Can Standard Operating Procedures work in healthcare?

I was recently was told of a posting in response to a previous blog of mine about learning from failure. The writer was Barbara Harris and here is some of what she said:

'Dear Martin, My husband died two years ago having lived for five weeks after a laryngectomy for throat cancer. He was placed back on the refurbished children’s ward within hours of surgery with no 48 hr stay in ITU or HDU, as per NICE guidelines, his bed alongside day cases, hot bedding two per bed per day, having their sinuses drained etc. No staff were appalled by this. He developed pneumonia and a fistula and each day the doctors round swept by his bed and waved as they passed. He eventually haemorrhaged after thrombylosis and it took five hours to get him to theatre. I had his case independently reviewed by an eminent surgeon in the field who found 9 instances of below standard care. I added another 9 for below standard nursing care.

I did not sue because had I done so they would have learned nothing and solicitors would have got rich. It has taken me two years to make the Trust separate day cases from major complex surgical cases. The Trust were more interested in their complaints process than in their clinical failures.

My husband was an ex RAF, passenger and night freight pilot. He could spot incompetence at 50 paces and he knew he was being treated badly. I did complain but was fobbed off by ward doctors. In the end the carotid and jugular artery ruptured, worn away by the salivary fistula.'

Barbara’s husband was unable to drink, eat or speak for five weeks after the surgery, and felt ignored by senior clinicians. In her posting she spoke of the various errors in care that lead to her husband’s death, and went on to highlight what she saw as the problem of ‘guidelines’. As she said, ‘they shouldn't be guidance: they should be standards and these should be rigorously applied. At the moment, no one is doing this’. 

I got in touch with Barbara and we had a very informative conversation. She has a story that needs to be told in full, and I hope one day she will. In the meantime, I’d like to reflect on standards, guidance, guidelines and ‘professional judgement’.

Barbara’s husband, Malcolm, grew up with Standard Operating Procedures (SOPs), as do virtually all professionals in safety critical industries. In Malcolm’s sad case, it was clear that certain NICE guidelines were ignored that were followed in another trust. Barbara couldn’t understand the logic of this.

I faced a similar, to me bizarre, scenario in my late wife’s case. The Royal College of Anaesthetists recommended (at the time) that managing ‘can’t intubate, can’t ventilate’ scenarios should be dictated by the development of local policy. Were they seriously suggesting that people are anatomically different in one part of the country from another?

Professionals often get riled at talk of SOPs; in some way it diminishes their sense of self worth and value: ‘How can you possibly distil all of my learning from the last 30 years into a checklist or procedure?!’; ‘I get paid to use my clinical judgement, not read from a book!’.

The same arguments have been heard in every safety critical industry; yet every one of them has come over to using rigorously applied standards of operation.

In aviation, SOPs are the distilled wisdom of professionals plus scientific evidence. They are broadly developed by the professional bodies, and then it’s up to each local frontline organisation to develop the details. One SOP is used for all normal situations, based on all the regulatory requirements.

A clinical example of this is the Safer Surgery Checklist which ensures that certain evidenced based behaviours and practices take place in every operation to maximise success. Unfortunately a lack of training has meant that this excellent tool is poorly applied. Care pathways are another attempt to standardise responses and improve patient outcomes, although I often wonder how well they’re understood and whether the whole pathway is subject to audit, not just the small parts.

If you end up in ‘abnormal’ or ‘emergency’ situations, then you move to the use of tools which again standardise responses based on evidence. An excellent example of this might be the work by Matt Inada-Kim’s sepsis response box, ensuring that everything the evidence base says should be done to prevent death from sepsis is done in a timely fashion, every time. The beauty of Matt’s work is that he’s made it easy and user friendly – he’s designed it around the real world pressures and hassles of a hospital.

In aviation SOPs make life much easier for frontline staff with one set of procedures which includes all guidelines. Of course it gets adapted, but the changes are easier to comply with because everyone already has the same mental framework. Compliance is monitored by training staff observing frontline staff in action, and feedback is provided. It’s an ongoing training programme, not a tick box exercise or a process designed to catch people out. The regulator (who signs off the SOPs but is more interested in how they are actually applied) also observes from time to time to ‘get a feel for what people really do’.

SOPs provide a starting point, allowing newbies to do things in a way that gives a greater chance of success when they don’t yet have years of experience to fall back on. It also gives the whole team a common framework which improves efficiency as everyone works from the same script. How easy would your job be if your boss was predictable?  How easy would your job be if all your colleagues did what was expected of them, every time?    

The benefits are just as great for experienced staff. You can walk into a situation and find that what needed doing has already been done; and most importantly it means you don’t have to worry about small details but can concentrate on the high level problems – your mental workload is reduced and you can think more clearly. 

Staff across the NHS have different levels of training. Staffing levels are organised and led in different ways and have different equipment and facilities available to them, so local adaptation of procedures and guidelines will be necessary.

I also recognise that healthcare is vastly more complex than other industries; but that can’t excuse large variations in practice and outcome. It won’t give comfort to Barbara. But given that so much of healthcare and the human condition is predictable, it’s really sad that historical and professional inertia continues to perpetuate cases of harm. Healthcare is the last safety critical industry to catch on to this.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.