Learn from errors and don’t cover up
Listening, leading and learning. David Hare reflects on the Independent Healthcare Providers Network’s joint Patient Safety Conference with the Care Quality Commission.
As the representative body for independent healthcare providers, it is a real highlight in IHPN’s calendar to host our annual joint conference with the Care Quality Commission (CQC) looking at all things patient safety and quality.
The theme for this year’s event was the ‘Culture of Care: Listening, Leading, Learning’.
More than 120 chief medical and nursing officers and safety and quality experts from the sector had the pleasure of hearing from a wide range of speakers from across the patient safety landscape, from clinicians and regulators to researchers and patients.
We kicked off the day with the director of secondary and specialist care at the CQC, Nicola Wise, who talked through the watchdog’s progress in implementing its new single assessment framework.
Five key questions
Like its predecessor, this is based on the five key questions and ratings system and will be supported by improved technology.
This means that physical site visits by the CQC will now be used for specific purposes such as observing care, understanding how staff interact and what the environment is like, to name just a few, rather than being the default.
It is not without controversy, and we have heard from members and those that work in the sector about some of their challenges around this – particularly through the provider portal and the removal of the relationship manager role.
However, there was a welcome reassurance from Nicola that sorting these issues is a priority and that the CQC will continue to work with the independent healthcare sector through the IHPN to ensure private providers and practitioners are confident of the new approach.
Later on in the day, the CQC’s chief executive Ian Trenholm gave his reflections on the CQC’s wider strategy and some of the complexities of regulating health and care services in such a challenging operational environment.
How do you assess a facility that is providing excellent care but, due to rising waiting lists, the ability of patients to actually access it is poor?
And how do you balance the role of a regulator as a judge versus a coach – acknowledging their role in spreading best practice and scaling up innovation but equally understanding they are ‘not in the management consultant business’ and cannot directly implement change.
Also, how can tackling health inequalities be assessed when you cannot inspect an outcome.
Surgical mesh victim support
While understanding the regulatory environment that we operate in is obviously important, healthcare, of course, begins and ends with the patient.
We were therefore so pleased to be joined by Paula Goss, who is a campaigner for people who have been injured by surgical mesh and is the founder of Rectopexy mesh victims support.
You could hear a pin drop in the room as Paula spoke of her experiences of being injured by surgical mesh. She talked not just about the physical impacts, but the psychological and financial ones as well.
Communication with patients is so important – both in terms of practitioners ensuring there is informed consent, with patients well equipped to ask the right questions, as well as the need to not just listen to patients but really hear them and ensure their concerns are acted upon.
Paula’s remarks really set the tone for the rest of the day.
Following her session, members had the opportunity to hear from the Patient Safety Commissioner Dr Henrietta Hughes, who talked through her key priorities in the coming year.
These include implementing Martha’s Rule across the health system, and the importance of working with other patient safety bodies to ensure there is a joined-up approach in what can seem like a very crowed safety landscape.
Private sector and the HSSIB
Indeed, a new player in the patient safety world is the Health Service Safety Investigations Body (HSSIB) whose role is to investigate incidents where there are implications for the safety of patients. Its remit has expanded to investigate all healthcare services in England, including the private sector.
Interim chief executive Rosie Benneyworth talked through the key investigations the organisation is currently undertaking including ‘Workforce and patient safety – temporary staff, the digital environment, primary and community care co-ordination’ and safety management systems.
The aim is to understand how a wide range of sectors tackle these issues and share insights and information across the whole healthcare system.
In the afternoon sessions, we took a look at the vital role of healthcare staff themselves in fostering a culture of safety and learning.
Open cultures
National Freedom to Speak up guardian Jayne Chidgey Clark looked at the importance of having open cultures so staff can feel they can speak up not just about safety issues, but equally about issues of improvement.
A fascinating discussion with members also took place about how it feels for leaders to be on the receiving end of ‘speaking up’ and the importance of ‘listening with fascination’ and not taking the defensive stance.
Spire’s Erica Bowen built on this theme and outlined how the hospital group had fostered a ‘ward to board’ approach to speaking up with the need for all parts of the organisation to be ‘clinically curious’ and not ‘comfort seek’ when it comes to safety matters.
The importance of the ‘top of the office’ embracing the speaking up agenda was also highlighted and the need to be explicit about what action has been taken in response to staff concerns.
We then ended the day with some brilliant academic insights from the brains of the industry.
What patients can tell us
Prof Jane O’Hara from The Healthcare Improvement Studies (THIS) Institute at Cambridge University showcased her research on ‘What can patients and families tell us about safety, and why should we care?’
All too often, there are cases of patients and families not being sufficiently involved in investigations despite, in fact, being the only people there across the journey.
Not only are you therefore missing the opportunity to fact check and gain new insights, but also the opportunity is lost for those involved to ‘heal’ and understand what went wrong.
Jane has worked on some fantastic resources on how to meaningfully engage with patients and families, which I would recommend all those in the sector to look at.
Learning from errors
Another brain from the sector was HSSIB’s senior safety investigator Saskia Fursland who presented the case on ‘Learning from errors and mistakes – retained swabs following invasive procedures’.
While this took place in the NHS, there were key take-aways for all parts of the health system. These included the often overreliance on serious incident reports in making predominantly ‘people-focused’ recommendations – such as surgical check-lists.
They have a limited application of a systems-based approach to investigation which look at the more complex and interrelated system factors at play in avoiding future incidents.
We finished the day with our sponsor, legal services company Bevan Brittan. While looking specifically at how healthcare providers can use incidents and inquests as an opportunity for pro-active learning and improvement, the presentation really summed up the day nicely around how to develop the right ‘culture of care’.
This included being as open and inclusive as possible in any investigation and really getting people’s buy-in to the process. This often involves something as simple as a ‘thank you’, asking open questions ‘with curiosity’ and always seeing incidents as learning opportunities where patient care can be improved, rather than failures.
There was so much for both practitioners and providers to take away from the day, with a clear steer to listen with fascination, don’t comfort seek and ask questions with curiosity.
And remember that patients are unique – they are you, me, our families and friends. Keep this in mind as a practitioner and you can’t go too wrong.
David Hare is chief executive of the Independent Healthcare Providers Network (IHPN)
