Patient safety is a symptom of our dysfunctional organisations
Dear Editor,
Your Research article entitled “Sensitivity of routine system for
reporting patient safety incidents in an NHS hospital: a retrospective
patient case note review” confirms what I and others have suspected all
along. Existing attempts to introduce a culture of incident reporting are,
and will continue to be, unworkable while we continue to run our
organisations in the traditional ‘command and control’ way.
No matter how much well intentioned clinicians try to foster a ‘no-
blame’ culture in order to encourage transparency and learning, it will
never work while the rest of the organisation continues to focus on people
rather than processes in their attempts to remedy situations.
Evidence these past few years has clearly shown that only by studying
and improving processes that result in medical error can we ensure patient
safety. Regrettably this simple truth has never really been widely
understood or it would have been applied to everything else that we do in
our various organisations.
Nothing much has changed in the wider NHS or in my own field of
operations – the ambulance service - nor is there much sign that it will.
Unfortunately our managers remain locked into traditional management
culture and ignorant about or resistant to new organisational thinking.
Where effective approaches have or are being tried (lean thinking,
for example) attempts are being made to use the methodology within
existing, traditional systems. In other words, attempts are being made to
graft successful methods onto dysfunctional systems.
Moreover, these dysfunctional systems are governed by targets which
are arbitrary measures that reflect desire rather than useful knowledge
about our system’s capabilities – a prerequisite to improvement.
Targets have had a number of drawbacks. One drawback is their effect
of leading NHS organisations to concentrate on areas needing improvement
at the expense of overall system harmony and, often, patient well-being.
Another is to deflect focus away from appropriate method towards attaining
results by fair means of fowl – often the latter in the absence of
organisational knowledge about how to work differently and better. They
are the reason we are in such a moral, structural and financial mess
today.
Management and government often complain about staff being resistant
to change, but here we have an example of the reverse being the case.
Managers are very keen to urge operational staff to use ‘best evidence’
for clinical practice, but have shown little or no inclination to question
the very basis of their own actions. They are constrained by their limited
training and experience, and are almost entirely focused on doing the
government’s bidding in order to qualify for their funding. The
government’s obsession with arbitrary targets and ‘carrot and stick’
approach ensures compliance with the worst kind of management thinking and
behaviour.
There is much evidence about the drawbacks of our traditional
approach (recommended reading: “Hard Facts, Dangerous Half Truths &
Total Nonsense”, J. Pfeffer & R. I. Sutton;). There are much better
measures we could use and a wealth of knowledge and wisdom about
organisational performance which, if we do not avail ourselves of them
soon will lead to the dismantling of our NHS.
The Government appears to have run out of ideas and instead seems to
be relying more and more on using the private sector in order to attain
some kind of illusory solution. Anyone tempted to believe as they do
should read “Good To Great” by J. Collins in order to understand once and
for all that most of the private sector have similar or worse problems
than we do. The only difference is that they reward failure probably
better than we do!
We have all – government, managers, staff and patients - become
victims of an ineffective and damaging organisational system. If we are
sincere about improving patient safety, then we must have the courage to
question the very basis of our organisational theory and practices.
Anything less will guarantee failure and ever deteriorating quality of
patient care and outcomes, with only occasional, short lasting and
illusory advances.
Rapid Response:
Patient safety is a symptom of our dysfunctional organisations
Dear Editor,
Your Research article entitled “Sensitivity of routine system for
reporting patient safety incidents in an NHS hospital: a retrospective
patient case note review” confirms what I and others have suspected all
along. Existing attempts to introduce a culture of incident reporting are,
and will continue to be, unworkable while we continue to run our
organisations in the traditional ‘command and control’ way.
No matter how much well intentioned clinicians try to foster a ‘no-
blame’ culture in order to encourage transparency and learning, it will
never work while the rest of the organisation continues to focus on people
rather than processes in their attempts to remedy situations.
Evidence these past few years has clearly shown that only by studying
and improving processes that result in medical error can we ensure patient
safety. Regrettably this simple truth has never really been widely
understood or it would have been applied to everything else that we do in
our various organisations.
Nothing much has changed in the wider NHS or in my own field of
operations – the ambulance service - nor is there much sign that it will.
Unfortunately our managers remain locked into traditional management
culture and ignorant about or resistant to new organisational thinking.
Where effective approaches have or are being tried (lean thinking,
for example) attempts are being made to use the methodology within
existing, traditional systems. In other words, attempts are being made to
graft successful methods onto dysfunctional systems.
Moreover, these dysfunctional systems are governed by targets which
are arbitrary measures that reflect desire rather than useful knowledge
about our system’s capabilities – a prerequisite to improvement.
Targets have had a number of drawbacks. One drawback is their effect
of leading NHS organisations to concentrate on areas needing improvement
at the expense of overall system harmony and, often, patient well-being.
Another is to deflect focus away from appropriate method towards attaining
results by fair means of fowl – often the latter in the absence of
organisational knowledge about how to work differently and better. They
are the reason we are in such a moral, structural and financial mess
today.
Management and government often complain about staff being resistant
to change, but here we have an example of the reverse being the case.
Managers are very keen to urge operational staff to use ‘best evidence’
for clinical practice, but have shown little or no inclination to question
the very basis of their own actions. They are constrained by their limited
training and experience, and are almost entirely focused on doing the
government’s bidding in order to qualify for their funding. The
government’s obsession with arbitrary targets and ‘carrot and stick’
approach ensures compliance with the worst kind of management thinking and
behaviour.
There is much evidence about the drawbacks of our traditional
approach (recommended reading: “Hard Facts, Dangerous Half Truths &
Total Nonsense”, J. Pfeffer & R. I. Sutton;). There are much better
measures we could use and a wealth of knowledge and wisdom about
organisational performance which, if we do not avail ourselves of them
soon will lead to the dismantling of our NHS.
The Government appears to have run out of ideas and instead seems to
be relying more and more on using the private sector in order to attain
some kind of illusory solution. Anyone tempted to believe as they do
should read “Good To Great” by J. Collins in order to understand once and
for all that most of the private sector have similar or worse problems
than we do. The only difference is that they reward failure probably
better than we do!
We have all – government, managers, staff and patients - become
victims of an ineffective and damaging organisational system. If we are
sincere about improving patient safety, then we must have the courage to
question the very basis of our organisational theory and practices.
Anything less will guarantee failure and ever deteriorating quality of
patient care and outcomes, with only occasional, short lasting and
illusory advances.
John Matthews
Paramedic, Ambulance Service.
Competing interests:
None declared
Competing interests: No competing interests