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The NHS Consultant, the Airbus 380, the Whistleblower….the opportunity.

In September 2014 David A Evans JP and Wendy Addison submitted an article called The NHS Consultant, the Airbus 380, the Whistleblower….the opportunity to the independent review on Whistleblowing in the NHS chaired by Sir Robert Francis QC.  This article should be essential reading for all staff in the NHS as it considers the approach taken by the NHS to Whistleblowing, and explores how the NHS can learn from the aviation industry about how to operate a true safety based culture.  

 

The NHS Consultant, the Airbus 380, the Whistleblower….the opportunity.

This article is co-written by David A Evans JP and Wendy Addison.

 

About the authors.

Wendy Addison founded and runs Speakout Speakup, an organisation based in London which supports individuals who would like to speak out, and organisations who want to create a culture and climate of voice thereby avoiding a whistleblower entering the scene. Wendy was South Africa’s most prominent whistleblower and successfully fought and won a heroic 11 year battle for justice. 

David A Evans JP is the Managing Director of D A Evans Ltd., specialising in resolving people and relationship issues in business. He is a former Managing Director in Accenture, and is an experienced Global Executive, Mediator, Magistrate, Diversity Lead, and Advisory Board member.

 

"In a democracy dissent is an act of faith. Like medicine, the test of its value is not in its taste, but in its effects.”

J. William Fulbright, U.S. politician (1905 - 1995).


 

 

Executive Summary

This article considers the approach taken by the UK National Health Service (NHS) to Whistleblowing, and explores how the NHS can learn from the aviation industry about how to operate a true safety based culture.  We contrast the approach operated by the airline industry to that of the NHS in relation to the treatment of staff who raise concerns, and the general approach taken to safety. In both industries, safety – in the case of the airline industry, staff and passenger safety, and in the case of the NHS, staff and patient safety – should be central and paramount in management and leadership thinking.  Continuing horror stories about the treatment of Whistleblowers in the NHS suggests otherwise.  One of the latest NHS Whistleblower cases - that of Dr Mattu - will cost the NHS £17 – 20 million.  We contrast the approach of the NHS in dealing with one of its most valuable assets (a hospital consultant) with that of an airline dealing with one of its most valuable assets (an A380 aircraft).

The NHS could turn on its head the current approach of marginalising and attacking Whistleblowers by adopting the approach operated in the aviation industry, where safety is at the heart of all activity. We set out how the NHS can learn from the aviation industry.  In particular we acknowledge the thinking of Michael Ferguson and Sean Nelson in their 2013 book Aviation Safety: A Balanced Industry Approach.     Ferguson and Nelson set out how the aviation industry needs to build on an existing safety culture within today’s heavily regulated aviation environment. As we discussed Ferguson and Nelson’s proposition we were struck at multiple points by both the similarity of characteristics between the aviation industry and the NHS, and the contrast in how they lead and manage on safety.  In essence Ferguson and Nelson set out their proposition that “a strong organisational culture should foster the development of a strong ethical culture, of which a strong safety culture is a key element, and that this strong safety culture should be the foundation of an organisation’s business culture,” and further that “a strong effective safety culture is the result of wilful, intentional decisions, actions, training, and policies specifically designed to create an internal culture where safety is among the foremost of a company’s priorities.”

It is clear however that in the case of the NHS the need for the positive application of wilful, intentional decisions did not apply in the approach taken by NHS management in the whistleblowing case of Dr Mutta. Essentially, for safety to operate in the true interests of patients in the NHS the current culture and leadership approach needs to be turned on its head, through the adoption of a Leadership led patient safety culture at the heart of all NHS activity.

We recognise that the NHS faces several major challenges in changing the way it operates in order to put patient safety first: Professor Roger Steare differentiates between the corporate application of the ethic of care in Britain’s NHS and the individual ethic of care operated by individual healthcare professionals; the research outcome  outlined by  Professor Dan Airely which suggests that human beings have become proficient at rationalisation as a way to make sense of the rules and regulations imposed upon them; the  importance of the culture and operating climate on the ground in the NHS; and the additional issues of the NHS arguably being less  motivated to avoid the commercial loss which results from reputational damage - patients in the NHS have limited opportunity to go elsewhere for treatment, so the NHS is largely immune from the advantages of competition, and doctors deal with the worst case scenario of a client dying every day, so in theory what’s the big deal? 

We set out what this patient safety culture, based on an aviation type safety culture, would look like in the NHS, starting with strong leadership sponsorship and behaviour. Leadership would support the implementation of a Safety Management System which would foster continuous improvement in safety through active reporting and analysis of safety information, and a gradual migration from non or purely reactive management, through proactive management and into predictive management of risks to patient safety.

The eight components of safety management set out by Ferguson and Nelson for the aviation industry could be applied directly into NHS hospitals and Commissioning Groups:

1. Commitment of Senior Leadership to Safety Management, 2. Effective and Consistent Reporting of Safety Issues, 3. Continual Monitoring, 4. Investigation of Accidents and Other Events, 5. Sharing Safety Lessons Learned and Best Practices, 6. Provision of Safety Training for Operational Personnel, 7. Effective Implementation of Standard Operating Procedures, 8. Continuous Improvement of the Overall Level of Safety

We see an overwhelming series of wins for NHS management, Consultants, Doctors, Nurses, other staff, and most of all patients from implementing a true patient safety culture. The benefits would be quantitative and qualitative – driving both safety and efficiency in the NHS.  We do not see any downsides.

Commitment of Senior Leadership to Safety Management

·       Patient Safety management would be at the heart of all planning and operational activity

·       A defensive and closed approach would be replaced with an open and transparent approach. 

Effective and Consistent Reporting of Safety Issues / Continual Monitoring / Investigation of Accidents and Other Events

·       Complaints against staff would be actively investigated and resolved as soon as possible.  Staff would be placed on paid suspension only if absolutely necessary, and for the shortest time possible.  The NHS would invest in patient safety investigations through the deployment of dedicated investigators of complaints to ensure rapid resolution of issues, and Mediators to settle patient complaints and legal claims within the shortest possible timeframe

·       All events and issues would be investigated to identify corrective actions (rather than allocate blame)

Sharing Safety Lessons Learned and Best Practices

·       Complaints from patients and staff would be encouraged, and the resulting action fed back to the Complainant

·       Embarrassment over failure and exposure would remain but would be reduced, and positively managed in an environment where complaints would be actively managed

Provision of Safety Training for Operational Personnel

·       all staff would be trained on safety monitoring, reporting, investigation processes, and the procedure to raise concerns – and on the benefits

Effective Implementation of Standard Operating Procedures

·       all operating procedures would reflect the criticality of patient safety

Continuous Improvement of the Overall Level of Safety

·       The Continuous Improvement focus would result in action to improve patient safety

Staff Morale and operating climate

·       Whistleblowing would reduce in an environment where complaints are welcomed and actively addressed

·       Staff engagement and morale would increase – due to working in a positive climate where it is accepted that mistakes occur but lessons are learned, and patients and staff are treated in a respectful way when issues occur

·       Consultants, Doctors, Nurses and support staff would have less hassle, less agro, less complaints, less disruption, less stress, less time off work – and greater job satisfaction.

Productivity and Costs

·       Direct and Indirect cost savings would result from: fewer and shorter suspensions of highly paid staff; fewer resultant cancelled clinics; fewer disciplinary sanctions or  dismissals of staff, and no dismissals of Whistleblowers; faster treatment of patients; fewer mistakes impacting patients; fewer complaints and legal claims from patients; reduced legal costs and damages pay-outs.

 

Introduction

This article contrasts the approach operated by the airline industry to that of the UK National Health Service (NHS) in relation to the treatment of staff who raise concerns, and the general approach taken to safety. In both industries, safety – in the case of the airline industry, staff and passenger safety, and in the case of the NHS, staff and patient safety – should be central and paramount in management and leadership thinking.  Continuing horror stories about the treatment of Whistleblowers in the NHS suggests otherwise. 

The Daily Telegraph 2014 report1 on yet another high profile NHS whistleblower to win his legal case is shocking:  

A hospital consultant who was “hounded mercilessly” out of his job after raising concerns about patient safety has won a landmark legal victory for unfair dismissal after the longest-running and most expensive whistleblowing case in NHS history.

Dr Raj Mattu, a cardiologist, was suspended for eight years, then sacked, after warning that patients were dying because of cost-cutting practices introduced by a Coventry hospital.

NHS bosses hired private investigators in an apparent attempt to discredit him, spending an estimated £6 million in pursuit of the case against him. Colleagues said he had been “hounded mercilessly” by hospital managers after speaking out.

MPs said the employment tribunal ruling, which found the whistleblower had been unfairly dismissed, shone a light on a “sinister and dystopian” culture of cover-up within the NHS, which destroyed the lives of those who tried to speak up for patients. Experts believe Dr Mattu, now 54, could be in line for damages of as much as £10 million.  

Dr Mattu said: “My treatment by the trust over the past 13 years has damaged my health, my professional reputation and my livelihood and its effects on my personal and private life have been devastating.” He said he hoped that the health service would learn from the case and start listening to whistleblowers.

Charlotte Leslie MP said: “This shows just how far the NHS was prepared to go, spending millions attempting to protect its reputation by taking on someone who was simply fighting for good patient care….This is a pattern, a dystopian world in which the priority is to hush up inconvenient truths and pursue sinister and aggressive policies to destroy those who speak out.

Understanding the value of your assets

The NHS has two main assets – its buildings and the knowledge of its staff (it’s human capital), with the Consultant group of Doctors arguably representing the NHS’ most valuable asset.  In this article we contrast the approach taken by the NHS to its most valuable asset, the NHS Consultant, with that operated in the airline world in relation to one of its most valuable assets, an aircraft such as an Airbus 380, and the overall approach and safety culture operated in both industries.  Which one is the more valuable asset? 

We have chosen the airline industry as the comparator as it is as focused on safety as the health service should be.  Airlines operate within a heavily regulated environment but still have to balance risk to passenger safety with commercial risk every day. Airlines balance the risk to their reputation and commercial survival of putting an aircraft into the air when there are safety concerns.  From commercial information available we can see that airlines operate an approach within this operating context which is designed to get aircraft back into service as soon as (safely) possible. All and everything will be done to resolve whatever issue is preventing an aircraft being air worthy, and returning to service.

Airlines know how much they lose commercially when they cannot deploy their most valuable assets.  Air France sought compensation for a grounded A380 estimating lost revenue at €30-50m per annum2. In 2011, a major airline cancelled approximately 300 flights after a crack appeared in the fuselage of a Boeing 737 while in flight. The airline placed 79 planes into airplane on ground status until they could be inspected and any repairs necessary completed to make them safe for flying. Industry insiders estimate that the airplane on ground status of these flights cost the airline as much as $4 million in lost revenue, equating to $13.3m per 737 flight3.

The NHS incurred very significant costs in “defending” Dr Mattu’s Whistleblower claim. Dr Mattu was suspended from work for 8 years on his Consultant salary.  The NHS will have incurred further significant direct costs through replacing him with locum Consultant resources, incurring legal costs of £6 million, and with damages to be paid out as a result of losing the legal case of an estimated £6 – 10 million. The NHS has also incurred significant indirect costs through the consequent loss of Dr Mattu’s talent and expertise to the NHS, lost productivity due to cancelled clinics and procedures, loss of knowledge, and a significant distraction of senior medical staff and executive time. All of these costs are likely to cost the UK tax payer a staggering £17–20 million4.  This is in addition to the BMA reported figure of £564,112 as the estimated basic cost to the NHS of training a Consultant5.

Perhaps Airlines have learnt to focus their attention on the natural loss of reputation, and by default revenue, post any disaster and as a result have placed the Ethic of Care / Safety at the forefront of their operation by focusing on the safety of their passengers.

Is there an alternative approach for the NHS to take?

If we accept that there is merit in the NHS changing its view of how to maximise the return on investment in an NHS Consultant, and thereby looking to return Consultants to duty as soon as (safely) possible, what would need to happen in order to make such an approach feasible?

From our research we believe the NHS has much to learn from the aviation industry.  We were supported in our thinking in May 2014 by comments made by Sir Robert Francis QC, the Mid Staffs Inquiry Chairman, and now President of the Patients Association charity.

Francis warned that “standards across the NHS have become so poor that if the health service were an airline ‘planes would fall out of the sky all the time’ ”….and …“If we ran our airlines industry on the same basis, planes would be falling out of the sky all the time. We’ve got to change the attitude because it’s provided by the state, it’s all right for a number of people to be treated badly; well it’s not. Airlines would go out of business very quickly if they worked that way.”6

In this article we set out how the NHS can learn from the aviation industry.  In particular we acknowledge the thinking of Michael Ferguson and Sean Nelson in their 2013 book Aviation Safety: A Balanced Industry Approach

The Ethics of Safety

Ferguson and Nelson set out how the aviation industry needs to build on an existing safety culture within today’s heavily regulated aviation environment. As we discussed Ferguson and Nelson’s proposition we were struck at multiple points by both the similarity of the aviation to NHS industry characteristics and the contrast in how they lead and manage on safety. Both industries are heavily regulated, are subjected to frequent intensive scrutiny by the media when a significant safety event occurs, and have reputedly strong safety cultures. 

We have set out a summary of Ferguson and Nelson’s proposition for the next generation of aviation industry safety.

Instead of lagging behind and being laissez faire with respect to safety leadership, current and future leaders in the aviation industry need to ensure that their organisations must have the complete and unwavering support of those in decision making positions7.

Organisations should not only do their best with respect to safety to ensure compliance, but also that organisations should foster the development of an organisational ethical culture that values safety in order to protect employees, assets, and the public, while working to ensure operational efficiency and fiscal responsibility – in other words a balanced approach8

“It is evident that the existence of regulations, standards and company policy and procedures, and the potentially undesired media attention fail to automatically translate into people following all the rules, procedures and policies within aviation organisations, nor does it translate into people behaving ethically in the aviation workplace.  There are those who continue to make unethical decisions and even coerce others into doing the same.  Therefore ethics, as applied to individuals and companies, is not just a question of obeying laws and following rules. It is more a question of individual and corporate character, code and culture.  In general people tend to make decisions and choices that are aligned with their personal values perceptions and beliefs. Conversely organisations tend to make decisions based on the internal culture created by the leadership of the organisation.”9

A strong organisational culture should foster the development of a strong ethical culture, of which a strong safety culture is a key element, and that this strong safety culture should be the foundation of an organisation’s business culture – “preventing accidents simultaneously protects people and limited economic resources, both of which can add to the bottom line of an organisation.”10

“A strong effective safety culture is the result of wilful, intentional decisions, actions, training, and policies specifically designed to create an internal culture where safety is among the foremost of a company’s priorities.” 11

In addressing head-on the leadership challenge on safety Ferguson and Nelson did not feel the need to state that the wilful, intentional decisions should be positively orientated. It is clear however that in the case of the NHS the need for the positive application of wilful, intentional decisions did not apply in the approach taken by NHS management in the whistleblowing case of Dr Mutta.

Essentially, for safety to operate in the true interests of patients in the NHS the current culture and leadership approach needs to be turned on its head.

The challenge in turning the current NHS culture and leadership approach on its head.

The NHS faces several major challenges in relation to its culture and operating climate to address in order to successfully change the way it operates and put patient safety first.

Professor Roger Steare12, Corporate Philosopher and Visiting Professor of Organisational Ethics at Cass Business School, differentiates between the corporate application of the ethic of care in Britain’s NHS and the individual ethic of care operated by individual healthcare professionals. Steare states that “Healthcare professionals demonstrate some of the highest ethics scores on the MoralDNA™ test, when compared to other professions. However they need to challenge the managerial and political elites who place thoughtless obedience to financial and other targets as more important than the quality of patient care.”

The MoralDNA™ test has been completed by over 120,000 people in over 200 countries, and measures how we prefer to decide what’s right based on the ethics of obedience, care and reason. Several major corporations now use MoralDNA™ to monitor, challenge and improve the judgement and behaviour of their leaders and employees.  Steare concluded: “Looking at the MoralDNA™ of healthcare workers, politicians and those working in government demonstrates clearly where the problems lie. We should let healthcare professionals get on with caring for patients rather than demand that they meet the ill-conceived and self-serving targets of politicians and bureaucrats”.

Organisations, including the NHS, implement all kinds of codes of conduct, with good intent - but they are too fuzzy: ‘we care about our customers’; ‘we have fiduciary responsibilities’; ‘our patients come first.’ These statements are so general that the range of grey zones within them allows good people to misbehave.

Professor Dan Airely, Professor of Psychology and Behavioral Economics at Duke University, has long been fascinated with how emotional states, moral codes and peer pressure affect our ability to make rational and often extremely important decisions in our daily lives. His research13 suggests that human beings have become proficient at rationalisation as a way to make sense of the rules and regulations imposed upon them. As a result of this rationalising behaviour there are all kinds of trade-offs to support how we act.  In general, we do not like very clear-cut rules because we understand the exceptions. We understand that we cannot create the ultimate ‘good’ rule. But good rules really help us. Good rules are the rules that allow us to figure out for ourselves what is good.

Businesses need to think about what their code of conduct is, how specific versus general it is, and how good behaviour and bad behaviour are transmitted through the organisation. The transmission of any behaviour creates the climate of the organisation as opposed to the organisational culture. Denison14 (1996) defined organisational culture as “the deep structure of organisations, which is rooted in the values, beliefs, and assumptions held by organizational members”.  Climate, on the other hand, is “relatively temporary, subject to direct control, and largely limited to those aspects of the social environment that are consciously perceived by organizational members.”  Climate arises through organisational events, processes, and communication.  It also arises through the shared perceptions of the work environment and the shared meanings that arise from employees’ interactions with one another.  The NHS has to reverse decades of top down negative pressure to not do the right thing, in order to create an ethical patient centred safety culture and an operating climate that puts patient safety first.

A further challenge for the NHS which often goes unmentioned within a discourse such as this is reputational loss.  Normal commercial entities are motivated to avoid the commercial loss which results from reputational damage.  The reality of the Mid Staffs scandal showed that the NHS operates on the basis that it does not need to care about reputational damage for two convenient but uncomfortable reasons. Firstly patients in the NHS have limited opportunity to go elsewhere for treatment, so the NHS is largely immune from the advantages of competition. Secondly doctors deal with the worst case scenario of a client dying every day, so in theory what’s the big deal? Research has shown how organisational incentives influence behaviour, what incentive does the NHS have to influence better behaviour?  We do not address these behavioural challenges in this report, however we recognise they are critical issues to be addressed, once the proposition about a patient centred safety culture is accepted.

The NHS leadership says many of the right statements about improving patient safety, but the reality of how Whistleblowers like Dr Mutta are treated shows the need for courageous NHS management teams to rip up the current management approach and literally do the opposite of their current actions in order to create an ethical safety culture.

The Importance of leadership in Establishing an Ethical Safety Culture

We wholeheartedly agree with the contention that Leadership is paramount in order for an ethical safety culture to develop and be maintained over time.  Ferguson and Nelson set out their requirements of Leadership.

Leadership need to demonstrate their support for the required culture by fostering an internal culture embracing safety and putting this in writing in the form of a “commitment statement”, so that it becomes an actual corporate value supported across the board by leadership.15

The assertion about the benefit of a strong safety culture is supported through the implementation of a Safety Management System (SMS) – a system of policies, procedures, and practices implemented within and by an organisation to enhance safety.15 The intention is that safety is intertwined as a vital and necessary part of the overall business plan, constantly supported by Leadership – both verbally and financially.

Furthermore leaders need to back-up their stated commitment through leading by example, consistently following the rules, especially when they think no one is watching. In modelling the appropriate behaviour leadership needs to hold themselves and the employee group accountable for maintaining the safety standards, and bring corrective actions to bear as needed. Corrective actions are not automatically synonymous with disciplinary action.

We have been struck by the degree to which the concepts set out by Ferguson and Nelson apply directly to the NHS.  If the word “patient” is introduced into the arguments set out in Aviation Safety: A Balanced Industry Approach, the arguments presented can apply to the NHS, affording it an opportunity to manage in a radically different way from now – and creating an operating culture where Whistleblowing would be welcomed, but where the incidence of Whistleblowing would end up being less than today. There are a series of wins available to the NHS from implementing a true patient safety culture at the heart of its operations. The wins are both financial (direct and indirect savings) and qualitative (patient and staff experience).

Employees are on the front lines of every organisation and therefore often have first-hand knowledge of what works and what doesn’t.  This knowledge leads to the improvement of current operations or to the development of new and novel ways of working.  However, unless the organisational climate has been created to encourage speaking up it may never occur.  A climate of voice is set by the tone of the leadership that is filtered down to the front lines.  If speaking up is to be accepted and encouraged in the workplace, this message will come from the leadership.  Employees look to their work environment to determine whether speaking up is appropriate. They listen, observe and share information with each other that either supports or negates whether speaking up is safe.  Because speaking up may challenge current operations it has the potential to upset others thereby carrying inherent risk.  Therefore, employees will only speak up if they observe the signals initiated and nurtured by leadership that such behaviour is accepted and encouraged.

What would the application of an aviation type safety culture look like in the NHS?

Many will argue that the NHS already operates issue reporting, trend analysis, and prioritisation of action against risk.  What the NHS does not demonstrate however is a top-down Leadership led patient safety culture at the heart of all NHS activity, and starting with strong leadership sponsorship and behaviour. Leadership would support the implementation of an SMS which would foster continuous improvement in safety through active reporting and analysis of safety information, and a gradual migration from non or purely reactive management, through proactive management and into predictive management of risks to patient safety.

The eight components of safety management set out by Ferguson and Nelson for the aviation industry16 could be applied directly into NHS hospitals and Commissioning Groups:

  1. Commitment of Senior Leadership to Safety Management – leadership must fully and consistently support safety management – both in their decision making but also in their financial investment.  This is the main determinant of a successful safety management approach which would truly put patient safety at the heart of all decision making.
  2. Effective and Consistent Reporting of Safety Issues  - the management of safety requires information and data in the form of reports submitted by employees – most of these voluntary, but also mandatory reporting of serious issues. The data gathered can then be used to conduct trend analysis to identify and prioritise action against risk.
  3. Continual Monitoring – all aspects of activity need to be monitored, in the same way as aviation safety is dependent on safe ground operations, as well as aircraft maintenance and fully competent pilots.
  4. Investigation of Accidents and Other Events – as soon as possible after a safety related event has occurred, the events should be thoroughly investigated to determine all causal factors and to develop effective, specific corrective actions. The focal point of the investigation should not be to assign blame but to find out exactly what happened to cause the event so that future events have a greater probability of being prevented. All accidents, incidents, near-misses (as much as possible) should be investigated using a standardised investigation process throughout the organisation.  Again, prevention of future events is the goal of investigation.

We have quoted Ferguson and Nelson’s prescription in full on this point in order to reinforce the degree of change required in NHS leadership thinking. How different would the world of the NHS be if Consultants raising issues were embraced positively and their concerns investigated thoroughly and expeditiously?

  1. Sharing Safety Lessons Learned and Best Practices – this speaks for itself, and should be easier in the NHS than in aviation due to the lack of competition.
  2. Provision of Safety Training for Operational Personnel – providing specific comprehensive safety training will help to ensure that employees know the expectations and policies related to safety that they are expected to follow.
  3. Effective Implementation of Standard Operating Procedures – which need to be continuously accessible to all employees.
  4. Continuous Improvement of the Overall Level of Safety – changes to processes or ways of work need to be made as problems are identified.  No one in the organisation should ever get to the stage where they are comfortable they are operating at “complete safety” – the mind-set needs to be on continuing improvement.

What are the implications for encouraging, supporting, whilst reducing the incidence of Whistleblowing in the NHS?

We see an overwhelming series of wins for NHS management, Consultants, Doctors, Nurses, other staff, and most of all patients from implementing a true patient safety culture. The benefits would be quantitative and qualitative – driving both safety and efficiency in the NHS.  We do not see any downsides.

Commitment of Senior Leadership to Safety Management

·       Patient Safety management would be at the heart of all planning and operational activity – with a focus on what are the risks? and how do we reduce or neutralise the risk?

·       A defensive and closed approach would be replaced with an open and transparent approach. 

Effective and Consistent Reporting of Safety Issues / Continual Monitoring / Investigation of Accidents and Other Events

·       Complaints against staff would be actively investigated and resolved as soon as possible.  Staff would be placed on paid suspension only if absolutely necessary, and for the shortest time possible.  The NHS would invest in patient safety investigations through the deployment of dedicated investigators of complaints to ensure rapid resolution of issues, and Mediators to settle patient complaints and legal claims within the shortest possible timeframe

·       All events and issues would be investigated to identify corrective actions (rather than allocate blame)

 

Sharing Safety Lessons Learned and Best Practices

·       Complaints from patients and staff would be encouraged, and the resulting action fed back to the complainant

·       Embarrassment over failure and exposure would remain but would be reduced, and positively managed in an environment where complaints would be actively managed

Provision of Safety Training for Operational Personnel

·       all staff would be trained on safety monitoring, reporting, investigation processes, and the procedure to raise concerns – and on the benefits

Effective Implementation of Standard Operating Procedures

·       all operating procedures would reflect the criticality of patient safety

Continuous Improvement of the Overall Level of Safety

·       The Continuous Improvement focus would result in action to improve patient safety – for example - in the same way airline passengers have the same 100% safety expectation on a weekend flight as a weekday flight, patients would expect the same level of safety to apply in hospitals at weekends, and all actions required to ensure patient safety would be a “no- brainer”

Staff Morale and operating climate

·       Whistleblowing would reduce in an environment where complaints are welcomed and actively addressed

·       Staff engagement and morale would increase – due to working in a positive climate where it is accepted that mistakes occur but lessons are learned, and patients and staff are treated in a respectful way when issues occur

·       Consultants, Doctors, Nurses and support staff would have less hassle, less agro, less complaints, less disruption, less stress, less time off work – and greater job satisfaction.

Productivity and Costs

·       Direct and Indirect cost savings would result from: fewer and shorter suspensions of highly paid staff; fewer resultant cancelled clinics; fewer disciplinary sanctions or  dismissals of staff, and no dismissals of Whistleblowers; faster treatment of patients; fewer mistakes impacting patients; fewer complaints and legal claims from patients; reduced legal costs and damages pay-outs.

 

Conclusion

In a study undertaken by Newton et al., 2012 Newton examined the relationship between ethical climate, moral distress and voice, and offered insights into both the meaning and impact of being silenced in the workplace17.  A nursing supervisor told a staff nurse to “stop the noise” – to stop discussions about ethics in the context of the nurse’s moral distress. When workers within a health and caring industry feel there are limits to behaving with a duty of care or they are unable to speak out or take action when faced with an ethical lapse, they feel moral distress.  Moral distress is associated with lower levels of patient care, job dissatisfaction, feelings of powerlessness, burnout and an intent to leave the organisation.  Being empowered and supported to express themselves in time of moral distress is likely to improve patient care.

Newton and her colleagues identified four themes that prevent a professional in a health and caring industry from speaking out:

  • The choice to remain silent because of professional or organisational factors supporting the status quo.
  • Doctors and Senior Administrators, in particular, dismissing what more junior staff had to say.
  • The difficulty in articulating their concerns especially at times of human suffering and death.
  • The lack of skills in utilising their voices.

In today’s world, where information travels globally with the click of a mouse, transparency is no longer simply desirable, it is becoming unavoidable. But like dissent, being transparent takes moral courage and trust both from an individual and organisational position.

Legislation alone will not make the NHS open and healthy. Only the character and will of those who run and participate in the NHS can do that. New regulations can help restore much-needed trust, but they can only go so far. If a culture of silence or collusion exists instead of a culture of candour, participants will find ways around the rules, new or old, however stringent. Candour and transparency become widespread only when leaders make it clear that openness is valued and will be rewarded. Openness happens only when leaders insist on it and demonstrate it themselves.

The first beneficiaries of a culture of candour and transparency will be the employees of the NHS itself, who are in a position to act on maximum rather than restricted information. By observing the internal transparency of the NHS hand in hand with the principle of acting on information, the default benefit will pass from the employees to the patients and thirdly, to the tax payers.

Creating a patient centred safety culture of candour in the NHS will require balancing the organizational and employee’s desire for patient care, employee loyalty and bureaucratic targets with a personal dedication to integrity, more specifically, truth-telling. We are not saying that this will be easy but we are saying that ultimately all stakeholders will be winners.

 

 

"In a democracy dissent is an act of faith. Like medicine, the test of its value is not in its taste, but in its effects.” - J. William Fulbright, U.S. politician (1905 - 1995).

 

 

 

Source

1.       The Daily Telegraph 17 Apr 2014.

2.       http://airnation.net/2012/10/30/air-france-compensation-a380-cracks/

3.       http://blog.covingtonaircraft.com/2011/11/09/airplane-on-ground/

4.       Costs estimated based on press reporting.

5.       www.bma.org.uk/-/media/files/.../bmabrief_medicaltrainingcost.docx

6.       http://www.independent.co.uk/life-style/health-and-families/health-news/if-the-nhs-were-an-airline-planes-would-fall-out-of-the-sky-all-the-time-says-mid-staffs-inquiry-chairman-9436811.html

7.       Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach.  Preface

8.       Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. p4

9.       Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. p5

10.    Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. p10

11.    Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. p10

  1. http://www.moraldna.org/francis-report/#
  2. http://knowledge.wharton.upenn.edu/article/dan-ariely-dishonestys-slippery-slope
  3. https://www.tamu.edu/faculty/bergman/denison1996.pdf

15.    Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. p10

16.    Michael Ferguson, ‎Sean Nelson – 2013 Aviation Safety: A Balanced Industry Approach. P21

  1. Newton, l., Storch, J.L,, Makaroff, K.S., and Pauley, B. (2012) ‘Stop the noise’: From voice to silence.  Nursing Leadership, 25, 90-104