I wrote part 1 and part 2 of this blog as a small group of people were struggling with the question, ‘how do we close the gap in patient safety?’ Let me explain what I mean by ‘the gap’...

Other safety critical industries have suffered disasters in the 20th century, and as a result have learnt and made significant improvements in safety. It doesn’t really matter which data or which industry you choose to look at, the evidence of improvement is generally overwhelming.

Yet the concept of ‘disasters’ in health care has seemed strange to some. Is the death of one person, such as my late wife, a disaster worthy of national and professional learning in the same way that perhaps a train crash killing many people is?

If there was any doubt, the disasters of Mid Staffs, Morecombe Bay and so on will hopefully have changed professionals’ minds. Of course the data about unacceptable harm across health care was always there (which is ironic really, given that I was always told about the importance of evidence-based medicine). But, with the exception of a few brave leaders, the evidence only came into focus for the many when stories of multiple sufferers made the headlines.

Having struggled with the question of how we close the gap, in July Helen Hughes and I went to meet a number of people. First stop was David Behan and David Prior, Chief Executive and Chair of the Care Quality Commission (CQC). The reception I received was completely different to the sort of reception I’ve often received elsewhere in health care in the last nine years. Both Davids were thinking along different lines; not like the old NHS – an institution which is doing its best – but as if they were regulating a safety critical industry (which of course they are!)

There was a clear commitment from both of them to learn from the past, and to continue to embed human factors understanding and best practice, both in the work of the CQC and in future strategies with those who deliver health care. The problems they face are huge, and they both were very candid about their own internal struggles to bring the culture of the CQC into the right place.

Remember, situational awareness is everything, and so I left the meeting feeling more positive than I imagined I would.

Later in July we met Professor Sir Bruce Keogh, followed immediately by Simon Stevens, the new Chief Executive of the NHS. I think we all spoke openly – it was both nice to be listened to and nice to be challenged. I emphasised my belief that commissioning should include commissioning for safety and there was broad agreement that this should be the case. How it should be enacted is more complex however, and Simon left me, my colleagues in the Clinical Human Factors Group, and you dear reader, with a particular challenge: ‘How do we encourage human factors and safety best practice through commissioning, using levers that are reasonably simple?’

Between myself and Helen, we made sure that the many ideas and thoughts of clinicians who are actively applying good human factors practice in their workplace shaped our conversations at these key meetings. And with the support of an amazing team we pulled these thoughts into a report which we left with Simon, Bruce, David and David: First Do No Harm: Closing the gap in patient safety.

The report identifies how we can move forward using human factors to underpin learning from disasters, driving improvements and developing systems and policy to make it easy to do the right things. It identifies some key ideas:

  • Keep building on the National Quality Board Concordat as some organsiations, such as the CQC and HEE, are doing
  • The centre to provide vision and direction for efforts, through words and levers
  • Investigations to be done with consistency and rigour
  • Use expertise from outside the system, such as ergonomists and system experts from other industries
  • Set up a resource centre and knowledge network to support the above actions (but the above actions can go ahead without this)

What happens from here on is anyone’s guess. But I can assure you that, as I’ve referred to in the past, once you open the Pandora’s box that is human factors to frontline professionals, they will make things happen and improve.

The question for you is, do you want those improvements to happen soon and achieve savings of lives and money, or do you want those improvements to happen in a haphazard way, with little sharing of learning and take a long time?

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, www.twitter.com/MartinBromiley.

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