UK Government to launch healthcare investigations organization

Written by Andy Smith, MTM publisher

The British Government published a Joint Committee report on 2 August 2018 regarding the establishment of a Health Service Safety Investigations Body.

Intended to create a ‘legal safe space’ so that “anyoneinvolved in the delivery of care can speak openly is crucial if the healthsystem is to learn from its mistakes,” stated Bernard Jenkin MP, CommitteeChair.

He went on to say: “When serious incidents take placepatients have a right to find out what went wrong and staff need to feel thatthey can be open without being blamed or made a scapegoat. Poor qualityinvestigations fail to address the concerns of patients, breed mistrust amongsthealthcare professionals, and do not help make care safer. Putting the HSSIB ona statutory footing to conduct independent safety investigations will helpaddress each of these concerns.”

In 2015 the U.K. estimated that 12,000 avoidable hospitaldeaths occur each year and in England alone there are 24,000 serious incidentsand 1.4 million low-harm or no-harm ‘near misses’ annually. For comparison, thepopulation of England is 54 million and that of the UK as a whole 67 million. U.K.comprises England, Scotland, Wales, N Ireland, and each manages its ownhealthcare service.

This initiative, which may be a world first, couldpotentially be comparable to the U.K.’s Air Accidents Investigation Branch,French BEA and the U.S. NTSB in that it would presumably result in care andtraining recommendations as a result of incident investigation. Certainly allaviation incident investigations result in training improvement recommendationsbecause, as with healthcare, Human Factors are usually a major element in all incidents.

Two recognizable airline terms have begun to intrude on thehealthcare space and into thinking on healthcare performance improvement. HumanFactors (HF) is one and CRM, in this case Crew Resource Management, the other.In simple terms HF begins with the acceptance, or expectation that errors willbe made (to err is human) and designs procedures and safety systems to foilthem. James Reason’s Swiss Cheese Theory is worth reading for some of thethoughts underpinning this approach.

CRM can be thought of as assuring that the full resources ofthe team are deployed and utitlised in safe completion of the ‘mission’.Assigning specific tasks to each team member and working to establish acommunications protocol to ensure all are heard and concerns are taken intoaccount, the team works within a protective cocoon of safety proceduresestablished by the operators and regulators to ensure that, if at all possible,errors are avoided. Should the worst happen and an incident does occur, thecrew are held harmless assuming all protocols have been followed.

The system however is held to account and improved if found thatit is needed.

It is a system that healthcare needs to establish if it isto reduce avoidable error, improve outcomes and reduce waste. TEAM STEPPS wasdesigned to take CRM into the healthcare environment. Regrettably, as is usualin healthcare, critical team members are often missing from TEAM STEPPSexercises as these training exercises are not mandatory.

Whilst choice and voluntary good behaviors seem laudable, they have not led to safe, cost-effective and efficient healthcare provision and the individual is open to lawsuits as a result.

For more: https://www.parliament.uk/business/committees/committees-a-z/joint-select/draft-health-service-safety-investigations-bill/news/health-service-safety-investigations-bill-report-published-17-19/

Professor James Reason: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/

Clinical Human Factors Group: https://chfg.org/

CRM in Healthcare: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488012/

For airline training updates: https://civilaviation.training