Skip navigation

Transparency will only change culture if we eradicate blame as a response

In the 2014 Reith LecturesAtul Gawande made a powerful case for 'lifting the veil' on healthcare; making what is now invisible in healthcare systems visible.

He recognised that shining a light on what really goes on 'behind the curtains' is not easy.

There is much to celebrate in modern healthcare, but it can and does fail to deliver all the benefits it could. Gawande says this is not because of ignorance, but because of what he calls ineptitude, a failure of health systems to apply consistently the knowledge we have to prevent ill health or to treat disease.

The use of the term ineptitude is, as he recognises, not ideal, because it implies culpability of the systems or of those implementing them. This is not what is intended. It is not a criticism of individuals, but a recognition that the system that delivers healthcare is not set up to provide the care we intend. Patients suffer because they do not consistently get the best care and so do staff because they know they are failing to deliver and blame themselves.

Towards a safer NHS

The 2013 Berwick report Improving the Safety of Patients in England set the bold ambition that the NHS in England could become the safest healthcare system in the world. It too made transparency about all aspects of the quality of care the essential prerequisite for this to be achieved.

Both Berwick and Gawande agree that honesty about the quality of care that health systems provide is a key element of the change in culture that is necessary, but in itself it is not sufficient to achieve the quality improvements they envisage. The system must respond effectively to the information that is made available.

 

Blame: the default response

Berwick identified fear as toxic to both safety and quality improvement and urged the NHS to abandon blame as a tool and to trust the goodwill and good intentions of the staff. Despite this and numerous reports with similar conclusions in the past, blame is still the default response to problems in much of the NHS.

When CQC publishes a report that identifies quality issues in a trust, someone, somewhere always seems to call for senior resignations. This is foolish. Apportioning blame is a falsely reassuring response to quality issues. As long as we can identify someone or some group to blame we can feel confident that they are the problem, not us. Doctors blame managers; managers blame doctors; primary care blames secondary care and vice versa, and on it goes. Blame as a reaction is comforting; it is easy, but it is counterproductive. As long as blame is attached to quality failures, the information about them will be supressed and good people, staff and patients, will find themselves victims of a healthcare system that, like all modern healthcare systems, is imperfect. Blame will not lead to quality improvement and it is the wrong response to transparency.

 

Findings from our inspection programme

The Care Quality Commission programme of inspections of acute hospitals has now reached its halfway point. The inspections of community services, mental health services and ambulance trusts are also well advanced. The findings from the initial inspections have been summarised in the State of Care report published in October 2014. For those who have read the Francis report, the Berwick report or have listened to the Reith Lectures, the findings of these inspections will come as no surprise. For those who believe that modern health systems are essentially sound and that quality problems are limited to a few failing services, the findings will make unnerving reading.

One example will perhaps demonstrate the central problem we face, the gap between what we intend to deliver and what we actually do deliver. In his second Reith Lecture, Gawande discussed the surgical safety checklist he was instrumental in introducing. When it was piloted at eight different surgical centres around the world in 2008, surgical complications were reduced by 36 percent and surgical deaths by 47 percent. Six years later during our visits to acute hospitals we have found that despite this evidence the checklist is not yet properly embedded in many of the surgical services we have inspected. The NHS knows the surgical checklist can reduce complications and deaths, but has failed to implement it effectively.

 

If you read our reports you will find many other examples of basic, evidence-based safety and quality procedures that are not applied rigorously or consistently in many hospitals. This is not a problem particular to the NHS; it is a problem for healthcare systems worldwide.

 

Honesty is an essential starting point

What perhaps is unique about the NHS is its increasing openness about the problem. This is something we should celebrate, since honesty about where we are is an essential starting point if we are to change.

The Care Quality Commission's inspection programme is contributing to this openness. Our findings are challenging and while we have seen trusts use them effectively to promote improvements in their services, we have also seen examples of denial and anger. Inspection provides honesty about what the quality issues are, but without cultural change, the change called for by Sir Robert Francis in his reports, it will not deliver quality improvements.

During our inspections we have been impressed by the openness and candour of frontline staff, by their willingness to share with us their concerns about the care they provide and by their frustration at not being able to bring about the changes they believe are necessary. This change in the frontline culture of the NHS is one of the most encouraging aspects of our findings. As yet it does not always seem to be matched by an equivalent cultural change elsewhere in the system.

The Health Service Journal recently highlighted its concerns about the scapegoating of NHS managers and called for a more balanced public debate about the NHS. Scapegoating of managers or any other group is part of the blame culture that the NHS must eradicate if it is to improve. It will do nothing to solve the NHS problems. The NHS faces many daunting challenges. Operational demands, staff shortages, financial constraints and quality concerns often present conflicting priorities. Managing clinical services is demanding and we need to accept that in this environment, services will have problems regardless of the skills or commitment of those running them. The Care Quality Commission inspections are intended to promote truthfulness about the problems, not to apportion blame. The findings are there to help managers tackle difficult issues, many of them cultural, by challenging complacency or misconceptions in the services concerned.

 

Leadership and the long-term view

The wider system must respond to quality issues identified in our reports in a balanced and proportionate way. Many of the problems we find in acute hospitals reflect broader issues in the local healthcare economy. The hospitals cannot solve them without the support of their health and social care partners. Stable leadership with a long-term view is essential to achieve the needed improvements; many of the trusts we see with the most problems have been through periods of unstable leadership. The senior leadership of a trust faces a major test when our inspection discovers unexpected quality concerns. They need to be supported in rising to this challenge.

 

What we are finding by lifting the veil on quality issues in the NHS is making many us feel uncomfortable and is challenging our cultural assumptions, not only about the NHS, but about the accepted systems for delivering healthcare. The challenge for all of us is not to see such findings as demoralising, but to use them to promote improvement; honesty without criticism, transparency without blame. This will not be easy and will require a fundamental change in culture.

 

For more information see original source:

http://www.cqc.org.uk/content/transparency-will-only-change-culture-if-we-eradicate-blame-response

 

Relevant forthcoming events:

Investigating Incidents and The Duty of Candour
Tuesday 28 April 
Hallam Conference Centre
London

Root Cause Analysis Conference: Investigating & Analysing Patient Safety Incidents
Wednesday 24 June 
ICO Conference Centre
London

 

Investigating Incidents and The Duty of Candour
Thursday 25 June 
Cavendish Conference Centre
London

 

Complaints Handling, Investigating, Resolving and Learning
Wednesday 1 July 
ICO Conference Centre
London

 

Reducing Medication Errors
Wednesday 1 July 
Manchester Conference Centre
Manchester

 

Leading your Organisation to Zero-Harm
Thursday 9 July 
Hallam Conference Centre
London

 

Investigating Incidents and The Duty of Candour
Thursday 17 September 
Hallam Conference Centre
London

 

Leading your Organisation to Zero-Harm
Thursday 22 October 
Manchester Conference Centre
Manchester

 

Leading your Organisation to Zero-Harm
Thursday 10 December 
Hallam Conference Centre
London


25 February 2015

 PreviousNext 

    Partner Organisations

    The Tavistock and Portman NHS Foundation TrustInPracticeClinical Audit Support CentrePlayoutJust For Nurses
    GGI (Good Governance Institute) accredited conferences CPD Member ASGBI (Association of Surgeons of Great Britain and Ireland) professional partner BADS (British Association of Day Surgery) accredited conferences