Quality Improvement and the Just Culture 20/02/2017

Quality Improvement and the Just Culture

The atmosphere and culture in which we work remains difficult and at times confrontational, yet there are some signs of a wind of change.

The Chair of the Public Administration and Constitutional Affairs Committee of the House of Commons said in January this year:

“There is an acute need for the Government to follow through on its commitment to turn the NHS in England into a learning organisation; an organisation where staff can feel safe to identify mistakes and incidents without fearing the finger of blame.” This is music to my ears. For too long now many surgeons (me included) have been confronted with enforced outcome publication, together with a regime of outlier management that sounds punitive and – ultimately – the intimidating prospect of an IRM: no other profession is subjected to this degree of intrusive scrutiny. The whole outlier lexicon, with its system of alerts, alarms and heavy regulation, smacks of guilty unless proven otherwise. The greatest shame is that, inevitably perhaps, the NJR is perceived by many within our speciality to be partially responsible for this when it is quite rightly acknowledged by the profession internationally as a jewel in the global crown of orthopaedic registries. The value to our patients is huge but could be even greater if the learning organisation principles are applied.

Progressively we have not been idle on this front. A year ago my predecessor, Tim Wilton, argued the case strongly with HQIP (the operators of the NJR) that the categorisation of individual surgeons as outliers was entirely counterproductive: not only did it stigmatise unnecessarily, but it also impacted psychologically on the individuals concerned and, importantly, acted as a most unhelpful barrier to the wider development of new registries focused on quality improvement. He proposed a more positive, balanced and supportive approach.

Interestingly, Tim’s views ultimately prevailed. At a Clinical Outcome Programme (COP) leadership seminar last May the National Medical Director for NHS England – Sir Bruce Keogh – said that:

          • The whole emphasis of the COP should shift from one of rooting out poor performance to celebrating success.
          • Outcome publication for all future audits should be unit or team based.
          • And that rather than concentrating largely on the negatives, all audits should in future highlight the positives.

More recently, I, Martyn Porter (the NJR Medical Director) and others met with Bruce Keogh and secured his agreement that the NJR would not publish individual surgeon revision rates. In addition, Bruce acknowledged that the NJR’s outcome reporting language and culture would change to focus on the positive aspects of joint replacement surgery that transforms orthopaedic patients’ lives. As a direct consequence, the NJR Surgeon Outlier Committee will be renamed the Surgeon Performance Committee and, while there will still be a requirement to publish individual surgeon outcomes, the NJR and the profession have the discretion to determine what is put out there. Bruce also noted that the BOA will offer supportive Elective Care QI Reviews when requested by units.

This was also music to my ears. Why? Because although it took a year to achieve not only does it demonstrate the extent of our influence at a high level, but it also aligns exactly with the BOA’s position on Quality Improvement. Our view is that it is part of our professional skills to reflect on our practices and develop insight by reviewing our results in comparison to our peers. Where registries are available to support this reflection with observational science, then we have a professional duty to make use of them and the insight that they can provide. In addition, important enabling processes such as GIRFT can provide alternative sources of data with which to inform reflection and review. All individual reflection should of necessity focus on the positives as well as any areas where there appears to be scope for improvement. Comprehensive assessment of our individual practice by each of us – as an individual – means that it is then possible to discuss our results with an appraiser, and to contribute to unit reviews of performance. This has to be in our patients’ interests. It is also vital that the total context of this data is considered: it is intrinsically true that being a good surgeon in a struggling unit does not make you a better surgeon. Having the resources to look at the data can only add power to your quality improvement efforts. The simple statement ‘no data no argument’ will always catch us out. The more we have clinically insightful data the more we can push and control positive change. To help when units run up against problems that they are unable to solve, the BOA as your professional body, in conjunction with all the affiliated Specialist Societies, will assist with a supportive review. Here we intend to build on our extensive trauma experience of multi-disciplinary hip fracture service reviews, which have been well received by those units that have requested them.

This is what we mean by the Just Culture and it is one that has been widely adopted by the aviation industry with which we are so frequently compared. In a just culture it is important always to take a balanced and objective view: taking variation as an example, as Colin Howie so often says ‘variation can be good or bad, but we do need to understand it’. In this way we avoid jumping to an over-hasty or ill thought through conclusion and use the full spectrum of available evidence to inform our decision making. Similarly, in a just culture the focus will always be first and foremost on learning from mistakes, errors of judgement and untoward incidents, rather than pointing the finger of blame. In this way we avoid the unnecessary spread of risk aversion and understand the essentials of and rationale for good practice. To be sure, if a surgeon is reckless and ignores the evidence without good cause, then there will be a case to answer, but those instances are rare in our specialty. Finally, in a just culture it is entirely professional to seek the support and advice of a fellow professional: while I appreciate this is instinctive to many, it is not always the case for some and is something to be positively encouraged.

So the key ingredients of a just culture are, as the name suggests, evidence based objectivity, a positive frame of mind, a quest for learning with which to promote further quality improvement, and supportive professionalism. As your professional body, it is the BOA’s role to promote these principles. This accords entirely with our strapline of Caring for Patients; Supporting Surgeons, and I would hope that we could all subscribe to them. In closing, I would strongly encourage you all, if you have not already done so, to familiarise yourselves with our GIRFT implementation guidance and our statement on transparency, all of which can be found here. These documents spell out the detail of our quality improvement intentions. I will be in touch shortly with further details of our Elective Care QI Reviews.

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