In the last few years, the way we talk about patient safety has started to shift. Thanks to our ability to observe, study, evolve, adapt and learn, we have gained enough information and knowledge to begin addressing the safety of patient care and the working conditions within healthcare. We have gained an understanding of what the right culture for safety should include; one that is fair, just, respectful, restorative and compassionate. We have taken the first step by being aware of the problem. However, today we see the report by Imperial College and Patient Safety Watch – the National State of Patient Safety 2022, What we know about avoidable harm in England. When you read it you could ask; ‘What has changed over the last twenty years?’ Are we learning? What could we do differently?
To improve patient safety we need to understand it.
In a world where expertise is rightly held in high esteem, it would be really lovely if we could increase the knowledge across the health service in the science of patient safety. The only way forward is to create a critical mass of people who truly understand what it is in its entirety, not just incident reporting and investigations. How to monitor our complex adaptive systems, how to study the functionality of our everyday work and to use that knowledge to understand the connections between structure, people and processes. How to create psychologically safe environments for teams.
Understanding behaviours, relationships, communication, the design of systems, processes, equipment and the environment to maximise safety should be seen as a priority skill. To have a complete overview of the systems and sub systems so that from there the solutions can be found. Once you have a full sense of what patient safety is then you will more or less know what to do. Understanding the reality of people’s lives will provide clues as to what needs to be changed and how quickly they are needed to be put in place. If your objective is to have really good safety systems then surely the first step is to have people who know what that looks like.
To improve patient safety we need to ask fundamental questions.
Why does it fail when the majority of the time it succeeds? What is it exactly that we want to solve? What is our goal? Is it lower incidents, or less harm or improved systems or better relationships? Is it focusing on culture or systems thinking or capturing more or less data? Is our goal to safeguard the present or sort out things for the future? To free time means asking, what should we stop doing?
To improve patient safety we need to be far more proactive.
As Desmond Tutu says ‘There comes a point where we need to stop just pulling people out of the river. Some of us need to go upstream and find out why they are falling in‘. or as Greta Thunberg says… ‘When your bathtub is about to overflow, you don’t go looking for buckets or start covering the floor with towels – you start by turning off the tap, as soon as you possibly can’. Safety needs a whole new way of thinking. The solution is not exactly rocket science. What we need to do is understand what peoples work is like when it succeeds and when it fails, then design systems that prevent things from going wrong and help the people work as safely as possible.
To improve patient safety we need to care for the people who care.
Healthcare resilience that has been so vital to us will not last forever. The evidence seems to suggest more and more clearly that there is a relationship between staff wellbeing and patient outcomes. Staff wellbeing is achieved if we pay attention to their emotional, physical and mental health but it also their own safety. Sadly it feels like we are entering into a new era of deterioration. Deterioration in peoples ability to cope, to work safely, to care for patients in the way they would like to. Deterioration in the right resources, people and equipment. Deterioration in having the time to care. Deterioration in terms of behaviours between one another and therefore the positive kind relationships needed for safety.
To improve patient safety we need to link it up with everything else.
There are countless issues that deserve our full attention and that have to be focused on. To tackle safety…. tackle sustainability, tackle efficiency, effectiveness. Have procurement policies that help reduce our impact on the climate and improve safety. Tackle equality, diversity and inclusivity. Tackle staff wellbeing. Tackle them all together and they will impact on each other. Leaders have great opportunities to see it all and to join them all up. There cannot be safety without equality and inclusivity for a diverse workforce. Equity means believing that another world is possible but also building it with the understanding that the only way to get there is through collective action. (Nicki Becker). We cannot have one without all the others. For example, the work to build a just culture within healthcare helps us build a society that is fairer on every front.
Transformation often starts slowly but then it begins to accelerate. While two decades seems a long time to me it is not very long in the history of healthcare – so we can see this as ‘the slow period’ in which we have been gaining traction. Therefore with the coming of 2023 it can be the time to accelerate. As Don Berwick has said in the past, there is still time to undo our mistakes, to step back and choose a new path.