I have been re-reading the Kings Fund report The chief executive’s tale and was really struck again by what an astonishing insight it is into how a chief executive in the NHS feels and thinks and the aspects that are so very relevant to our work at Sign up to Safety.
Firstly, we have focused on understanding the unique aspects of patient safety (as opposed to quality) related to human error, human factors and the cross cutting, systems approach to safety. This is often misunderstood, for example, as Jonathan Michael says:
One of the frustrations particularly recently has been the lack of understanding that health care is an inherently risky business but there has been this drive .. to somehow present it as something that ideally ought to be risk free. Being alive is risky.. being treated is risky… but equally not being treated is inherently risky.. the drive is generating a degree of pressure on clinicians, on organisations and therefore on the chief executive…
Secondly, we have chosen to purposefully not micro-manage from the centre and to build local ownership of self directed safety improvement. There is already enough of that from regulation and other national mechanisms. As Angela Pedder says, the job of a CEO is ‘holding up an umbrella to keep the stuff that’s coming down from up high away from the people that need to do the really good work day to day with patients’. The trouble with that is that if you are perceived as part of that ‘stuff’, how do you get through, how do you convince people that you are different? How do you reach the people who are doing the day to day work with the patients? Steve Shrubb describes our approach when he says; ‘the key is to use the power you have to give it away to the leaders in your organisation so that they can actually create the change.. and feel part of it’. He goes on to say; ‘if you can get the staff feeling engaged, informed, involved and cared for then you will deliver good, efficient care’.
Thirdly, we choose to be a different voice – a positive, caring, kind voice. This report and those we talk to on a regular basis describe the ‘hostility’ in the NHS. With the on-going emphasis on reducing avoidable mortality, we believe that we should move as far away as we possibly can from the experience described by Catherine Beardshaw:
I remember sitting on one side of the table with six or seven of my team to talk about… our quality strategy and reducing our avoidable mortality and there were 38 people from other agencies sitting opposite demanding ‘where, why, how’, each of them marking our homework.
Instead we need to do as Steve Shrubb suggests; ‘prepare our talented leaders to lead in a very challenging environment, surrounding them with people who can nurture them and support them from an early stage; we need to apply the same supportive values to CEOs that we seek to apply to the rest of the staff’.
Fourthly, we have focused relentlessly on describing and promoting the right culture of safety; one that is supportive, proportionate and fair (a just culture). Sadly an experience related to ‘risk summits’ shared by Mark Newbold is so far removed from what a good safety culture looks like.
It was the worst moment, I think, in my professional career. It was like a ritual humiliation and bullying session. And the tone of it was as if they thought that we were somehow now sufficiently concerned about the problems, not trying hard enough to sort them, where here was a highly experienced and deeply committed … team that was living and breathing these issues.
Finally, we are committed to helping people talk to each other about what they know about keeping people safer. We are doing this by working through different concepts and methods to find ways in which people can speak out, share their stories, truly listen and notice what is being said and what isn’t. This report is a beautiful illustration of the power of story telling. In our work we have also been exploring the value of using metaphors to explain thoughts and feelings in order to see if we can get deeper into people’s experiences. Along with Angela’s umbrella metaphor, there are some great metaphors within the report:
if felt like you were tied to a tree, and each time they just went around with the rope another time, so you were getting more and more tied down (Mark Newbold)
The chief executive’s tale is a very moving report. As Marcus Powell from the Kings Fund says in his summation; ‘the consistency of commentary should be deeply worrying to anyone who has an interest in health’. He goes on to say that the ‘forces at work to keep any system the same are stronger than people acknowledge‘ … the ‘task is to support and encourage them to adopt the paradigm change that’s now needed and not just reinvent the past’. Thinking differently about patient safety is a key part of our work and our promise at Sign up to Safety is to share our learning about how we can step beyond the short term and help the frontline, the people who know their own situations better than we do, be the guiding force for change.