Safeguarding Quality : A Professional Imperative Panel Discussion Sir Stephen Moss

1. Safeguarding Quality : A Professional Imperative Panel Discussion Sir Stephen Moss Prof. Jane Reid Ian Cumming OBE Panel Chair : AfPP President Tracy Coates

2. What happened ..some personal reflections

3. Question • Could there be another Mid Staffs ? • Answer • ?????????

4. 3 Key Messages • Variation • Assurance • Support of front line clinical teams

5. The Public Inquiry • The Process • The Timescales • The Impact Week 1 8/10/11 Week 37 1/12/11

6. Professional Priorities • Keep Mid Staffs on your radar • Recognise the human impact of all that you do/have capacity to influence • Avoid complacency like the plague

7. CULTURE

8. Columbia 1983 Challenger 1986

9. “ 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 …”

11. Robert Francis QC • If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten, when policies are being made and implemented.

12. Source NCB led Webinar 24/12/12 available at http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-news/

13. The Royal Cornwall Hospital warned to improve or face enforcement action by the Care Quality Commission (CQC) after its fifth surgical 'Never Event' within 18 month August 17, 2011 • CQC to investigate 'atypical' rise in never events 5 October, 2011 Nottingham University Hospitals Trust reports 11 never events since April 2009; eight recorded in six months. • Seventh so-called 'never event' recorded in Derriford since April last year. July 21, 2011 • CQC orders improvements at Great Western Hospitals FT 22 February, 2012 Wrong site surgery and wrong implant • Cambridge trust warned about surgical safety 17 July, 2012 Five never events in the theatre areas at Addenbrooke’s Hospital • Croydon warned on surgical safety and equipment shortages 1 August, 2012 Third Incident in weeks. Two wrong lens implants and a retained swab. Source : HSJ news search

14. Breaches of clinical governance • Focus on benchmarking vs organisational status. Failureto measure, observe trends, or triangulate data • Failure to listen, leading to professional apathy, isolation and compassion fatigue • ‘significant organisational drift’ ‘normalisation of the abnormal’ simply ‘the way things are around here’

15. Safety culture can be seen as: What people at all levels in an organisation do and say when their commitment to safety is not being scrutinised. Jim Reason

16. Human Factors? The study of the interrelationships between humans, the tools they use, and the environment in which in which they live and work.

17. HF impacts • Mental workload • Distractions • The physical environment • Physical Demands • Device / product design • Teamwork • Process design

18. HF Non-technical Skills Cognitive (mental) skills: • Decision making • Planning • Situation awareness • Triage/prioritization • Efficient management of multiple patients Social skills: • Team-working • Leadership • Communication • Effective coping with disruptions/distractions

19. Safeguarding Quality : A Professional Imperative For the sake of our patients we must learn ? Open Floor/Q&A