NSW Health Service
A good inquiry can accelerate improvements that otherwise would take years to make. I am all for them. But I question the utility of the special commission of inquiry into NSW health services. Since 2003 there have been three major inquiries into health services: Camden and Campbelltown hospitals, Canberra Hospital and Perth’s King Edward Memorial Hospital. All were found to have serious workforce problems (low morale, poor communication systems, poor compliance with institutional protocols, inadequate leadership from senior clinicians and more). Has anything changed? Our workforce is well trained; our hospitals in the main well-equipped, and our managers knowledgeable. So why do we, like many other countries, have an unacceptably high number of errors in the system? Public trust requires three things: a health system capable of delivering safe and quality health care; health professionals who meet their professional obligations; and a system of accountability that is robust and transparent.
In health care we are not used to examining deeper issues such as whether a culture of safety exists. We are root bound in the blame game, making the culture of safety harder to build. Pivotal to blame is the belief that punitive action sends a strong message to others, that errors are unacceptable and that those who make them will be punished. We think that because doctors and nurses are trained they should know better. Our own sense of personal responsibility plays a role in the search for the guilty party. Expressions such as “the buck stops here” or “carrying the can” are widely used. I am not advocating a blame-free culture. When I was the health care complaints commissioner it was evident that systems problems usually accompanied breaches of professional responsibility (weak regulations, reporting requirements or inadequate training).
If we are to reduce the harm caused by health care we need to move from a blame culture to a culture of safety; one sadly absent in most health-care services. A culture of safety recognises the problems caused by increasing specialisation. It minimises the communication difficulties among the different specialists by providing safeguards. Staff are trained to work together in multidisciplinary teams because we know that when they talk to each other patients have better outcomes. Relying on we patients to relay information backwards and forwards is unsafe; we are sick or have inaccurate memories or are poor historians. A culture of safety does not pressure hospitals to reduce costs by seeing more people in less time because we know this creates disharmony, increases workloads, leads to inadequate staff cover for the number of sick patients, allows the premature discharges for sick patients and delays surgery for many. Each of these is a known factor in patient adverse events.
A culture of safety exists when everyone knows and talks about patient safety; when senior doctors and nurses are open about errors and involved in managing risk; when silos no longer exist. Doctors and nurses working in the same hospital often see their work as totally separate from the work of others. Teamwork is a well recognised activity associated with decreased adverse events, yet multidisciplinary training is sporadic. Doctors will name other doctors as team members but only when reminded will they name others such as nurses and allied health professionals. Rarely is the patient thought of as part of the team. Patient safety education is a new area, just beginning to penetrate health professional education programs. The community too needs education about the complexity of health care and the potential for errors. The extent that we patients have a role in our own safety is under- researched. But there is plenty of evidence to say that the more engaged we are as patients in our own health care the better outcomes we will have.
By: Merrilyn Walton, Associate Professor of Medical Education, Centre for Innovation in Professional Health Education and Research, The University of Sydney, SMH, Forget the blame game we need a culture of safety, 19/02/08
