A chance encounter of the safety kind
We would like people to talk to each other about keeping people safer, they said. Sure, I do that all the time, I thought.
We would like people to listen as well, they said. Hmm… I’m not sure I always do this, I thought. What could we do to make this work? I cogitated. But, having a strong preference for being a reflector, I “saved it for later”.
A few days afterwards…
The Sanctuary, a multi-faith space located in the oldest building of our hospitals, was in the process of being decommissioned. A series of short lunchtime organ recitals had been arranged, open to all, prior to the organ going to its new home. Being a music lover, I made a conscious effort to put these in my calendar with the hope that I might be able to go along for one or two. My opportunity came. Armed with papers to read for a meeting I was chairing later that day, off I went.
I was greeted by a wonderful gentleman volunteer who was hosting the recital, we chatted for a bit about the Sanctuary and the organ and he then left me to my reading. There was a delay in the organist arriving and while I was waiting, nose in meeting papers, one other person came along; a consultant whom I did not really know, but whom I recognised.After spending a while talking to the gentleman volunteer and even having a quick play of the organ himself, the consultant wandered in my direction and we started talking.
What did we talk about?
It started off with the usual things, how was the unit today? Was it busy? We discussed how the specialist area that he worked in could be unpredictable and keeping patients safe was the absolute priority in sometimes difficult circumstances. We agreed that work in improving patient safety could be challenging but, with determination and passion, the satisfaction of helping to make a difference was extremely rewarding.
We then talked supporting staff and developing a just culture where if someone makes an error they are cared for and supported and if they deviate from policy or practice they are asked why before being judged. We questioned whether this was the real experience of staff in our organisation or whether they felt they were being blamed for what happened. If so, why might this be and what could be the contribution of stakeholders to such a situation whose expectations of the outcome of an investigation may be different? Did people (managers, board members, commissioners, regulators) understand how accountability fitted with a just culture?
We reflected how everyone involved in healthcare comes to work with the intention of providing high quality care to patients with the best possible outcomes and there are extremely rare exceptions when people intentionally put their patients and themselves at risk.
Oh and, by the way, we put loads of time and effort into investigating when things go wrong, wouldn’t it be good to understand and learn from when things go right? Would staff feel more positive about such an experience?
We talked about how people want to be open and honest with patients and their families when things go wrong. We agreed it was the right thing to do and this can be difficult, when in some cases, by doing just such a thing a natural reaction of wanting blame and seek consequences for the individuals involved could occur. Staff were acutely aware of the devastation felt by bereaved families when an unexpected death occurred but there sometimes seemed to be a conundrum between supporting families and meeting their expectations and doing the same for the staff involved.
Solutions to the difficult issues
We considered the kinds of solutions put in place following incident investigations, such a new guideline or further training, and how sometimes these could feel like ‘sticking plasters’. We discussed whether incident investigators were sufficiently trained, skilled, resourced and empowered to uncover potential big, complex and interacting systemic and cultural issues that are difficult to fix, may be outside the control of the service or organisation and take a long time to do so. Could this be the reason why recommended solutions on occasions seemed to be sticking plasters? Could such solutions sometimes present increased risk? 4
Unfortunately the organist never arrived for the recital and my meeting papers largely remained unread, with just a few fluorescent pink page markers to show for my efforts. Had I just wasted twenty minutes of precious time? Absolutely not -it was one of the best conversations I have had about patient safety. It just felt more real.
Could we, by talking to a sufficient number of people throughout the country about the issues we discussed, find other people who could help with some of the answers?
I wonder what other people’s safety conversations are like…
About the author
Anne reader is the Head of Quality (Patient Safety), University Hospitals Bristol NHS Foundation Trust.