The part we all play

A Risky Business

What do service users, patients and carers think about the risks and experience of receiving health care in the UK National Health Service (NHS) today?

Most people perceive that health care is a risky business. A UK National Audit Office report entitled A Safer Place for Patients: Learning to Improve Patient Safety ¹ noted that one in 10 patients experience some sort of safety incident when they go into hospital. The number of staff and patients seeking redress through litigation when things go wrong is on the increase. Not surprisingly, much of the UK Department of Health (DOH) guidance is focused on service re-design and service improvement.

We know that simply working harder and more diligently will not improve safety and that the responsibility for safety cannot be delegated. Safety requires a culture shift, dedicated leadership and a change in behaviour. The same goes for service improvement in general. We will need to take a considered look at our organizations’ systems, structures and functions, and at our peoples activities, actions and behaviours. To change our behaviour, if we wish to avoid causing undue stress, we must want to change it, and to want to, we must understand why we need to behave differently.

Have we Forgotten the Basics?

In 2006 I had the mixed pleasure of spending a total of three solid months observing six patient admissions and numerous outpatient appointments across five hospitals and three community services in the south of England. The opportunity this afforded me to be a fly on the wall gave me renewed insight into the patient experience through the eyes of a carer/relative. I was able not only to observe keenly the service that patients and their carers were receiving, but also to talk to them about their views and feelings on the subject at the time of receiving the service or soon afterwards. In Table 1, in no particular order, I have listed some of the less positive experiences that came up time and again. They are not necessarily the views of the editor, but the observations and comments of over 150 patients, service users and carers regarding the administrative, professional and hotel services provided by a number of acute and community health-care services across clinical departments that included accident and emergency (A&E), general surgery, medical, paediatrics, anaesthetics, intensive care, high dependency, ophthalmology, day surgery, investigations, radiology, general practitioner (GP) and community services.

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Table 1

Poor patient, service user and carer experiences

Leadership	• Almost impossible to know who was in charge of the ward and who people were; patients rarely knew who their named nurse was in each shift • The functioning of the ward was greatly influenced by who was in charge – the atmosphere and staff behaviour was noted to change perceptibly when particular sisters/charge nurses took the helm
Records and communication	• Lost, misplaced, unavailable, untraceable notes – being assessed and treated without the notes wasted time, increased the risks for all involved and generally irritated the patients and carers • Inadequate information was available to the patient, carers and ward staff regarding the surgery actually done; patients were sometimes not seen by the consultant or operating surgeon postoperatively, and no one was available who knew the details of what had been done; patients therefore went home still unclear as to exactly what they had had done or what to expect in terms of prognosis, ongoing symptoms, management, etc. • Poor communication with patients and carers; a common complaint from both patients and carers was that information about the patient seemed to be a closely-guarded secret that professionals often went out of their way to protect. Carers, in particular, found information withheld from them, even when patients had requested that they be involved and informed. There were numerous, rather distressing, stories to support this view • Clinical staff seemed to spend excessive amounts of time poring over documentation at the nurses’ station at the expense of time being spent with patients and carers
Basic care	• Basic care on the wards was wholly inadequate to meet the needs and safety of patients — Only the most critical tasks were done by ward staff — Little, if any, time was spent talking to or reassuring patients, or providing basic care; patients felt that they had to keep their questions and requests until a dressing was being changed or other bedside task attended to — Nights were often frightening for patients with disturbed and confused patients unsupervised and at risk, and people in pain who had difficulty moving about who had to be helped to the toilet by other patients due to unavailable ward staff
Medication	• Administration of medication on the wards — Rarely on time; sometimes omitted — Incorrect doses were given — To re-start medication after surgery was forgotten — Medication that patients were known to be allergic to was offered — Inadequate pain and sickness control once in the ward – there was no one around to ask — Patients were promised medication but no one came back to administer it — Delays were caused by doctors being unavailable to write up medication — No one was around for long periods of time; ward staff were too busy to ask for medication — Distress and frustration at not being allowed to manage their own medication, but nursing staff failed to manage it correctly or on time • TTOs — Poor planning caused delayed discharges — Insufficient medication was available (a particular problem at weekends) so patients went home with insufficient medication to tide them over until their GP could be reasonably contacted for repeat prescription • Patients were expected to make appointments to see their GP to organize repeat prescriptions often after only a couple of days post-discharge. With the early discharge policy these days, many patients felt that they were still in the early recovery stage and found this requirement to make a trip out to visit their GP both traumatic and tiring. They commented that it would have been useful to know before admission that this would be the case so that carers could have been ready and primed to help
Infection control and hygiene	• Inadequate cleanliness of the environment • Little hand washing to prevent the spread of infection • Poor attention to infection control, e.g. when cleaning wounds, changing dressings, moving between patients –less trained and skilled staff were often delegated these tasks with less insight into potential risks
General appearance, attitude and conduct of some staff	• Inappropriate conversations were held within the hearing of patients, with some reported breaches of patient confidentiality and unprofessional remarks about patients and carers • Sloppy and unprofessional appearance with badly fitting, dirty uniforms, hair ‘all over the place’, poor manners, posture and demeanour, and a lack of badges • Some staff got away with being repeatedly rude, unkind and, in some cases, ‘cruel’ to both patients and colleagues • Patients felt fear of reprisal and were apprehensive about tackling any of these issues
Waiting	• Poor or ‘block’ planning of theatre schedules often meant fasting for much longer than was actually necessary, creating problems in particular for children and increasing risks for those patients vulnerable to the effects of dehydration, postoperative stroke, etc. • A lack of information after referrals had been made; patients often had no idea who they had been referred to, where or how long they might have to wait. They had no contact details that would allow them to chase up referrals or make enquiries. When they were contacted, it was often for an appointment at less than two weeks’ notice (after many months wait), causing inconvenience to them as regards re-planning of their own or their carers’ work and other commitments
Discharge planning	• Little or no involvement of the patient or carers • Little or no knowledge or attention to the patient's home circumstances, particularly when there was an assumption that the patient would require ongoing care and support at home • Inadequate notice for carers • Timing caused problems • Little or no information to patients or carers was given about what to look out for as regards wound infections, DVTs and other postoperative complications, and when/what to do if they were concerned • Poor or inadequate information about any care that could be expected in the community or who might provide it, e.g. the role of district nurses or GP services in removing stitches, changing dressings, checking wounds, etc. • TTOs not ready in time • No contact numbers in the event of concerns • Many of the worries expressed by patients and their carers were exacerbated by the trend towards earlier discharge from hospital, with patients now routinely going home only a few days after major surgery, when wound infections, DVTs and other postoperative complications were still a very real risk
Carer involvement	• There was a general feeling of being a nuisance and interrupting a frantically busy person if needing to ask a member of staff for anything; there was great sense of reluctance to allow carers and patients themselves to take some of the burden of care off over-stretched professionals • Many carers felt that they were resented and discouraged if they wished to be involved in the care of the patient, or if they asked too many questions; advocacy was not a desired or encouraged quality in a carer • Carers were neither invited to be present at ward rounds, nor welcome if they asked to be present. Ward rounds were well outside visiting times and often the only times when members of the team able to answer questions would be available; carers were reluctant to request meetings with doctors as this was not seen as the norm and seemed difficult to arrange for the over-worked ward staff • Patients were usually present at ward rounds, but rarely felt brave enough to question the large group of professionals at the end of the bed, and usually forgot or were confused by what had been said, being unable to update carers and gaining little personal benefit themselves. Many of them expressed a wish to have the option of inviting a carer to be with them for the ward rounds

GP, general practitioner; DVT, deep vein thrombosis; TTOs, drugs to take out

It should be kept in mind that alongside the comments listed here were numerous positive observations, most often about the quality of particular individuals’ attitudes, conduct and skills, and in relation to the skilled undertaking of the major interventions themselves.

It was notable that few people I spoke to had any problem with the technical/professional interventions themselves; it was the care and experiences around them that gave the greatest cause for concern. I found both the personal experiences and the number of stories of neglect, unkindness, inappropriate attitude, drug errors, poor hygiene, sloppy infection control and slack processes unacceptable and was not surprised that some patients expressed a degree of fear and apprehension regarding their admission. Many of the issues seemed to have little, if anything, to do with the lack of staff, time or resources so often blamed, and more to do with the attitude and organization of those elements.

The comments concerning leadership in A&E departments and on the wards were also interesting. Over a dozen people mentioned that they had noticed a tangible difference in the cleanliness of the environment, the energy and motivation of the team, the timeliness of actions and activities, and the standards and professionalism when particular senior personnel started on shift.

At least in these areas, surely we could do more.

The challenge will be to know where our risks and problems lie, to be clear about how to minimize them, to communicate this consistently at the point of delivery, to capture our real life challenges, to measure the effects of our changes, to feedback and understand those results, and most importantly to celebrate, share and spread our successes.

A Staff Perspective

In relation to how care pathway documentation was viewed in one ward, I overheard a day surgery unit nurse who was sitting in the nurses station documenting her care exclaim, ‘I hate these orthopaedic care pathways; they're a real pain’. Later on, I asked her why she disliked them so much and she explained that they required her to record information about a list of activities on the care pathway, but then she still had to complete all her regular notes in line with local day unit policy. I asked whether she or her team had had any involvement with the care pathway or ever received any feedback for their efforts such as variance/trend analysis, and she looked at me blankly before replying, ‘You must be joking’. It turned out that she, a full-time member of the staff who had worked in that hospital for the past eight years, had never received any feedback for the documentation of her care and, furthermore, had had only very minimal involvement with clinical audit over the time and no involvement with any care pathways. She thought that the orthopaedic care pathway document had been in use for ‘some years’.

Fuelled by the conversation about the orthopaedic care pathway document, I spent the next six months asking anyone that I came across who had any experience of using care pathway documentation what they thought would make a more popular care pathway document. These were some of the comments. I like care pathways where:

A Shift from ‘Collecting’ to ‘Using’ Information

Overall, the comments suggest that more needs to be done for the individual care pathway user if we are to increase the popularity of care pathway documents and therefore their potential to prompt improved behaviours and capture more useful information. Far more emphasis needs to be put on what happens as a result of collecting the information rather than on the collection of the information as an end in itself, and making the documents ‘support’ rather than ‘hinder’ practice must also be a priority.

A document, even a care pathway document incorporating a good variance tracking mechanism, is unlikely to have any significant or lasting influence on behaviour, culture, attitudes or performance on its own. It is the cyclic process of planning, developing, implementing, reviewing and learning from/updating the care pathway that is key to achieving and sustaining continuous scrutiny and improvements in practice.

Things that we know from long experience increase the chances of success are listed in Box 1.

So what is being done nationally to support this shift from ‘collecting’ to ‘using’ information? The UK National Patient Safety Agency (NPSA) was recently criticized in the DOH Safety First report ² for delays in delivering its national reporting and learning system and for failing to make a local impact. In 2007, the NPSA is to refocus on collecting and analysing information in an attempt to increase the impact at the Trust level. The aim is to establish a timely, complete and accurate picture of the major safety problems faced by the NHS, to share best practice and to support NHS organizations and frontline staff to act on analysis. The Safety First report has been widely welcomed and, in particular, its emphasis on a ‘no blame’ culture, although I do note that the joint chief executives of the NPSA have been on ‘extended leave’ since August.

One initiative that may concern those interested in the stability and motivation of teams is the new draft NHS workforce plan, which advocates a new level of flexibility in the workforce, bringing in skills ‘as and when they are required to meet service standards and targets’. I will watch with interest to see how this will affect the generation and implementation of ideas for improvements.

What Did Sir Gerry Robinson Think?

Most of the poorer experiences of patients, service users and carers listed in Table 1 are not huge issues. Many of them could probably be tackled pretty quickly by teams locally without needing to spend much, if any, money. So how difficult would it be to make these small changes in the NHS?

In a recent UK TV documentary on BBC Two entitled Can Gerry Robinson Fix The NHS?, ³ management guru Sir Gerry Robinson (Figure 1) accepted the challenge to reduce waiting times in an acute NHS Trust in England within six months and with no additional funds at his disposal. The former Chairman of Granada and Allied Domecq admitted, ‘I had absolutely no idea what I was taking on. I knew it was going to be tough, but it was one of the most difficult challenges I have ever attempted’.

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Figure 1

Sir Gerry Robinson

He was quickly shocked and disheartened by the seemingly impossible task of ‘making anything happen’. He explained that he thinks that management is ‘about setting a scene in which people can do things, they feel they can do things, they feel they have the space to take a chance and actually get on with it’. He found, on the other hand, that in the NHS hospital it was clear that to get any change at all, to get people to think that they could actually do something now rather than waiting six months or maybe a year, sometimes two years to actually do something, was extraordinarily difficult.

His impression was that, in the UK, health service staff were very protected, so they could take their time, they did not have to change. It was all very casual and very, very different, and much, much slower than it would have been in even the worst-run commercial organizations. He believed that the hospital management structure did not allow things to be discussed quickly, the solution found and implemented. Proposals just literally went up each individual line of management, and this included a line for nursing, a line for individual specialties within the consultant body, a separate line for management, another for anaesthetists and so on. Anything at all that involved more than one discipline was pretty well guaranteed either not to happen or to happen very, very slowly.

Sir Robinson thinks that no matter what discipline or area you are looking at, the people who really know the answers are the ones who face the problems right down at the sharp end. He said of the hospital staff, ‘I don't think people on the shop-floor believed for a minute that it's worthwhile talking about any idea because it ain't going to happen. And that absolute sense of it doesn't really matter what you say and you can talk about it and go around the houses on it because actually nobody is going to do any of this stuff. That sense is a killer, because unless people feel that they can get that idea, they can be recognized for it, people can say well done, if they feel that that can't happen, they very quickly stop coming up with anything, and that's what's happened’.

Despite all the difficulties that he had encountered, at the end of six months Sir Robinson commented that he felt it had been the most rewarding project that he had ever undertaken. He summarized some of the things that he had learnt as follows:

What is heartening is that looking down this list, the activities and culture clearly reflect common care pathway methodology and practice.

Easy Answers?

Care pathways often herald changes. Perhaps the lessons that Sir Robinson learnt above hint at the reasons why care pathways are often reported to take as much as two years to develop and implement, and an even longer time for teams to start getting a measure of their success? So much energy is often put into resisting change. Where people are engaged, involved, enthused and excited about the very real possibilities of proposed changes, their energies diverted away from resistance and channelled into making things happen, the potential for improvement is huge. The health-care industry is teaming with individuals and teams capable of great things, and most of their energies in the current climate are dissipated with minor frustrations and the overwhelming pressures of the day-to-day grind.

Perhaps we should stop making such a meal of all the changes and, in Sir Gerry Robinson's words, ‘just get on with it'! Tackling the little things that take less resources and efforts to address may surprise us with quite significant shifts in behaviour and successes.

It is not just assessing and knowing about the risks and incidents in our organizations or of being aware of the problems that will make the difference, but acting upon that knowledge to change and improve things. In Box 2 I have suggested some of the things that we could do to ensure that health services continuously improve, that risks are actively and consistently reduced and managed, and that the morale of our people is boosted.

Our Own Part to Play

The greatest changes will result when each of us plays our part. If each one of us takes responsibility for our own attitude and behaviour, keeping an open mind to ideas, believing that things can and will happen for the better, making sure that it is not we who are resisting or sabotaging change, and bringing a positive attitude to the table, how much easier it will be to make things happen and to try things out.

Let us shift from a ‘committee’ culture to one where we still meet, but where the meetings are well attended because we all know that this is where the ideas will be raised, the issues debated, the decisions made and the effects of those changes monitored and discussed. To keep up the momentum, motivation, and sense of urgency and excitement, and also to prevent changes that do not work from having too devastating an effect, this cycle of idea, discussion and decision, test, review, try again/implement, celebrate needs to happen in rapid succession (Figure 2). Success will fuel the next move and we will quickly learn from things that do not work.

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Figure 2

In favour of a rapid turnaround

Let us also be clear about the information that it would be useful and interesting to collect in order to enhance the clinician's job and the patient's experience, as well as to support the reporting of targets.

What Data Would Really Provide an Effective Measure of Success?

With each and every member of the team, including service users, patients and carers giving their attention to safety and playing their part in the continuous, incremental improvment of services, the health service will continue to be an exciting, safe and rewarding place to work, and we will see a greater flourishing and spreading of all the good ideas that we know are already floating about in the system today.