In healthcare, here and elsewhere, there is often a serious disconnection between the standards we espouse and the standards we achieve, writes Denis Doherty.
“There are policies and practices in place but not all staff are aware of them”
Would you feel comfortable booking a flight with a major airline about which a finding like that was made?
Would you feel that if not all staff are aware of the policies and practices, the likelihood is that even fewer of the staff are observing them?
What would your reaction be if you then discovered that while there is evidence of learning from incidents by the flight crews involved this is rarely the case across the airline?
Would you be inclined to change your mind if, after all that, you were still contemplating making a reservation and heard that, while there are risk registers in all departments, some identified risks are not being acted upon?
Our response to a negative event can range from deflecting blame, to demanding more staff and better equipment to describing it as an historic event that is unlikely to happen again.
When we take a flight or avail of a health service we entrust our lives to the service provider. I have taken the liberty of attributing the actual failures of the biggest NHS trust in England to a mythical airline for the purpose of illustrating how we tolerate different safety standards by service providers in different sectors.
Criticisms of the kind I have set out above, if attributable to an airline, would be catastrophic. So why has the report of the Care Quality Commission into an NHS trust attracted relatively little attention? For a start, the report relates to the largest trust in England and many of the findings in the report are positive ones. Then there is the issue of choice. Users of the services of the trust do not have the option of transferring en masse to another provider who is clearly compliant with best practice.
The Care Quality Commission report deals with “Never Events”. A ‘never event’ is a jargon term for a serious, largely preventable patient safety incident. ‘Never events’ are deemed unacceptable in any circumstances. The aspirational nature of the term is borne out by the finding that, during a period of twelve months, ten ‘never events’ occurred at the trust in question, six of the ten at one hospital.
The recent RTE documentary on babies who died at birth in the Midland Regional Hospital at Portlaoise distressed many viewers who judged them to be ‘never events’. The reassurances offered to mothers the following day, which emphasised how safe it is to be born in Ireland, sounded less than convincing and seemed insensitive to the feelings of the bereaved parents. It must have been cold comfort to them to know that, despite their great loss, our maternity services are among the best in the world. There is as little justification to settle for an acceptable level of avoidable infant deaths as there is to accept an acceptable level of plane crashes.
It is encouraging to observe the Minister for Health acting promptly and decisively to deal with the concerns arising from the RTE documentary. In the past, reports have sometimes tended to attribute shortcomings and even tragedies to ‘system failures.’ There now exists an opportunity for the Minister to deploy his leadership skills to enlist the support of the entire maternity care system to eliminate ‘never events’.
It can be done. The airline industry and Formula 1 racing have shown what can be achieved. Not that long ago Formula1 racing was considered to be so dangerous that it risked being banned. It is not any longer considered to be dangerous.
The airline industry and Formula 1 racing have shown that high safety standards, observance of operating protocols and learning and implementing the lessons of adverse incidents enable them to convincingly demonstrate truly remarkable improvements.
In healthcare, here and elsewhere, there is often a serious disconnection between the standards we espouse and the standards we achieve. Worse still, the disconnection often goes unnoticed. Our response to a negative event can range from deflecting blame, to demanding more staff and better equipment to describing it as an historic event that is unlikely to happen again.
In contrast, even though airlines have had to lower their expenses by reducing, front line and back office staff and dispensing with ‘frills’, they have, at the same time, succeeded in improving passenger safety by insisting on observing best professional practice.
Our maternity services may be an ideal choice to test the feasibility of achieving, in our health services, a ‘never events’ outcome, comparable with achievements of the airline industry and Formula1 racing.