David Oliver: The CQC, hierarchies, and hospital safety
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2310 (Published 30 May 2019) Cite this as: BMJ 2019;365:l2310All rapid responses
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Editor
Braillon says that I "wrongly" focus on comparisons between health care and aviation. I am not sure how my choice of topic can be "wrong". The article was written in response to a speech by the Care Quality Commission Chief Inspector of Hospitals who made this comparison. I had a legitimate right to question what he said and in doing so, cited a detailed and scholarly article by Kapur et al in the Journal of the Royal Society of Medicine. I am not sure I can be "wrong" in choosing to do this.
Moreover, I chose to compare acute (not elective) healthcare with aviation and made no arguments about elective or planned care.
He also wrongly says that Dr Natalie King is a Physician Associate when she is in fact a senior hospital doctor who has worked closely with Physician Associates and is writing in support of them.
David Oliver
Competing interests: No competing interests
Oliver’s concerns for safety of care wrongly focused on one difference from the aviation model.(1) Certainly, aircraft “do not take off unless fully staffed” and care involves “hard human choices“ in emergency conditions. However, we must first confess that lessons from scheduled flying which transfer straightforwardly to elective healthcare procedures, the most frequent, are far from being adequately implemented in clinical practice.
Oliver rightly warned that “hierarchies and deference in healthcare can worsen safety and that staff should feel confident and empowered in challenging unsafe practice or stopping the line if patients are at risk.”(1) Coincidentally, King, a physician associate, also rightly challenged traditional hierarchy to improve care.(2) Here is the main difference between healthcare and flights. In airplanes, one of the two pilots – regardless of rank – acts as “pilot flying”, the other acts as “pilot monitoring”. Cross-checking is common sense supported by observational studies.(3) Further, we shpuld not overlook a randomized trial showing systematic cross-checking between emergency physicians reduced adverse events.(4)
Another major difference between care and flight is not that doctors and nurses have a much harder job than pilots but that they are held personally liable in a way pilots are not. The ALARM method has been promoted to investigate and analyse clinical incidents focusing on organisational factors (5) However, individuals are still being held accountable in a way that obstructs improving safety.(6)
Last, healthcare professionals' training, as for pilots, must consider attitudes toward fatigue management, team building, communication, recognizing adverse events, team decision making, and performance.(7)
Obviously, the healthcare system is enduringly flying in the face of the evidence from the aviation model. The motto “translational medicine” seems an oxymoron when dealing with quality of care and management.
1 Oliver D. David Oliver: The CQC, hierarchies, and hospital safety. BMJ 2019;365:l2310
2 King N. Medical associate professionals: we need to challengetraditional hierarchy to keep patients at the centre of what we do. BMJ 2019;365:l2394.
3 Freund Y, Goulet H, Leblanc J et al. Effect of systematic physician cross-checking on reducing adverse events in the emergency department. The CHARMED Cluster Randomized Trial. JAMA Intern Med 2018;178:812-819.
4 Perren A, Conte P, De Bitonti N, Limoni C, Merlani P. From the ICU to the ward: cross-checking of the physician's transfer report by intensive care nurses. Intensive Care Med 2008;34:2054-61.
5 Ross N. Second letter to the GMC chair regarding Hadiza Bawa-Garba. BMJ 2018;360:k667.
6 Vincent C, Taylor-Adams S, Chapman EJ et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000;320:777-81.
7 Grogan EL, Stiles RA, France DJ et al. The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 2004;199:843-8.
Competing interests: No competing interests
Whilst it is apparent that many healthcare bodies seem prepared to divert resources in advance of a CQC visit, it does also seem to be the case that organisations ultimately take heed of the CQC's recommendations and opinions. This can only be a good thing.
Personal experience of CQC visitors is that they are appropriate to the role, prepared to listen and, most importantly, appear to form a balanced opinion.
What should be of concern is the tendency for some organisations to be disproportionately reliant on external 'adverse' CQC opinion to provoke change, rather than listening to the opinions of their own clinicians, nurses and allied professionals about potential shortcomings in the workplace.
Competing interests: No competing interests
Re: David Oliver: The CQC, hierarchies, and hospital safety
May I make a few observations? Now an elderly patient, I have had encounters with hospitals in the years gone by and doubtless will have more.
1. The CQC inspections are not worth the money spent on them. They cannot actually see how the patients are looked after.
Suggestion: The inspections should be a SURPRISE.
2. Looking back - there used to be the Community Health Councils in England. They were abolished. On the excuse that they were not needed.
I found them very useful allies. The Secretary or sometimes a member would phone me up with information - enabling me to investigate quietly -and matters would be put right.
Suggestion: Community Health Councils should be reincarnated.
3. The Director of Public Health. Is he (she) responsible for improving the health of the population?
If so, should the DPH not be responsible for inspecting the hospitals?
4. Pre-1974, the medical officer of health had the right, indeed a duty, to investigate shortcomings. He also had the right to close down a hospital if necessary.
Does the DPH have this right? (I realise that many DsPH are not registered medical practitioners.)
5. Assuming that the uselessness of the CQCs is accepted, why not abolish them?
Save money.
6. Could the Dept of Health not set up a voluntary register of doctors and nurses with experience and willing to inspect hospitals AWAY from their normal place of abode, to inspect hospitals, free of charge?
Competing interests: Patient with personal experience - and also, once, inspected hospitals and nursing homes.