Sunday, January 27, 2013

Have things changed? Would you force them to?

I want to provide a description of a hospital and ask you whether it might apply to a place in which you work.  Later, I'll tell you the source, and I will also present some questions to you.  I hope you will submit your answers as comments.

A clinician-management divide; an excessively devolved system of management; an oral culture; a commitment to turning questions back on the questioner. A concentration of power combined with a fragmentation of responsibility. This militated against the provision of an adequate standard of care. Early warning signals of problems were less likely to be picked up if the care provided by some unit of the organisation were to become less than adequate.

The clinical directorates became isolated from each other. The development of `silos', channelling activities into separate and distinct compartments which did not effectively communicate with each other.

Clinicians taking up managerial duties lacked the training, experience and time to recognise and respond to problems which might exist in their area of responsibility. They were not equipped to identify the need to develop lines of communication nor how to introduce good managerial practices. It was not recognised by senior management that they should be given the opportunity to acquire the necessary managerial skills.

The lack of managerial expertise at the level of clinical director and, as important, the lack of training to acquire expertise, led to a further problem: the failure to develop effective teamwork within directorates.

The consultants, particularly the surgeons, saw themselves as having very effective teams. But they saw these as their teams, which they led. They were not part of the team, other than as leaders. Also, the teams were teams of `like professionals': consultant surgeon leading surgeons, consultant anaesthetist leading anaesthetists. The teams were not organised primarily around the care of the patient, they were not cross-specialty nor multidisciplinary, and they were profoundly hierarchical.

The source of this description was the Kennedy Report, investigating the death of several pediatric cardiac surgery patients at Bristol Royal Infirmary in the 1990s.  The report prompted an examination by the NHS of many aspects of its procedures.  The Guardian reported at the time:

A radical blueprint for a patient-driven health service independent in crucial respects from the government of the day was delivered yesterday by the Kennedy inquiry into the deaths of babies undergoing heart surgery at the Bristol Royal Infirmary. 

The vast and long-awaited report lifts the lid on the arrogance, ambition and "muddling through" at the hospital in the early 1990s where "too much power was in too few hands" and a "club culture" existed which shut out young doctors like the anaesthetist Stephen Bolsin, who tried to raise concerns about the death rates. 

Here are my questions for you.  As you work in your hospital, do you see any of the symptoms that were evident at BRI?  Do you feel comfortable calling out those problems?  What happens when you do?

As noted, the hero of this story was Stephen Bolsin, but he felt compelled to leave the UK and practice in Australia by the time it was all over.  He tells his side here.  Excerpts:

The contrast in attitudes to whistleblowing between the BRI and the Geelong hospital could not have been greater. I decided to inform the interview panel in Geelong of my reasons for leaving a UK teaching hospital for a regional hospital in Victoria. I briefly explained everything, including the difficulties I had encountered, before any questions had been asked. The response of Patricia Heath, the Chair of the Hospital Board almost reduced me to tears. “What you have told us sound like excellent qualifications for the position we have advertised Dr Bolsin.” This response in 1995 amazed me and was the first positive affirmation of my actions from a senior healthcare manager.

Leaving the UK with my wife and family was an incredibly sad and disappointing time but I am sure now that there could never have been ‘Clinical Governance’ or a change in medical attitudes while I remained in the UK. Only when I had a contract in a new hospital, in a new country did I feel secure enough to report the mortality rate in the Bristol paediatric cardiac surgery unit to the GMC.

Another question for you: Would you leave your job if you felt that the attitude of the clinical and administrative leadership was jeopardizing the care of patients?

Luckily, it eventually worked out well enough for Bolsin:

I have developed my career in Anaesthesia, Patient Safety and Medical Ethics with numerous publications and chapters in textbooks. In Geelong I led a team that successfully allowed junior doctors to measure their competence in medicine as part of an ongoing, lifelong commitment to assessing quality in healthcare. The same group also published the world’s highest incident reporting rate in medicine using the same mobile computers in a supportive environment.


Brian Jarman said...

From Twitter:

Paul, as a member of the Bristol Inquiry panel, I am not convinced that the situation we found has improved.

Dermot O'Riordan said...

From Twitter:

Think they are a BIT better than they were. Big question is how things are after #Francis report

Sally Davies ‏ said...

From Twitter:

We thought: lots of changes with training, governance. Still silos. Lack of learning across organisation.

Mark Newbold ‏ said...

From Twitter:

I agree. Better but patchy and most of us, sadly, would recognise what is described today.

Bruce Ramshaw said...

I am familiar with this because I raised issues about these types of structural problems at two hospitals and had to quit my job both times. One was as a tenured Professor and Chief of General Surgery at the University of Missouri.
I believe we need to apply principles learned from research in disruptive innovation and complexity science. In an attempt to do this we have started own own organization that is accountable to provide care for and with definable patient groups, starting with hernia disease.