Page last updated at 10:23 GMT, Wednesday, 6 January 2010

Better communications can aid patient care

Peter McCulloch
VIEWPOINT
Mr Peter McCulloch
Oxford University

surgeons
Instructions are issued for post-operative care, but not always followed

A safe operation with no mistakes should be what every patient receives in a UK hospital, but that is not always the case.

In this week's Scrubbing Up, Mr Peter McCulloch of the Nuffield Department of Surgery at Oxford University, explains how his department is adapting techniques from other industries to try to make patients safer.

The story of the patient in the intensive treatment unit (ITU) was one all the consultants at the Morbidity and Mortality meeting had heard before: most of them had had a similar case themselves.

The original operation had been long and difficult, the patient frail and unfit.

Modern healthcare systems have grown up like London or Rome, with the ancient and modern parts haphazardly cobbled together in combinations which more or less work, but have never been analysed for their pitfalls.

The surgeon had been worried, but initially all seemed to go well.

The surgeon ordered intensive observation and gave detailed instructions for post-operative care.

But when the patient became ill on the third night, these had not been transferred, the appropriate care had not been given, and the vital recording in the notes had been lost.

The nurses knew what to do, but the registrar, who had reluctantly filled the vacant rota posting at the last minute and was inexperienced in the speciality, did not.

Insecure and not wishing to appear incompetent, he attempted to manage the situation for several hours without senior help.

Help from other departments had been hindered by evident tensions between the registrar and the nursing staff, leading to confused communications.

By the time senior help was called and theatre prepared, the patient's situation was grave.

'Clinical failure'

This is typical of the detail behind many stories of clinical failure and medical "mistakes".

No-one has actually acted outrageously, and everyone has been trying to do their best.

But the system, and the nature of human communications within it, conspire to produce avoidable harm anyway.

Nurse and doctors, trained separately, rapidly develop inter-professional attitudes which can exacerbate conflict in difficult situations, as well as hierarchies which inhibit "speaking up"

If the system was carefully thought through to avoid delay and error, if the staff were trained to communicate clearly and unemotionally - and felt safe doing so - this kind of problem could be avoided.

But modern healthcare systems have grown up like London or Rome, with the ancient and modern parts haphazardly cobbled together in combinations which more or less work, but have never been analysed for their pitfalls.

Worse, the attitudes developed by traditional professional training can encourage heroic thinking among medical staff, by fostering a belief in our complete individual responsibility for the patient's wellbeing.

At times of stress, this makes it fatally easy to ignore advice, or the need for it.

'Not rocket science'

Nurses and doctors, trained separately, rapidly develop inter-professional attitudes which can exacerbate conflict in difficult situations, as well as hierarchies which inhibit "speaking up".

Without meaning to, we have developed unsafe systems and unsafe culture hand-in-hand. In this environment, the best of us can easily end up harming a patient.

Toyota-style re-design of ward care processes, using the input of the "coal face" workers, can dramatically improve them

We all want to work in a safe, reliable system where things never go wrong.

Many of the things we need to do to achieve this seem pretty obvious and simple, like keeping good notes or, to use a topical example, using checklists.

As someone who works in this area, I frequently get told: "It's not rocket science, is it?"

No, but I have recently seen a slide of a picture of the infamous "O rings" which failed on the Challenger shuttle.

They are covered with frost, under which you can just read the words "do not use in temperatures below 16C".

So even rocket science is not rocket science.

Adapting techniques

To improve reliability in health care we need to tackle at least three things.

The system needs to be reanalysed to eliminate the obvious pitfalls; staff culture needs to be changed through training to improve clear communication and eliminate fear of saying what needs to be said; and we need to look carefully at our use of technology.

We and other research groups have been trying to do some of these things.

Change sticks best if, like the changes brought about using the Toyota system, it makes life easier and better, not harder or more stressful for the workers

It's early days, but some of the techniques we have tried to adapt from other industries seem promising.

Aircrew training in briefing, debriefing and keeping a "flat" hierarchy improves both teamwork and technical error rates in operating theatres.

Toyota-style redesign of ward care processes, using the input of the "coal face" workers, can dramatically improve them.

'Professional culture'

The key, however, will be changing the professional culture.

This is a long and difficult job, and will need to be attacked in many different ways - education of the young, regulation, training, incentives and leadership from the top.

One key lesson we have already learned.

Change sticks best if, like the changes brought about using the Toyota system, it makes life easier and better, not harder or more stressful for the workers.

For safety, the message is clear: don't try harder; make the safe thing the easy thing to do - or ideally the only possible thing.

Have you experienced problems with confused communication among health professionals? What was the outcome?


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