I would like to thank Amanda Oates [ @amandajoyoates ] Joe Rafferty [ @JR_MerseyCare ] and Beatrice Fraenkel [@BFraenkel ] together with large swathes of staff at Mersey Care NHS FT whose names I may never know for providing those of us who have been working in patient safety with hope.
I have just watched the film about their work in growing a just and learning culture across their organisation. This work has been in partnership with Sidney Dekker [ @sidneydekkercom ]. The film can be found here.
Complex systems like healthcare and hospitals are filled with hundreds of moving parts, scores of players and varied expertise. The moving parts and people are ever-changing with constant adaptations in action. Even though there is an attempt to create mechanisms of ‘command and control’ it is impossible for the senior leadership of a hospital to be able to control everyone’s behaviours and actions. However, despite this the prevailing view is that people should be controlled in some way with targets, policies, standards and guidelines and that when people inevitably deviate from these or fail to achieve them that they (the individuals involved) should be punished or sanctioned in some way.
The leadership at Mersey Care think differently. They are doing their best to think and act differently about how to respond when things go wrong.
The film shares snippets of the individual stories of staff who have been hurt by the traditional way in which people are dealt with when an incident happens or a complaint is made. This is not isolated at Mersey Care, it is in fact the default position across a lot of the NHS. Sadly I have numerous stories from staff from all professions and all care settings who have been treated badly. They have been suspended, investigated, banned from practising, moved, shifted, sacked. They have felt ashamed and in some cases have taken their own lives as a result. There is a moral imperative to support staff not blame them when things go wrong.
People make countless adjustments during their work. Most of these lead to success. Some lead to failure. There is no error. There is just work, which we can try to understand. Takes the blame out of failure (Adrian Plunkett via twitter @adrianplunkett )
We could fire everybody who makes a mistake, punish everyone who makes an error and put in an entirely new workforce but it would be far more useful to learn about why the mistakes and errors happen, together with learning about what actually goes ok or even well. This balanced view means we stop defining an individual by the single mistake they make and instead understand the context of the thousands of times they got the same thing right. People are not the problem.
Mersey Care are doing just that, working out how they can learn from when things go wrong, hearing from the people involved and what happened and not simply get rid of the people. The film describes how they are doing this beautifully so I don’t need to repeat that, but the film would not have happened, the work would not have happened and the chance of hope would not be there if it wasn’t for the inspired leadership at Mersey Care and the fact that people want to follow.
They themselves say they have not yet got to where they want to be. As I always say safety is not a 3-5 month project its a lifetime of work. I for one cant wait to follow their progress.
Patient Safety Now 