Many of the issues identified at the Mid Staffordshire NHS Foundation Trust could be seen at any hospital in the NHS. The overwhelming message of Francis was the need for 'cultural change' in the NHS. However, this is a tall order since the NHS doesn't so much have a culture, it is a culture and it's the individuals within the organisation that make up that culture. In short, it's 'the way we do things around here'. But, the way we do things can be greatly influenced for the better by IT systems.
Somewhere along the line, according to Francis, the NHS seems to have lost its way. The causes are no doubt manifold, but I believe that new technology can be used to help re-establish these principles, and should certainly be part of the solution.
Francis report key finding: 'Secrecy'
IT systems can show you what's going on. Some of the shocking and callous treatment that patients were subjected to at Mid Staffs would be impossible if only we could 'see' what was happening. A good example is the recording of clinical observations.
Most inpatients will have their vital signs recorded regularly. Parameters such as, blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, pain scores, etc, are noted on charts so that a longitudinal picture can be seen, which indicates whether the patient is deteriorating, improving or staying the same. Early Warning Scores (EWS) exist that can detect when patients need more intervention.
Key finding: 'A lack of openness to criticism'
At present, bedside observations are done manually and are most often paper-based. There is audit evidence that only about 70% of observations are actually done and/or recorded. When electronic systems are introduced recording increases to nearly 100%. Partly, this is due to the fact that it is obvious where the gaps are and, perhaps more importantly, who is responsible. Steps in tasks can be made compulsory, no 'corner-cutting' or skipping items. (Think of buying an airline ticket online; you must follow the prescribed sequence else you can't complete the task). More sophisticated IT systems can proactively assimilate automatically information from disparate sources to predict which patients are most at risk.
Regulators, commissioners of healthcare and the public also need information to make meaningful comparisons between organisations. Sharing and comparing the outcomes of different hospitals can drive up standards.
Key finding: 'Acceptance of poor standards'
With the best will in the world no doctor or nurse can know everything. Health IT can help direct care and ensure that the patient stays on the right track, i.e. receives all the appropriate care that they should in a timely manner: right thing, right way, right time. For instance, when teams hand-over care using electronic systems, communication is improved. This helps to overcome the fragmentation of care delivery, where the left hand doesn't know what the right hand has done. Similarly, electronic prescribing systems contain decision-support software that can automatically alert clinicians about potentially harmful drug-drug interactions.
Key finding: 'Misplaced assumptions about the judgements and actions of others'
According to Francis, the quality of care should be described in standards. IT systems can be used to monitor how closely these standards are adhered to and to guide practitioners in what to do in given situations. At present, in the UK, very little use is made of such electronic, standard-based applications. Where they can replace tedious, repetitive, high-speed and complex tasks currently performed manually, they can improve safety. Electronic systems are logical and operate to high standards.
Key finding: 'Clinical intelligence'
IT systems collect huge amounts of data. If all the data currently held on paper were available for easy analysis, we would be able to produce reports in 'near real-time'. In other industries, great use is made of such data and is called 'Business Intelligence'. To make this concept culturally acceptable to the NHS, I would suggest calling it 'Clinical Intelligence'.
There are three main applications:
- Direct patient care: what's happening to this particular patient? The EWS above is a good example
- How well is this doctor/team/hospital performing? There is huge variation in the performance of different individuals and teams, yet rarely is this made known.
- Wide-scale issues: with good population data, we can track large-scale changes, such as the obesity 'epidemic', 'flu outbreaks, and the uptake of public health measures.
Key finding: 'Defensiveness'
Electronic systems permit the automatic capture of data. This can be structured, semi-structured and unstructured. Coding systems, such as SNOMED CT and ICD10, aim to overcome ambiguity in language by providing terms that have defined meaning. If information is captured it can be investigated, analysed and presented in meaningful ways providing the possibility for remembering and learning from mistakes as well as providing a real-time picture of how things are (current status, dashboards), and how things are likely to be in the future (prediction).
Key finding: 'A failure to put the patient first in everything that is done'
Having the necessary information about a patient is essential to good clinical care. Having that information at your fingertips, when you need it, helps avoid pitfalls and promotes personalised decisions. The patient feels valued, listened to and at the centre of your attention.
In my experience, patients love to read their medical notes! It helps with shared decision-making and simple errors can often be detected. But, in reality, it rarely happens and the NHS makes it pretty difficult to do. It is technically quite easy to provide the same information to the patient that the clinician has, in a secure and safe way. For a number of reasons though, clinicians are often the biggest barrier preventing patient access to records.
Feedback from patients and carers is a great idea, but only means something when it impacts on individuals and teams in some way. For the first time, doctors have to collect patient feedback in order to revalidate their licence to practise. Moreover, financial penalties for 30-day readmission rates could reduce NHS hospital income by as much as 3%. Quality will count.
Conclusion
There will be much soul-searching and analysis following the Francis report. For me, the key is better information leading to better care. Francis states: "If the culture of those engaged in and with the NHS is to change, information must be made available about the performance and outcomes of the service provided to enable patients to make treatment choices and have a proper understanding of the outcomes for them."
As we have seen, electronic systems can help reduce risk through a variety of mechanisms. I believe that the time is now ripe to exploit health IT fully in the NHS in order to reap the patient safety benefits. These systems, properly implemented, can provide the step-change in patient safety that everyone knows we need. The result will be 'a rich and varied source of information on each patient to help patients avoid or manage chronic disease, deliver truly personalised health care and proactively monitor safety and quality of care.'