Policy into Practice Won’t Go? HNEH Quality Exposition and Scientific Program, Newcastle

1. Policy into Practice Won’t Go? HNEH Quality Exposition and Scientific Program, Newcastle Professor Steven Campbell Head of School, Health

2. For 10 years: Acted as Director of Nursing, and Head of Nursing, Board Member Member of Modernisation Board Head of Nursing R&D, R&D Director City Hospitals Sunderland NHS Foundation Trust R&D Director, Technologies for Health (Medical Device Evaluation) 1000 bedded hospital. 2500 nurses out of 5000 staff Professor of Nursing Practice, Northumbria University

5. Jesmond Schools

8. History of Politician based initiatives. • History of Policies. • Why don’t these work? • Why do the mistakes keep happening?

9. Some Issues from the NHS all UK IT project

10. Errors dominate the risks to patient safety (as in all hazardous systems). IT does not eliminate error, it relocates it and can also change its form: Centralised mistakes rather than localised slips and lapses A greater potential for rare but catastrophic organisational accidents The human factor

11. . The Bathtub Curve • Change creates errors. • Expect them. • Don’t stigmatize them. • Share them. • Learn from them. • Keep system transparent. • Make it forgiving. Probability of technical and human failures Age of system

12. ELEMENTS OF AN ORGANIZATIONAL ACCIDENT (SWISS CHEESE) Some holes due to active failures Hazards Other holes due to latent ‘pathogens Victims Successivelayers of defences, barriers, & safeguards

13. Active failures: errors and violations at the ‘sharp end’—often short-lived in their consequences. Latent pathogens: seeded into the system by designers, programmers, managers, etc.—long-lasting in their effects, but present now. Defensive weaknesses

14. What are the hazards? What defences exist to prevent these hazards from harming patients? What are the possible scenarios of failure (when hazards come into harmful contact with patients)? Some ‘broad brush’ issues

15. What are the barriers to harm?

16. Radical changes require trial-and-error learning. Errors and screw-ups are inevitable - but they also mark the boundaries of acceptable performance. The mental skills of error detection and error correction are essential: become error-wise and error-vigilant. Learn global rather than local lessons. Take-homes

17. People • People as health professionals • People as critical thinkers • People following policies • People owning policies

18. People who started with a shared value set and diverged at birth in universities • Why divergence? • Silos in universities not just in practice • Wanting to make students in their own image • Behaviour needed to join the club. • Rules from statutory bodies that preclude sense. • Vested interest in professional identity.

19. What would the public make of this? • Would not and do not understand it. • Believe we all respect each other and understand each other’s role. • When undertook 18 clinical services redesign: Discovered that MDT did not understand each other’s roles. Some things did not get done. Some things got done twice. Met people they’d been working with for 30 years.

20. When very senior and still practising the security gives you back sense • Example of the Northumbria University study with future of medicine in the North of England.

21. Outline results • Politicians or Managers were scared to tell them what was needed. • Wanted to know what was wanted. • Senior Medics wanted to be told what was going to happen so that they could work out how they could adapt to these changes. • Not all about wanting to blame the Politicians or Managers.

22. Specific examples • Desk Urologist argument. • Paediatric Anaesthetist and Anaesthetics argument. • 53 Sub-Specialties in the UK • The Generalist is King/Queen

23. Have graduates made a difference? • Is it just a more difficult way to become registered as a practitioner? • Graduate level bed making Is meaningless • Graduate level communication starts to become understandable. • Graduate level critical thinking. • Should make a difference at the level above competencies. • Act as the glue in the system and the safety net. • Stop the holes in the cheese lining up

24. The nature of critical thinking

25. The nature of critical thinking

27. Bullying and shared responsibility • Not going to go into why bullies do what they do. • They just should not do it. • In risk terms, clearly shown to increase risk. Why? • People distance themselves, including from responsibilities. • Brains stop working, especially the bullied and including the bullies. • Need to be a team, mutual respect.

28. Reducing bullying • Zero tolerance needs to be seen to be so. • Even if it’s the only surgeon in that specialty. • Example of Medical Director on a UK hospital who threw instruments at staff, shouted at nurses, but the CEO thought was great. • Undermined whole approach to bullying in the hospital. • Appoint senior HR people to deal with the senior staff bullying. • Lead by example

29. Environment for mutual support • If there’s bullying – how does that impact on environment of mutual support? • Supportive • “There but by the grace of God go I” • Open to near misses being made public with no recriminations.

30. CLINICAL RISK SOURCES & MANAGEMENT • Incidents • - Near Misses • Adverse • Events Audits and Surveys Patient Safety Complaints and Claims Media and Coronial Reports Risk Assessment Root Cause Analysis Risk Register/Action Plan Cost Benefit Analysis Communicate Risks & Investigation Outcomes

31. Limited Adverse Occurrence Screening (LAOS) objective measure of potentially preventable adverse events periodic sampling of 40% medical records 6 defined criteria (death, transfer to HDU / ICU, non fatal cardiac arrest or MET call, return to theatre, unplanned readmission, extended stay) retrospective attuned to objective measurement = a performance indicator What’s a reasonable rate? (1.7 – 2.2%) Incident Information Monitoring System (IIMS), AIMS, Riskman incidents risk rated using Severity Assessment Coding (SAC) based on likelihood of recurrence and potential consequences SAC 1’s = the most serious – lead to Root Cause Analysis (RCA) prospective attuned to improvement opportunities How many incidents and over what period? Clinical Incident Detection

32. 88,000 Incidents - NSW Health - 05/06 Falls 26% Errors in medications / intravenous fluids 20% Clinical management issues 13% Aggressive patient behaviour 8% Human performance 7% Documentation 6% Occupational Health & Safety 5% Incident Information Monitoring

34. A less scientific distinction between patients and customers “the more horizontal they are, the more they are a patient; the more vertical they are, the more they are a customer”

35. Improving process efficiency could patient details be recorded more efficiently? could information on the risks and benefits of different care pathways be provided more efficiently? if ophthalmology services were configured differently, could demand be managed better?

36. Factors in effective clinical teams showing a positive attitude to patients finding out what patients and colleagues think about the quality of care delivered assuming collective responsibility for performance showing leadership and competent management having clear values and standards demonstrating an enthusiasm to learn communicating well caring for each member of the team

38. Thank you