the humblest cottage hospital admin), consultants, nursing chiefs and other heads of department pay were subject to five year rolling performance improvement targets - using a large basket of objectively measurable outcomes and performance indicators.
This would ensure that achievable targets were set and the direction of travel agreed.
At the moment there is no incentive to do other than blackguard the 'others'.
Yours sincerely
Steve Ford
Competing interests: No competing interests
While citing Kotter, it is also important to determine what the organisation is that needs to change.
The editorial, in my view, makes the persistent error of hypostatising the NHS as a single, coherent organisation which it isn't. It is, instead, a system made up of many moving parts interacting in complex ways.
The executive leadership of the NHS itself controls no levers that make the NHS work as there are no control levers. The NHS has been turned into a machine now experiencing catastrophic failure when it is really a dynamic service ecology able to evolve new ways of working.
Those who kept doing the wrong things, despite knowing better, are accountable for their actions and particularly for not addressing the system's operational misalignments and perverse incentives -- in effect, for stopping better ways of doing things from emerging.
David Owen, in his book, In Sickness and In Power, defines hubris as "the inability to change direction because this involves admitting that one has made a mistake". [Methuen, 2008]
What more can one say.
Competing interests: No competing interests
Whistle blowing is self evident failure, driven by the collapse of healthier communications, a product of an NHS climate disappointingly suspicious of open, rigorous clinical debate. Repressive towards alternative opinion, part of an insecure self protective management culture. The phenomenon of senior silence, so puzzling to the wider public, is a deeply embedded syndrome, extending well beyond the slide into crisis exposed at the Mid Staffordshire Trust.
For senior clinicians to rediscover their influence on operational policy, as the government insists it would like, then urgent reform is needed to improve the ethical and functional integrity of many trust boards. The crucial Medical Director role with its enhanced statuary powers, has moved from the boardroom advocate of balanced clinical opinion, to the enforcer of policy right or wrong.
Sanctions invoked to secure senior silence involve, ‘reorganisation’ to remove less than sycophantic clinical leadership, blocking performance related remuneration and resorting to the use or abuse of consultant suspension procedures.
The contrast with senior managers, is stark and startling. An absence of independent regulation, a feeble code of conduct and certainly no disciplinary powers comparable to the enhanced General Medical Council. Trust executives removed or resigning, enjoy reappointment elsewhere in the NHS, leavened by excessive compensation packages, concealed by the silence of the confidential non disclosure [gagging] agreements, routinely incorporated in employment contracts.
1. Jeremy Hunt, NHS Trusts warned over ‘Defensive Culture’, BBC Health, 16 Feb. 2013.
2. Jarman B. ‘When Managers Rule’. British Medical Journal, 2012;345:e8239
3. Turner, JJ, ‘NHS Reform: problems more than skin-deep’ The Times February 2, 2007.
4. Royal College of Physicians, Response to the publication of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, Feb 6, 2013.
5. GMC Statement: Mid-Staffordshire Public Inquiry, 06 Feb 2013.
6. Robert Francis, First Report, The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2010; Final Report, The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013.
Competing interests: Declaration. As a Royal College of Physicians of London nominee, provided independent case reviews for the Mid-Staffordshire inquiry.
Any 'top-down' management will fail unless it is provided by intelligent feedback on the service it provides. However vulnerable and uncritical patients may feel, they or their legal representatives must consent to what is to be done and are entitled to ask the necessary questions. The basic questions are: What am I agreeing should be done? For each action, what is the diagnosis? For each of these diagnoses, what are the supportive findings? These supportive findings makes up the ‘patient’s evidence’. If we do not specify the ‘patient’s evidence’ clearly, we cannot claim to practice proper ‘evidence based medicine’, however much research data we quote.
Informed consent also depends on an ability to retain the answers to these questions so that the patient can seek independent advice if necessary and then check that what is written is actually put into practice. The only reliable way of achieving this is by putting the answers to the questions in writing. This would provide a ‘patient’s evidence’ based transparent summary of ‘patient-centred’ care. There are a number of ways of doing this [1] some of which can be supported by modern technology [2].
The answers to these three questions also happen to be the information that the different doctors and other health professionals involved need in order to provide safe and coordinated care. In order to change the culture of the NHS, doctors, nurses and other health professionals could prepare answers to their patients’ basic questions in advance so that they can be given to them at any time on request. This would create well informed ‘customers’ that managers in the ‘market’ have to satisfy by supporting their front line staff. So to change the culture, patients, their supporters and all NHS staff will have to work together to use the ‘patient’s evidence’ intelligently.
References
1. Llewelyn H, Ang AH, Lewis K, Abdullah A. The Oxford Handbook of Clinical Diagnosis, 2nd edition. Oxford University Press, Oxford, 2009.
2. Llewelyn H. How to put into practice a culture of patient-centred openness and transparency. BMJ 2013; 346: f979. http://www.bmj.com/content/346/bmj.f979?tab=responses
Competing interests: No competing interests
Re: A change of culture, but how?
The Francis Report (2013) identified multiple problems relating to the safety culture of Stafford hospital in the period 2005- 2009, as well as serious failings in the supervisory and regulatory systems of the NHS. Particular criticism was directed at the Trust Board and clinical professionals for the culture that developed, notably organisational silence (Morrison & Milliken 2001), cultural censorship (Hart & Hazelgrove 2001), consensual neglect (Weick 2002) and compassion fatigue (Sabo 2006); conditions that conspired and failed to safeguard patients. Tolerance of the unacceptable simply became the ‘way we do things around here’ (Deal & Kennedy, 1982).
To the detriment of patient care and public confidence, safety culture in healthcare is too often noted when lacking, rather than celebrated and embraced as an enduring value, prioritised by all staff - Board to ward. If the NHS aspires to high reliability, then building and sustaining a safety culture will be an essential part of that endeavour. In a safe culture, system leaders are sensitive to the unintended consequences of policy, and staff at every level share responsibility for safety; acting to preserve, enhance and communicate safety concerns; striving to actively learn, adapt and modify behaviour that will enhance both patient and worker safety (Agnew et al, 2013).
Improvement starts by examining current behaviour patterns and identifying what needs to change. The airline industry did so 30 years ago, following a series of accidents that could not be attributed to technical failures, or deficiencies in technical skill. It was recognised that certain behaviours were required on the flight deck, to preserve safety. These related to decision making, situation awareness, communication, teamwork and leadership (Kanki et al, 2010): Behaviours that are equally essential to keeping patients safe (Flin & Mitchell, 2008).
There are three lessons from the aviation example that are relevant post- Francis. The first is the need to fully analyse accidents to include an examination of ‘human factors issues’ – especially workplace behaviours. Second is the importance of linking the findings from these analyses to ongoing training of the behaviours that constitute the non-technical skills in healthcare. Finally, there is need to appreciate that humans will always be prone to fail in systems that have not been designed using ergonomics/human factors principles.
These interventions have been the main focus of an NHS expert panel, established by NHS Medical Director Sir Bruce Keogh in 2010 and chaired by Sir Stephen Moss, former Chair of Stafford Hospital. Comprising clinicians and human factors specialists, the DH Human Factors Reference Group is partly drawn from the Clinical Human Factors Group (www.chfg.org), established by airline pilot Martin Bromiley, following an independent inquiry of his first wife’s death, which revealed the importance of non-technical skills in healthcare.
The Human Factors Reference Group submitted an interim report (HFRG, 2012) to the DH in April 2012, and its recommendations have considerable significance for the response to Francis, not least the need to build clinical human factors expertise in the UK to address these issues. There is no specialist Human Factors group within the NHS, in contrast to every other safety-critical industry, where human factors inspectors, human factors committees and human factors courses are now found.
There are now sources of healthcare human factors expertise in the UK. The Clinical Human Factors Group, which is an independent campaign group, continues to play a key role in raising awareness and promoting the role of human factors in safe practice. The professional body in the UK, the Institute of Ergonomics and Human Factors (www.ergonomics.org.uk/) is building representation from within the healthcare sector and providing a truly systematic approach to the design of safer socio-technical workplaces (Buckle, 2012).
In 290 Francis recommendations, there is no explicit mention of human factors but it is certainly an interventional approach that will be required if the cases of diseased safety culture within the NHS are to be treated.
Agnew, C., Flin, R. & Mearns, K. (2013, in press). Patient safety climate and worker safety behaviours in acute hospitals in Scotland. Journal of Safety Research.
Buckle, P. (2012). Systems approaches to risk assessing healthcare, how far have we come? Work, 41, 3847-3849.
Deal, T. & Kennedy A. (1982) Corporate Cultures. Reading, Mass.: Addison-Wesley.
Flin, R. & Mitchell, L. (2008) (Eds) Safer Surgery: Analysing Behaviour in the Operating Theatre. Aldershot: Ashgate.
Hart E, Hazelgrove J. (2001) Understanding the organizational context for adverse events in the health services: The role of cultural censorship. Quality in Health Care. 10:257–62.
HFRG (2012) (Report available at /www.chfg.org/news-blog/dh-human-factors-group-interim-report-and-recomme...)
Kanki, B., Helmreich, J & Anca, J. (2010) (Eds) Crew Resource Management 2nd ed . San Diego: Academic Press.
Morrison E, Milliken F. (2001) Organizational silence: A barrier to change and development in a pluralistic world. Academy of Management Review. 25(4):706–25.
Sabo B. (2006) Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work? International Journal of Nursing Practice. 12 : 3, 136–142.
Weick K. (2002) The reduction of medical errors through mindful interdependence. In: M. Rosenthal, K. Sutcliffe (eds.) Medical Error: What Do We Know? What Do We Do? San Francisco: Jossey-Bass; pp. 177–99.
Competing interests: No competing interests