Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
About the Author
Jono works for the South West Integrated Personalised Care team at NHS England and his role is to ensure that the voice of the patient is always placed at the centre of every decision. He wants to ensure that the human experience of healthcare is the best it can be, and works to ensure the team uses quality improvement methodologies and is focused on outcomes that ensures all interactions are delivered in a safe, reliable and effective way. To find out more about Jono. watch our Patient Safety Spotlight interview with him.
Questions & Answers
Hi Jono. Great to speak to you. Can you start by telling us how you became involved with the National Patient Safety Committee and your role there?
In NHS England we have a group of people across different roles and jobs that come under a title called ‘patient and public voice’. You can become a patient and public voice member at different levels ranging from somebody who attends an open public meeting all the way up to somebody who sits on a strategic board for NHS England.
It’s been six months since I’ve been involved with the national committees as I served the maximum four-year term as a patient and public voice member. Initially, I became a patient and public voice member on a committee that looked at the national reporting of patient safety incidents and patient safety alerts. When NHS England see issues coming up through the reporting systems and are deciding whether or not to put an alert out on a national level, they go to a wide-ranging committee of people who have specialist knowledge. On that committee are four members of the public, who are recruited specifically to give a public view to what those alerts should contain and whether an incident meets the criteria for public alerts.
Can you tell us more about these criteria and the decision-making process?
The old level for meeting a public alert or an alert to organisations was that something would be expected to cause severe harm to a patient within the next 12 months. There was a review of this three years ago because it was felt that there was an awful lot of time being given to responding to national patient safety alerts. Originally there were seven organisations that could publish national safety alerts. In the review, the committees came together to agree at a national level what a patient safety alert was, how it should be structured and what the reporting structures back should be for an alert. Following the review, the new definition for a patient safety alert was knowledge that disability or death within the next 12 months would occur if we did nothing. So, they raised the bar quite high for something to meet a national patient safety alert.
I was very happy for that to happen so that organisations could focus on those things that would cause most harm and not have to answer hundreds of these alerts each year. However, the difficulty I found with this new system was that there was nowhere for lesser harm but still significant harm to be reported or highlighted nationally. I felt we lost something and we didn't have a middle tier any more for things that could still cause significant harm but wouldn't cause disability or death.
And how were the patient safety alerts shared?
What was happening was incidents were being spotted through the NRLS and through other reporting systems. NHS England's senior patient safety group would take that data, look for things that were happening in multiple places and multiple times, that had significant issues around it; but it had to be issues that could be easily resolved if the right approach was taken to them. Then a national alert would be produced, put out to the systems and every organisation receives the alert nationally. They have to follow very clearly the instructions on the alert, including things like whether or not it needed to become public knowledge, or whether or not it should be an internal focus, and they would have to respond back to NHS England to say that they had completed it within the timeframe that was given. That timeframe was different, depending on the actions that were required.
My biggest concern at the committee was we frequently saw different information coming from trusts – some saying they'd completed all their actions within one day, which was impossible, and others not saying whether the tasks had been completed, and some not even responding. As we progressed there was much more focus on ensuring that trusts and organisation responded and asking regional teams to focus on areas where organisations were not responding to the alerts.
What involvement does the patient and public voice part of the Committee have and what makes it different from the role of the clinical and safety experts?
As a member of the public who is not clinically trained but who experiences healthcare on a regular basis, we have a different viewpoint to the same issues or situations. One thing that was very clear for me was that we were not there to represent the whole population because we cannot. The other thing that was really clear was we had to bring our own knowledge without ever bringing our own complaint or problem.
There has to be really clear guidance around what our activity is. We are there to look at things from the perspective of the public, from the perspective of patients – using our own internal knowledge or learning from lived experience – to make clear where we felt improvements could be made to both patient safety and quality, nationally.
Could you give an example of the type of issues that you and your colleagues would bring to the Committee that otherwise may have been missed?
Yes. If we go back to the very beginning of the pandemic you will recall there was a big issue around ventilators and getting enough ventilators into the hospitals – lots of people, lots of really highly qualified design companies, sorting out new styles, new types, of ventilators. One of the things that came to us to look at was on part of the ventilator system – where the tubing connects there is often a clip or a plug that is attached to the tubing so that you can add other elements or other gases to the tubing.
The tubing clips on a lot of ventilator kits were not attached and so two things were happening. It was either being removed to access the port that it held and then lost. And then, of course, you're having to replace the whole kit, take the patient off ventilation for a short period, put the patient back on, and change out a whole kit that causes risks and damages. Or the small clip or bow was actually being lost down the ventilation tube and causing possible choking hazards. So, a real simple fix suggested by the Committee was fully attaching the clip so that it couldn’t be lost or trapped. But that requires you, of course, to go back to all of the organisations and companies that are making that style of tubing, that style of kit, and to redesign it. It needs to go through a process of redesign and also a process of removing all the kits from the system in order to prevent similar harm happening again to a patient.
A patient safety alert was sent out to all organisations. In this instance, they did not remove the kits because of the numbers and also because of the the risk that by removing them it would have shortened the supply to such a degree that actually we may have caused more harm. Instead, what we pushed for was to make clear what the risk was to this particular tubing kit and ensure that all trusts were aware of the risk and to filter that down to all departments wherever that kit was used – theatres, ICUs, high dependency units – and to ensure that appropriate information and training was given so that the piece of kit was not dropped down into an airway tubing.
In the example you have just given, what was the unique insight that you and your colleagues had that might have been missed if you had not been there?
For us it was ensuring that patients were aware of all the risks when told about ventilation. It was about being open and honest with the public about risks that were there. However, with this particular safety concern, there was debate around how quickly it should be responded to. There was a belief from the clinicians that the number of incidents that had been reported was fairly small in comparison with the number of kits that were out there. They wanted a slower response rate than the public members at the table did. We didn’t agree with the timescale. We needed to prevent any harm and the slow response might allow another harm to happen. And so that was where our debate happened.
And did the Committee agree to go with the public members voice?
Yes, in the end, after quite a bit of going backwards and forwards, we did get to the agreement that a faster response was needed. The difference was that the faster response would be about training and enabling and making sure that people were aware of the issue rather than removing the kit. I myself wanted this to be the way of dealing with it. Another member of the public voice actually wanted the kit removed straight away, but, as I mentioned earlier, that wasn't clinically safer.
So yes, there is always a difference of opinion. But as with all boards, you come to an agreed position together, and you stick with that outside the room as well as inside. Those debates are quite hard but we bring our view, clinicians bring theirs and managers theirs, and a joint decision is made to progress a patient safety alert.
In our recent interview with Keith Conradi, he made the compelling argument that healthcare as an industry needs to have a safety management system in the way that other industries, such as aviation, do. Do you agree with this?
Yes. Although there has been opportunities, overall the NHS has not responded to the call for safety management governance and safety management systems in the same way as other organisations. Any highly technical safety culture needs both the appropriate governance and leadership, and knowing what that leadership line is, and the appropriate recording and monitoring systems so that organisations can be guaranteed to be doing the right thing with the information that they have.
We have to always acknowledge that patients’ safety is a bit like the Rumsfeld problem – that you only know what you know, and you might know some of the things you don't know, but what you don't know is what you don't know.
If you know something's unknown, you can go and investigate it. If you know something's known, you can deal with it. But those complete unknowns, for me, are where we fail to spot quick enough in the NHS. An honest and highly effective reporting system and a good governance structure is what will prevent major harms happening in future; by the right people sitting around the table looking at the evidence that is current and both responding to that evidence but also predicting what the likely unknowns are. And I think that's where we fail.
With LFPSE replacing the NRLS, NHS England are looking at using machine-learning tools and others to try and capture the the insights and learning from near misses. What are your thoughts on that?
That’s great, but my warning on all of these modern technologies, including AI, is they are not in place yet. In the interim we have to do our best as human beings to use the knowledge that we have. I believe there is a middle ground area that we are not covering and that will cause us issues. We’ll continue to see sadness’s, such as Ockenden and East Kent, because we're not viewing the whole picture. Why are we not learning from significant big incidents?
In Patient Safety Learning’s 'Mind the implementation gap', one of the four points we highlighted was on why we're not learning. If we're initiating enquiries and investigations but then not implementing the recommendations we're destined to repeat the failings of the past and the harm.
I completely agree. NHS organisations tend to pilot lots of projects, but don't learn from them and don’t establish them properly. We spend an awful lot of resource, time and money on new systems that seem to die very quickly.
Within patient safety, we still need to ensure that the new services for reporting safety work effectively for healthcare and, more, importantly, work effectively for the public and for patients. At the moment, this new reporting system is still not live. We're almost delegating some of the responsibilities away from trusts and organisations through programmes, such as Call for Concern. Although this is a brilliant way of telling a patient or family member that if they’ve got a concern about their safety or care, and the people around you are not listening, you can call a senior person come and talk to you. But we shouldn't need patients to do that, because on the floor people should be listening to the concerns of patients.
If we were to listen much more closely to families, to patients, to those experiencing care on a daily basis, and also listen much more carefully to those providing care at the ground level, we would have a much better safer system.
Why do you think the NHS are not learning from other organisations?
The NHS, in my opinion, has wrongly pushed back about patient safety governance and patient safety management systems. Senior people, particularly senior clinicians, are constantly saying the NHS isn't aviation or the NHS isn't nuclear because healthcare is always people focused. They have a point, but not a point that says therefore we shouldn't be doing this or we can’t do this as well.
We need to learn from other organisations. We need to learn from areas where they've got this right. Not perfect. We still know aviation has issues. But they are further down the line than we are. Simply saying the NHS is different because it deals with people is, in my eyes, a disgrace. Aviation deals with people, nuclear deals with people, we know that the majority of issues that go wrong in life are people focused. That's why we talk so much in safety about human factors. That's why we talk in safety so much about ensuring that we support our frontline colleague and our people.
We need to design systems that support people and make it easier for them to do the right thing. I often get push-back that systems and checklists are not for the NHS. They are, and in fact we've got good evidence from the World Health Organization’s surgical checklist that they work. But only when they're applied as they were intended to be applied.
The one thing that frustrates me in quality improvement is when I see people that have done one quality improvement course and then try to teach colleagues quality improvement badly, because that just trickles down the line of bad learning.
I see it often on our wards as a patient, when nurses come and perform treatments and I know how they were taught, I know what the clinical books say they should do and they simply don't do it because the person that taught them didn't teach them well.
If you're putting staff in unfamiliar circumstances, inviting them to work in areas where they haven't been properly trained or there isn't sufficient capacity to supervise them, you are putting them into error provoking environments. Do you think it's about recognising what those error provoking environments are and responding to them so that you're not waiting for harm to occur?
Absolutely. We do that in reverse every single day in the health service. A current term that I find frustrating when talking about the management of beds is ‘outlying a patient’. Outlying a patient means we're putting a patient deliberately in an area that is not their clinical speciality of need area. We've run out of spaces on the surgical ward because we've been putting all the medical patients there who we think are going home; nurses that are trained to be surgical nurses looking after medical patients can never be the right environment for either the nurse or the patient, and vice versa. The patient waiting for surgery comes in and has to be put on a medical ward or a care of the elderly ward where the staff have no idea what operation they're going for or what's going on. And this happens on a daily basis, nearly everywhere in the NHS.
How do we need to think differently in terms of a safety management system?
For me, I felt the committees didn't always have the right people on them. They did not reach out to industry or not beyond the committee themselves. Unfortunately, the other area where they didn't reach out well to, in my opinion, was to the voluntary and community sector. We have a lot of experience in keeping people safe in their own homes and, increasingly so, on the hospital at home schemes. So virtual wards, hospital at home, all of those are really important now with the voluntary and community sector.
It was very much a senior governance committee, a subcommittee of the NHS England board. I don’t think they had everybody at the table that should have been, but the problem is then how big a table does it become? Who are the core people that you would want? The people I was always surprised to see not represented was primary care. I was very surprised that we didn't have a GP representative on the national quality committee. There was a good blend of people, with regional directors and NHS England non-execs, who brought their own experience. And at the time I was there, Lord Darzi was a chair, and he brought knowledge and expertise from the surgical secondary care as well as from the parliamentary world. However, whilst I was there as a patient and public voice, there was nobody there from any of the harm groups who have campaigned significantly to prevent harm to patients. I think these groups of people need to be written into the governance so they can't be forgotten.