By Shane Tickell, CEO, IMS MAXIMS.I am a CEO of a health technology company and I make mistakes, probably everyday. As the leader of an organisation, I am accountable for those mistakes, need to learn from them and, where possible, rectify them. In addition to that, every single member of my team has a specific set of responsibilities and when they make a mistake they too must recognise it and be accountable for that. This is not so that they can be blamed, it is so that further mistakes are not made which could eventually lead to a larger problem.
In July 2001, the press published the following headline: ‘UK government and doctors agree to end "blame culture".The then health secretary, Alan Milburn, said the joint statement was aimed at 'raising standards' of care and added: "Medicine is not a perfect science. Even the best doctors can make the worst mistakes."
Twelve years on and we have seen some of the most horrendous examples of poor care, cover-ups and blame culture in the history of the NHS. Earlier this year conclusions were drawn that neglect by healthcare professionals resulted in hundreds of patients dying unnecessarily at Mid Staffordshire NHS Foundation Trust. Just this week it was revealed that a huge cover-up took place at Morecambe Bay University Hospitals NHS Foundation Trust to hide how the deaths of at least 16 babies at the maternity hospital were preventable.
I have absolutely no doubt that there were people in these organisations that saw something was wrong and tried to help, others probably knew that they were making mistakes themselves, so why did it happen?
While no one likes to be blamed for a mistake (think car insurance; the first thing you are advised is never to admit blame even when it was obviously your fault), in most other industries there is an environment where openness and transparency is encouraged. There is a platform provided for people to voice their mistakes or complain and then allowed to learn from that. That culture is simply not there in the NHS.
Take, for example, the RAF. In Carl Honoré's book 'The Slow Fix,' Honoré discusses how dealing with mistakes and complaints more openly has the potential to save lives.
He describes how one engineer, who carried out a routine test on a Typhoon aircraft, accidently sheared off the end of a dowel in the canopy mechanism, which could have resulted in the parachuting failing to open when required. The safety investigator team swung into action and within 24 hours the entire fleet was checked from Europe to Saudi Arabia and a process was implemented to ensure that when checks were carried out, canopies were not damaged.
Honoré explains how RAF safety investigators contact all those who flag-up a problem and tell them how the case was concluded. They also conduct weekly workshops for their engineers to explain what happened. He writes "You can see their eyebrows raise when they see that they won't be punished for making a mistake and that they might actually get a pack on the back."
Turn back to the NHS and this could not be more different to the "appalling" treatment that Kay Sheldon, board member at the Care Quality Commission (CQC) was subjected to for raising the alarm that the CQC had deleted a damning report into the high mortality rates at the maternity unit at Morecambe Bay. When you look at the comparisons it is no wonder that healthcare professionals have become so frightened of admitting mistakes and creating conflict that it has cost lives.
There are several key points here that I would urge organisations to consider:
1. Can you remove repercussions for admitting a mistake while ensuring that repercussions are put in place for NOT admitting mistakes? This gives the flexibility for individuals to admit and learn but never to cover-up and escalate the problem.
2. Inline with Jeremy Hunt's recent speech around openness, think about whether you and your organisation has started 'accepting the unacceptable' and whether this needs to be addressed.
3. Is there a platform for all staff to discuss their opinion, mistakes and problems without repercussion?
4. Is there a platform to act on those opinions, mistakes and problems?
5. Are you feeding back to staff on what has been done regarding their view?
6. Are you looking at perception rather than reality? And if that perception is accurate does change need to happen. If that perception is not accurate, do you need to work to change the perception?
We are increasingly seeing a toxic cocktail where a reluctance to complain and admit mistakes combined with that culture of defensiveness means that mistakes are covered up rather than dealt with. But in most cases, I truly believe that big mistakes are rarely the fault of a single person. Fundamentally, people want to do their job and do it well. Mistakes most often arise when there is lack of support in enabling them to do their job, whether that is lack of resource, processes management or guidance. Ensuring the above points are considered and maximum support is provided to enable staff to remain passionate and engaged with their role has the potential to break down the barrier of blame.
As Sir Liam Donaldson, former chief medical office for England once said: "To err is human, to cover-up is unforgivable, to fail to learn is inexcusable."
About IMS MAXIMS
IMS MAXIMS is an electronic patient record provider working towards better, safer patient care. Specialists in developing clinical and administrative software solutions for healthcare providers, IMS MAXIMS currently supports more than 150 organisations, 11 million patient records in the UK, and 1.9 million patient records in Ireland, approx 50% of the population, as well as 20,000 users of IMS MAXIMS products.
MAXIMS is at the heart of the clinical and administrative life of everything from large UK and Irish hospitals, to small specialist independent clinics. It gives patient data to clinicians in exactly the format they need, and allows it to be shared with colleagues and updated in real-time. MAXIMS suits any clinical specialism and is excellent for order communications and reporting. Medical and administrative records can be kept fully up to date, with minimum effort. MAXIMS is web-based so there is no need to install software on computers or invest in expensive extra hardware.