There have been 2 medical news stories recently, both of which highlight the importance of the human factor in where things can go wrong.
The first reported that the Parliamentary Health Service Ombudsman had used its powers for the first time to raise ‘serious concerns’ about University Hospitals Birmingham NHS Foundation Trust. The focus of the concerns was regarding the culture and leadership at the trust where staff had come forward with concerns both about poor patient care as well as the ‘toxic and Mafia-like culture’. An inquest has also been launched after a junior doctor who worked at the trust took her own life. A former consultant has said that ‘people are so afraid to speak up for fear of retribution that they don’t speak up’.
The second concerns the breast surgeon Ian Paterson, jailed for 17 counts of wounding people with intent after subjecting more than 1000 patients to unnecessary and damaging operations. Spire Healthcare, where Paterson practised privately, has found a further 1,500 former patients of Ian Paterson not identified in the original recalls and investigation who have been recalled to have their care reviewed. The Inquiry into the issues described primarily ‘poor behaviour and a culture of avoidance and denial’ that led Paterson’s behaviour and aberrant clinical practice being excused or even favoured.
Fundamentally, both of these are about dysfunctional and toxic work places, where employees are afraid to speak up for fear of retribution, harming their careers or just not believed or listened to. This can and has led to tragic consequences for not only patient safety but employee well-being.
Those old enough to remember will recall Sir Lancelot Spratt, the chief surgeon portrayed in the Doctor in the House series, lording over everyone and striking terror into those around him. The consultant as ‘god’ within his / her (usually his) realm was a stereotype and frequently a reality that persisted well into the 21st century. Perhaps it still does exist in places even today.
This phenomenon has been well recognised in aviation circles, being termed ‘captainitis’. This arose out of a plane crash near Washington National Airport in 1982. The flight recorder recorded an exchange between captain and copilot shortly before the crash with the copilot alerting the captain to an incorrect instrument reading. The Captain proceeds to say it is right and the copilot backed down, deferring to the captain. The plane crashed shortly afterwards killing the captain, co-pilot and 76 others.
The aviation industry has, since then, developed and implemented many additional safety procedures. One of these is the use of checklists, which has now been widely adopted within healthcare primarily for surgical operations.
Another is mandatory crew resource management (CRM) training, focusing on interpersonal communication, leadership and decision making in aircraft cockpits. Essentially, while retaining a command hierarchy, it is designed to foster a less-authoritarian cockpit culture in which copilots are encouraged to question captains if they see them making mistakes. This has now been extended to all including cabin crew. Essentially it is to develop team working and good communication to improve workplace safety.
CRM doesn’t seem to have been as developed within healthcare setting as widely as checklists. If the recent cases indicate, however, this type of communication and team work (‘flattened hierarchies’) as well as whistle blowing protection need to be embedded in training of all healthcare staff for the sake of patient safety.