Saturday, June 22, 2013

Cultural failure in the NHS and the CQC does not arise from the staff

I've been on airplanes a lot this weekend and therefore have had a chance to catch up on the international news that doesn't get covered in the US.  In particular, I'm trying to make sense of what's going on in the British health system.

First, I read in The i (a daily digest from The Independent):

Hospital inspections cannot be trusted, the head of the NHS watchdog admits.  David Prior, new chairman of the Care Quality Commission (CQC), made the stark admission after top officials at the health watchdog were revealed to have supressed a report highlighting failings at the Univeristy Hospital of Morecambe Bay NHS Trust.  More than 30 families are taking legal action against the hospital.

The Trust is being investigated by police over the deaths of eight mothers and babies.

Mr. Prior told his board: "We can have no confidence, I think, not just at Morecambe Bay but across many more hospitals, that we have done a proper job."  He also admitted to the BBC that the CQC was "not set up then, and we're not fully set up now, to investigate hospitals."

[Health Secretary Jeremy] Hunt told the Commons . . . "A culture in the NHS had been allowed to develop where defensiveness and secrecy were put ahead of patient safety and care."

The instant case includes the destruction of evidence, and The Daily Telegraph notes:

The NHS watchdog was last night accused of "broader and ongoing coverup" after refusing to name officials who ordered the destruction of evidence of its failure to prevent a maternity deaths scandal.

Jeremy Hunt . . . demanded that those responsible for the apparent cover-up ultimately be publicly identified, despite defending the CQC's decision not to name the individuals immediately.

The CQC claimed it could not disclose the identities of those who ordered the destruction of [the] report . . . due to data protection laws.

MPs derided the CQC excuse, saying it was in the public interest that individuals who destroyed evidenc be named.

Well, here we go again.  The body politic wants the blood of individuals, responding with an "off with their heads" approach. An editorial in the Telegraph jumps on this bandwagon, saying "Until individuals are held accountable for these appalling misdeeds, the culture will never change, however many structural reforms are undertaken."

While it is dangerous to judge from afar, I think this is the wrong focus, for it is clear that there are rampant systemic problems in the organization.  Look at this:

Dr. Heather Wood, who led the investigation which uncovered the Mid Staffordshire Hospital Trust scandal, in which up to 1,200 people died, accused the CQC of operating under a "culture of fear, which mimicked the very worst aspects of the NHS."

Such a culture does not arise over night.  While there might be short-term culpability among staff members, the people to blame are the senior leaders who have allowed their teams to develop practices and patterns of behavior that undermine the purposes and mission of the organization.

I recently wrote about a different kind of organizational failure, the highly publicized mistakes made by a division of the US Internal Revenue Service.  Referring back to an article I wrote in the Harvard Business Review, entitled "The Nut Island Effect," I explained one kind of dynamic that results in good teams going wrong. Whether the problems at the CQC parallel those of Nut Island or whether they reflect some other organizational failure, it is the senior leadership who should look in the mirror rather than asserting the exclusive guilt of others under their supervision.  Meanwhile, back at the NHS trusts themselves, questions still remain unanswered from their boards.


Mark Graban said...

There seems to be a culture around the NHS of setting targets (targets that might be beyond the capability of the systems) and then punishing people for not hitting the targets.

Whether it's reducing ED wait times or infection rates, this seems to be ineffective.

Hospital trust faces fines if it exceeds limits on the number of infections

The A&E departments have done all sorts of dysfunctional things to hit 4 hour length of stay targets -- cheating the numbers, admitting patients unnecessarily, etc.

I'm not surprised that fear and defensiveness would reign. That's sad and I'm not sure that really best serves patients.

Anonymous said...

Not too different from the hospital fines in CA. The real question is, how do you get people (and organizations) to do the right thing on their own? You'd think health care would be the one place where doing the right thing would come naturally, but it has been subverted into the 'business code' of behavior. I thought it was just in the profit-oriented US, but apparently not so.


Anonymous said...

I was one of the whistleblowers at the Mid Staffs Public Inquiry, having been an inspector with CQC and previous Healthcare Commission. I personally feel our problems came from (and reinforced by) the Board was led by a handful of people who seemed to see their main priority as protecting the Dept of Health from embarrassing media horror stories about hospitals. The Govt didn't want another Mid Staffs. And instead of funding hospitals/ensuring correct regulation, it was easier to supress bad stories. A large proportion of the senior mgt at CQC wrote to Bower and the Board back in 2010, politely outlining their (grave) concerns. Bower 'dealt with them' herself and rejected other Board member's attempts to engage mgrs. Kay Sheldon details this in her evidence to Inquiry. Good mgrs left. Mgrs who could deliver Bower's agenda were promoted. We ended up with a toxic mess. How good an organisation is depends on how good its leaders are, and what motivates them. Amanda Pollard.

Budd said...

Well, Paul, there is blame, and there is blame. Culture does its part, but the leaders protect themselves. There is little difference between corporations and the Mafia, and public officials do the same thing. Culturally in medical groups, this transformation of culture was described by Elliot Freidson in his Profession of Medicine book. Make larger groups and the clinicians start looking to their colleagues for their opinions and approbations, instead of to the patients. Government does this in spades. In politics, one academic description of the situation is that constituents are the enemy of the elected official, because it is they that the politician needs to cajole, etc., while he or she pursues his or her own goals.

Sometimes things come down from a culture at the top, Wall Street being a great example. Yes, find and prosecute the little guys (Fabulous Fab), but try to go after the Stephen Cohens as well. Root and branch as much as possible. In the end, the only way to break a culture is to make a new institution from scratch, or March through Georgia, and marching through Georgia ultimately doesn't work, either, as we have seen, if the same people replace themselves. So completely new institutions are often the best, when feasible. Thus my suspicions of ACO's. It's the same institutions with only slightly different rules. Put new people in charge, and maybe there would be change. But revolution has its own hazards.

On the other hand, there are instances when it is really the small people who do the damage. The Hubble Telescope fiasco is one of those instances. Yes, there were time and money pressures, but the culture and the top guys were really dedicated and effective. It was way, way down the organization that some technicians just "made something work" with a shim to a laser measurement that ultimately led to the horrible mistake. The guys at the top were really not to blame, they tested and they tested and you can't just do it infinitely.

It was this instance that made me think about your analysis of errors when the top nurse asked, "Did you do it on purpose?" Right, systems need to be in place. But you can't protect against rank stupidity, or against laziness of thinking, or in short, the fallibility of members of an organization. Sometimes it isn't at the top where the rot is found. So situations differ.

In this case of the NHS, in my mind, you need scalps. You need to find the people who contribute to this failed enterprise and make public examples of them and ruin their careers. Profumo suffered and made his life work at the end, and what did he do? Offend public morals. The people responsible for this governmental dereliction of duty should receive that treatment, public opprobrium. The reach should be all the way to the top, including the minister, if appropriate. Careers need to be ruined, at the very least.

Paul Levy said...

No black or white, as you suggest. The idea is to have a just culture in an organization through which such detemrinations are made fairly, openly, and consistently. Too often, there is not. That is especially true in public organizations, when legislators and the press call for someone's head. But, as you know, it is also often the case in hospitals, where the weak are blamed and punished for systemic problems and the strong go off scott free for bad bahavior and negligence. Real leaders take ownership of the organization's systemic problems and are "hard on the problems and soft on the people" where the problems are systemic in nature. They also enforce the rules fairly and impartially where someone does something intentionally.

Mark Graban said...

Spot on Paul -- this can't be emphasized enough, what you said:

"... the weak are blamed and punished for systemic problems and the strong go off scott free for bad bahavior and negligence. Real leaders take ownership of the organization's systemic problems and are "hard on the problems and soft on the people" where the problems are systemic in nature. They also enforce the rules fairly and impartially where someone does something intentionally."

In far too many cases, a front-line staff member (the "weak") gets fired or even thrown in jail for being involved in a systemic error. I don't recall a single instance where a C-level executive was either fired or resigned to take responsibility for what happened.

We all need to be working incredibly hard to proactively prevent the next horrible medical mistake from happening -- and that includes senior leaders setting the tone and creating an environment for quality.

As Dr. W. Edwards Deming said, quality starts in the board room.

AK2351 said...

There is a wonderful article, by Malcom Gladwell, entitled “Blowup” that I find to be incredibly relevant to this post, and the many more that have come before it, regarding ‘organizational failure’ and the role culture can play in its realization. The article uses the Challenger Explosion as a starting point, and Gladwell goes on to highlight the role NASA's internal culture played in the disaster. In the third section of the article, he cites a report, “The Challenger Launch Decision,” written by a sociologist, Dianne Vaughn. He writes, “What NASA had created was a closed culture that, in her words, "normalized deviance" so that to the outside world decisions that were obviously questionable were seen by NASA's management as prudent and reasonable.” Shortly thereafter, Gladwell goes on to quote Vaughn’s report, “"But the cultural understandings, rules, procedures, and norms that always had worked in the past did not work this time. It was not amorally calculating managers violating rules that were responsible for the tragedy. It was conformity." It seems quite obvious, as others have mentioned, that the NHS and CQC should examine the culture they have created.

Paul Levy said...

Thanks very much.

David Wogel said...

Culture can only be changed by having leaders with vision who engage the staff. Also there seems to be little in the way of effective performance reviews. It is essential in any large professional organisation to weed out the poor performers and ask them to leave. This is what management and leadership is about. Also regular professional competency testing is required, similar to the airline industry, and whistle blowers bust be allowed to express there concerns, and have them investigated without risk of retribution.
Lets start putting the patient first,