“Making improvements to patient safety comes second place to sorting out problems with the investigative process”
A director of nursing of a large teaching trust told me this late last year. The CCG and her own governance team were weighed down with questions about the quality of internal investigations and matters of deadline breaches. No one had much energy left for carrying out improvements to patient safety.
I suspect most NHS and independent healthcare organisations would say the same about the investigative work they are required to carry out. It’s a bureaucratic treadmill with limited returns. Moderate and severe harm patient safety incidents may be investigated but to what end?
Eighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? There are several explanations. Firstly, investigating a patient safety incident can be a complex task. And for frontline healthcare staff it is carried out on top of the day job. Second, training is in short supply and not standardised. In fact, quite a few investigators haven’t had any training at all but are thrown in the deep end, nonetheless. Third, the investigative tools are desperately inadequate – terms of reference and a Word template, if you are lucky. The investigator then must navigate their way to the completion of a written report. Fourth, the outcome often gets caught up in lengthy discussions about process involving trusts and their commissioners.
There is also a great deal at stake for the investigator(s). Patients, families and their lawyers want answers; coroners and other agencies want to know the outcome. Some incidents attract considerable media and political interest. Organisations have told me that the task of investigating is now so unattractive it is difficult to get frontline staff to volunteer to do it. Yet investigating patient safety incidents and ‘near misses’ is a key task if we are to improve safety of care and services. The challenge for healthcare to be a safer, high reliability service is the one confronting us now and over the next couple of decades. How can this complex problem be addressed? In my view there are three strands to the solution:
1) A consistent way of investigating
2) Aggregating data
3) Using technology – virtual worker robots – to get insights and information back to the bedside
Let me say a little more about each of the ideas.
Consistent way of investigating
Currently there is no single way to investigate patient safety incidents in healthcare. There is also no consistent use of the analytical tools that are available say, for example, in the NPSA root cause analysis toolkit. Classroom-based teaching has been the way we have tried to impart the skills and knowledge to frontline staff. However, a one-day session probably isn’t enough to learn how to investigate. Comparatively, aviation air accident investigators get a six-week training course at Cranfield. Even if someone in healthcare picks up the skills, they often don’t get the opportunity to apply them quickly enough or regularly enough. By the time they do, much of what they learnt has been forgotten.
The answer therefore lies in technology. By incorporating the investigative process into an intelligent application built on world-class technology it is possible to standardise the investigative process, embed the analytical tools to ensure that they are used correctly. The investigator can upload documents and relate findings and conclusions to the underlying evidence. The application prompts them to do the investigation in a consistent fashion and guides them when needed. Supported by an online training programme, the technology gives the novice investigator a fighting chance of doing a decent job and enhances the work of an experienced investigator. Additionally, investigating using technology allows a governance team to peer review an investigation while it is underway and offer guidance and direction to an inexperienced investigator. Technology can also allow patients, families and carers to play a part in the investigation right from the start. We all know that having them involved from the start is vital if they are to have confidence in the outcome. They usually have vital information too.
Aggregating data
Healthcare is awash with data. And since we have been investigating incidents for many years there is a lot of data about patient safety. However, it is difficult to get at. Even if we could, it would be hard to make much sense of it. A director of quality governance told me recently that the multiple incidents involving naso-gastric tubes in her hospitals had only come to light when a clinician had sat down and combed through a pile of incident reports. So much for identifying harm rapidly and putting in place solutions. However, if we have a single way of investigating using technology then we can gather and analyse data in a systematic fashion. If healthcare organisations start to pool data from their investigations, then the opportunity for gaining deep insights into patient safety grows. We may start to learn what the real risks are to patients being fed via a naso-gastric tube. This could, for example, prompt discussions with manufacturers and changes in clinical practice.
Insights and information
There is of course a danger that the aggregated data could simply sit there unused. However, big technology companies have the means to ensure that this doesn’t happen. Colleagues and I are in discussions with a Microsoft partner about using virtual worker robots – they don’t look anything like R2D2 – to extract insights from large volumes of data and deliver these to where they would be most useful. Imagine a system in a hospital where the virtual worker robot delivers a safety message to the nursing team managing a patient with a naso-gastric tube, or to the orthopaedic surgical team who are about to embark on the afternoon list. This way we could start to make much more meaningful use of data gleaned from patient safety investigations.
Conclusion
Donald Rumsfeld, secretary of defence in the US government at the time of the Iraq war, said ‘stuff happens’. His controversial reference to post-conflict looting in Baghdad applies equally to healthcare. The NHS sees 1 million patients every 36 hours. It is a high volume, high risk, complex business. Things can and do go wrong. When ‘stuff happens’ in healthcare we need to find out the answers to what, why, how and when as promptly as we can. And then focus on fixing the systems and processes that almost always explain sub-optimal performance. Our current approach to investigating is, frankly, not fit for purpose. Technology is the answer and the arrival of Eva provides a much-needed solution. Eva is our new intelligent investigation application – built with our tech partner Microsoft.
I have worked in healthcare since 1982 – caring for patients as a nurse, managing in a health authority and working in the NHS Executive and National Audit Office. I have worked at Verita for seventeen years and have been involved in hundreds of investigations – including Savile for secretary of state for health and the death of ninety patients at an NHS trust. That experience has taught me this: investigating is important but fixing things is more so. Let’s expend more of our effort in the coming years on making care and services safer for patients and clients. That way healthcare has a real chance of becoming the high reliability service it should be.
