In the news recently we have had the announcement that there will be a new set of measures for the NHS (other than GPs) related to wellbeing and organisations will be judged against 6 measures which will then be used to create league tables.
The 6 measures are; tackling racism, preventing violence, improving sexual safety, promoting flexible working, line management, and health and wellbeing support.
One of the key questions that springs to mind, not that it is important to address all of those 6 areas but…..
Do league tables really make healthcare safer?
Since working at the National Patient Safety Agency, I have always found league tables fascinating. In my naivety, I thought they were possibly a good idea. We should know how organisations are performing right? And yet…
The thing about any measurement or measurement system is the number is never straight forward. It may or may not represent what is actually going on.
Why do people like league tables?
Humans like comparing. As we speak we have the Football World Cup. The football world is full to the brim of league tables. But they are a little more simple than healthcare. Goals in, goals saved, games won, games lost, games drawn – all of that is relatively straightforward. Although it doesn’t tell you how hard the team played, or the beautiful way in which Messi or Mbappe or Bellingham move the ball or the types of referee or managerial decisions that might have been right or wrong. It just gives you the outputs not the performance.
And… despite my cynical view of performance measures as soon as I become a patient I am off to some search engine or AI bot to ask about the particular organisations performance and rating.
When comparison becomes judgement
However….the challenge is that healthcare is not a simple football competition. Healthcare is much more complex. One hospital may care for a much older population. Another may look after people with greater levels of deprivation. One may provide highly specialised services that attract the sickest patients from a wide area.
So when we place organisations in a neat ranking, we can sometimes create the illusion that we are comparing like with like when actually we are not.
A hospital being lower down a league table does not automatically mean it is providing poorer care.
And a hospital at the top does not automatically mean everything is perfect.
We all know how skewed things like trip advisor are and yet we are also allured by the statistic that is shown against a particular hotel or restaurant. We are also influenced completely by the negative comments and dismiss the positive ones. This is the whole problem with our safety I approach to healthcare in that we only listen to the negative. That only provides is with one side of the story. In fact the more interesting data in my view is the positive side. How safety is maintained and achieved rather than how it is failed – that is the attraction for me about Safety II.
The unintended consequences
There are always unintended consequences of any approach, particular in relation to comparing organisations, measures and league tables.
When people are being judged on certain measures, these measures become more important than other measures. The work to address those measures becomes more important than other work. Priorities change.
People pay attention to them because someone somewhere is scrutinising them.
If waiting times become the dominant measure, the system can start to focus on getting people through the system as quickly as possible rather than thinking about where they need to be to be safe.
If infection rates, or pressure ulcers, or falls become the focus, attention may move towards reducing the number rather than understanding the conditions that create the risk or poor outcomes.
Does the measure help people understand their work better and improve it?
What does this do to the culture?
Imagine you are working in an organisation that suddenly appears at the bottom of a national ranking. You may already be subject to external scrutiny, or be placed on the ‘poorly performing’ list. Even if not you feel fear.
And we all know a blame culture, which this can be a form of, encourages people to protect themselves. And when people feel they need to protect themselves, transparency and learning suffers.
I wonder if we sometimes ask the wrong questions
Perhaps the purpose of healthcare measurement should not be to create winners and losers. How about we get better at:
- Learning about how we can understand everyday work. How people are performing despite the imperfect conditions, how people are adjusting or working around issues and why. What conditions, culture, pressures are they working under
- Early warning signals, ‘weak’ signals, near misses – the really valuable data we still struggle to capture
- Understanding how people/units/departments/organisations succeed and what are they doing that helps them do that
We can use all of these to look at the 6 areas; tackling racism, preventing violence, improving sexual safety, promoting flexible working, line management, and health and wellbeing support.
PATIENT SAFETY NOW 