The move to on ‘open and transparent’ NHS culture
[London, UK] Is the NHS starting to build a culture where it is learning from its mistakes?
BJ-HC spoke to Matthew Syed, journalist and author of the bestselling book Black Box Thinking, more than two years after its publication, about progress in creating system-wide learning structures when it comes to failure.
Syed says a number of ‘important changes’ have been made during the past few months. One, for instance, is the creation of the independent Healthcare Safety Investigation Branch (HSIB), which became operational in April.
It carries out up to 30 investigations per year to identify patterns from incidents, following a model from the airline industry, providing a ‘space space’ for professionals so that they can speak up about their concerns.
“I hope that it will have a good effect. If you go to their website, you will see that they’ve already done a number of investigations. And they’re very impressive,” Syed says.
Under the draft patient safety bill published in September this year, a new organisation called the Health Service Safety Investigations Body (HSSIB) will replace the HSIB, with powers enshrined in law, meant to investigate serious incidents across the NHS in England related to patient safety.
The HSSIB will be required to publish after each investigation a detailed report making recommendations for ‘system-wide learning across the NHS’, support the development of national standards and provide guidance.
Health Secretary Jeremy Hunt described the draft bill as a ‘historic opportunity to achieve widespread cultural change in learning from mistakes’.
“I think there are definitely positive things happening,” Syed tells BJ-HC.
'We should see any error as an opportunity to learn'
But why is it so much more difficult to crack the issue in healthcare, in comparison to other industries that the NHS is currently learning from, such as aviation?
“I think there are two problems,” Syed argues.
“One is the tendency to blame professionals unfairly for honest mistakes, so the quality of the investigations is, I think, too low. There is a tendency to assume negligence when often the problem is more complex and systemic, that’s definitely a big issue.
“The second problem, I think, is that some senior doctors have sort of an ego problem, where they don’t like to admit to their mistakes because they think that that questions their professional competence.
“So they’re often much more likely to pass it off rather than confront it. In other words, it’s very important to see any error as an opportunity to learn rather than to become defensive about it. And I think there is a problem with some senior doctors who become very defensive about errors. So it’s a combination of high blame and egos that are too big,” Syed explains.
To get to a point where mistakes are no longer stigmatised in healthcare, Syed says it is important to build a ‘learning culture’ that is open and transparent:
“Some of the most powerful improvements can be discovered in the errors that are made and that is really the terrain that the NHS needs to be in,” Syed adds.
Clinical leaders should develop a 'growth mindset'
As they go through their training, professionals should learn to take every experience as an opportunity to improve: “We want have our doctors and nurses in a growth mindset,” Syed explains.
Earlier this month, the Public Accounts Committee emphasised that the lack of consistent data across the NHS means ‘it is not well placed to learn from its mistakes’. During the past decade, there has been a four-fold increase in annual costs of clinical negligence.
“I think that is something that aviation has done, again, very well, with its data collection, data analysis and then the way that the data is distributed to those who need to hear it is very, very important.
“That last thing, if there is an opportunity to improve, it would be helpful if that improvement can be addressed as widely as possible, rather than just one doctor or one hospital,” says Syed.
His next book, which will be published in April next year, will focus on encouraging young people to adopt a ‘growth mindset’ and build the confidence and resilience needed to thrive.