Whistleblowing Summit

Professor Jane Reid

Kohn 1999 Donaldson 2000

2001

2005-2009

2007

2011

• “where the offence is not to make a mistake, but to ignore an error or, even worse, to cover it up”

• where speaking up and challenge are seen as integral to safety and improvement within the organisation

• “patient safety above all else through a culture of high reliability”

Secretary of State for Health's speech - 'My ambition for patient-centred care‘8th June 2010

Columbia 1983Challenger 1986

“ The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture….

…Cultural traits and organizational practices detrimental to safety were allowed to develop and were normalised, including:

• reliance on past success as a substitute for sound engineering

• organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion …”

DH Human Factors Reference Group commissioned December 2010 by Sir Bruce Keogh

“enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings”.

Catchpole K (2012)

Clinical Human Factors

• Greater acceptance that to err is human

• HF and safety more commonly discussed

• Greater use of Team ResourceManagement and Notechs

• HF starting to be built in to early education

• Standardisation more widely appreciated

• Understanding the human is increasingly recognised as key to shifting the culture

• Some Trusts starting to employ HF specialists

• Examples of clinician led safety groups reporting directly to Board level

• GMC & NMC produced a joint statement of professional values recognising the essential role of “notechs”

BUT…………..

• HF viewed too narrowly as “teamwork”

• Equipment standardisation left to chance

• It’s still easy to blame the clinician not the system

But....• SUI’s “done to deadline”.....and then filed with no human factors insight

• Most processes still assume human perfection

• Professional leaders often reluctant to challenge clinicians and set standards

Lessons from Human Factors Research

• errors are common

• the causes of errors are known

• organisational culture determines the level of reporting and speaking up

• integrate systems and /triangulate data

Department of Health Human Factors Reference Group

Interim Report

1 March 2012

“...(We) need to integrate and mainstream human factors

knowledge and understanding in order to ensure consistent, sustainable delivery of safer care for our patients. Embedding this knowledge and understanding is not an optional extra. There is clear evidence from within and outside the NHS that human factors are a significant factor in disasters.”

Sir Stephen MossMid Stafforsdshire NHS Foundation Trust

“We can’t change the human condition, but we can change the conditions under which

humans work”

James Reason

Equip the Board and ‘frontline’

• Assertiveness• Communication • Conflict Resolution• Critical Language• Decision Making• Disclosure• Teamworking

• Leadership• Normalisation of

Deviance• Situational Awareness • Stress and Fatigue• Error Mitigation

(checklists/standardisation)

Improvement is dependent on• system wide enablers

• embedded organisational values

• clear thresholds and tolerances • committed consistent leadership at all levels

Whistleblowing Summit

Professor Jane Reid