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Who at the very top is responsible for patient safety?

Martin Bromiley
Martin Bromiley
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At the NHS Confederation Conference Sir David Nicholson, Chief Executive of the NHS, released his outline of the new NHS Commissioning Board (see 'Developing the NHS Commissioning Board'). It’s a 28 page document which by its own admission isn’t meant to be the finished article but an outline of how Sir David sees the development of the Board, its role and outline structure. But more importantly, in his own words the document sets out to ‘concentrate on culture, style and leadership’. I read through all 28 pages, took some time off then re-read it again. It is a document in my own style, laying open thoughts and ideas before they’re concrete.

Sir David also makes clear that the role of the centre will be to support local groups, not micro manage or dominate, and he talks about alignment and cross boundary working. In fact the whole style being put forward is one of matrix management, people being able to use the right resources and teams at the right time. However, human factors science tells us it’s really hard to shake off traditional hierarchies and ways of working, both at a micro and macro level. In fact people at the micro level look to the macro level for leadership by example.

So what does this mean for patient safety? The NHS outcomes framework already makes it clear that one of the five domains for improvement is safety, to quote ‘treating and caring for people in a safe environment and protecting them from avoidable harm’. Sir David outlines the structure for the Commissioning Board and describes how the professional leads for improving outcomes on mortality, long-term conditions and acute episodes will report to the Medical Director. The leads for improving patient safety and patient experience would report to the Nursing Director.

So, what was your gut reaction to the proposed division of labour? Pleased that a Nursing Director will have significant influence on a critical issue, or concern that traditional hierarchies and values will get in the way, and that safety will be marginalised or seen purely as a nursing issue?

Human factors tells us a lot about hierarchy and its role in the fine line between safety and disaster. If we look at the previous arrangements, I was surprised to learn that there was a Chief Nursing Officer when I first got involved in healthcare. We’re all familiar with the role of Chief Medical Officer, which Sir Liam made his own. I assumed when I attended a Patient Safety Forum meeting at the DH in 2009 at which the CEO, Medical Director and CMO were normally in attendance that the CNO would be there – ‘she’s not invited’ someone told me! And at a local level I have become all too familiar with the massive ‘authority gradient’ between medical and nursing staff on the shop floor – it was one of the factors that meant my late wife’s emergency ended up with her being dead. She wasn’t ‘protected from avoidable harm’.  

I firmly believe that the current Medical Director, Sir Bruce Keogh, and Sir David himself are well aware of the hierarchical problems in healthcare. I also know for a fact that Sir Bruce recognises that this is a problem in human factors terms which the medics must solve. (If I can be blunt for a moment to all you medics out there: ‘there are plenty of times when nurses know more than doctors').

But however clear the CEO’s words are on matrix management, the reality is that people will view the responsibility of patient safety shifting to the Nursing Director at a national level as being a marker, an indication that safety is not the first priority and can be delegated. I know the Medical Director’s responsibilities for clinical outcomes clearly include patient safety, but for once we need to be blunt and unequivocal if we are to send the right message, all the way from the top to the bottom.

I have two messages to end on. The holders of responsibility should be the people who have the most power to influence the outcome. So first, please make patient safety a joint responsibility of the Medical and Nursing Directors – the overall strategy should be coordinated and discussed between them, individual projects could be shared or delegated as appropriate, but this is a joint problem that needs joint working and joint solutions.

And secondly, I’m so impressed with the many nursing staff I work with on a regular basis, but at a national level the nursing profession of today has sometimes failed to stand up and be counted. Sir David talks about and demonstrates leadership by setting out his vision. His appointments (due soon) of a new CNO and a Director of Safety are also an opportunity to demonstrate leadership; by appointing strong leaders. The new CNO needs to inspire and encourage nursing organisations to lead the medical professions into areas that need attention. The CNO shouldn’t wait to be invited.

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





 
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Comments
Martin - Interesting blog. Must say that when I read the document the assigning of patient safety to the ND struck me as a bit odd and I couldn't agree more that it needs an integrated approach. That said, it is a work in progress and presumably Sir David is still firming up the details.
I am an aerospace engineer by background/training and to be honest the question "Who at the very top is responsible for patient safety" worries me a little. Ok you've made some good points here, but I worry that the patient safety responsibility in health care is always someone else - usually somone senior. If you ask an aerospace fitter who at the top is responsible for safety he will laugh at you - because he realises that safety is pervasive and he has direct responsibility for ensuring he uses the correct bolts at the correct torque - or someone dies. When the NHS "gets this" culturally and stops pointing at "managers", "senior clinicians" and "suppliers" - looks inwards and accepts "I am responsible for patient safety" - then we've won.

As a general aside, look in the Localisation papers from the Do0H back last year and search on "safety" - you find one or two bland references but aside from that no mention of how, responsibility etc. Neither have any subsequent policy papers covered this.
Ian makes a very valid point. The NHS has spawned a huge patient safety and clinical governance industry, thereby implying (a) you have to be a specialist to 'do' clinical governance and (b) by extension, it's distinct from the day job. Too often the focus seems to be on keeping the CQC off your back, or firefighting the latest media exposee.

Patient safety is truly 'everybody's business'.
Very thorough and well researched article, which I read with interest. Patient safety is of paramount importance of course in all healthcare facilities such as hospitals and nursing homes and there is obviously much that needs to be done in order to bring patient safety to a level that everyone can be happy with.

In terms of accident response on hospital wards and in care homes, nurse call systems are one of the most instrumental pieces of apparatus for healthcare facilities to install on their premises as these will make sure that there is a speedy response should a patient be in any pain, discomfort or distress. I'm not an expert on <a href="http://www.nursecallsystems.co.uk/wireless-nurse-call-systems/">nurse call systems</a> by any means but a company called Courtney-Thorne are described as the UK's leading supplier of this type of technology and I hope that more hospitals and nursing homes begin implementing this form of safety apparatus to help enhance the overall safety of patients.

http://www.nursecallsystems.co.uk/
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