News and Comment from Roy Lilley.
The Tinkerman has a new wheeze. The latest; an inquiry onto ‘never events‘. These entirely preventable mistakes keep happening. The numbers stuck.
He is right…
However, he’s wrong in how he’s trying to fix it.
To be fair, he doesn’t have that many tools in the box. He has bungs and beatings. He can bribe and throw money at problems… we all know he has no money. So, guess what he’s going to do…
I can hear a massive collective groan as I tell you he’s asking the CQC to do it. They won’t.
Why ask the people responsible for regulating quality to inquire into why they have manifestly failed to improve anything as basic as never-events.
We all know they will look for someone, anyone but themselves to blame.
So, expect lists, league tables, naming and shaming and down-the-line, discover harassed Trusts will have fiddled and gamed their way out of trouble.
The CQC, with their reputation for inaccuracy, delays, rows and arguments are entirely the wrong people to be trusted with this most important, mission critical job that will entail trust and a level of candour the CQC can only dream of.
Failure and errors can be a learning mechanism but the CQC are regulators, definitely not a learning organisation. Second, we have to take ownership of mistakes and failure but the CQC’s approach to ownership is to give the ‘owner’ the heave-ho.
In the best of organisations, from time to time, things go wrong. It is not a sin. The sin is to hide it, ignore it, not to learn from it and let it happen again. This is not to say, ‘anything goes’. There must be responsibility for practice and ownership of what happens and that must coexist with high standards.
If a never-event is repeated the sensible thing to do would be to get all the people who made the mistakes, into the same room and ask them, in a secure setting, what occurred that is in common. What’s learning.
Can you imagine that happening in the NHS? The regulators and the lawyers would make candour and verity out of the question. The press and the trade mag’s would make sanctuary and a safe place impossible to find.
Today, a million people will be looked after by the NHS. Can we expect zero-defects? Only if you are prepared to pay for it. Funding enough people, to have enough time and with enough resource to to do the job, well enough, for long enough, to eradicate errors.
We can’t afford it.
What we can do, which isn’t free but a dammed site cheaper, is to learn. To create a climate of learning. To create safe places for reflection. The CQC can’t do any of that… they are indelibly identified with a blame culture.
Not all failures are created equal and unscrambling deviance, inattention, effort and exhaustion, from procedures, guidance and system failure is beyond our faith in the CQC.
At the Academy they know sharing what good looks like is the fastest way to best practice. This week they have launched Fab-Safe; inviting everyone to share their work to prevent never-events, their learning and innovation on safe practice.
To consider an event as ‘never’ misunderstands complex systems. Spotting big painful deviations as failure is easy.
‘Stop! You are about to cut-off the wrong
However, never-events will almost certainly be the consequence of a series of smaller failures that no one noticed and were aligned, producing disastrous consequences.
‘How did we all stand and watch the wrong leg being cut-off…’
…because; there will have been a collection of errors in notes, pre-op checks, non-standard systems, confusion, unfamiliarity, inconsistency in procedures, temporary staff, tiredness, distraction… a cocktail of mistakes.
The Academy has built a free, learning-sharing social movement. Hundreds of ideas, millions of page views from around the world.
We must not short-change past failures, they are valuable. We must invest in eradicating them from the future. To do that we must know what went right, as much as what went wrong.
The Academy creates a free, immediate opportunity for us all to help the NHS become the safest health system in the world.
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