The problems of implementation
It was with a wistful eye that I read of the ‘new’ NHS rules saying that NHS clinicians will need to apologise directly to patients and their families for any medical errors and blunders (see report here). The ‘new’ is in quotes because this is hardly new at all. In 2004 I designed ‘Being Open’ – an NHS wide training programme for clinicians commissioned by the National Patient Safety Agency.
The basic premise of the training was that NHS staff needed to apologise for mistakes and errors, however caused. As with the current guidance, there was much concern expressed at the time by medics worried about litigation. They were wrongly anxious that an apology could be interpreted as admitting liability. There were concerns about continuing patient care – would the patient or family trust clinical staff in the future. Above all, there was concern about losing face.
As programme designer, I undertook significant research. There were statistics from the US and Australia about litigation reducing significantly in areas where a culture of transparent apology where things went wrong was already in place. There was support from the General Medical Council and from the other professional colleges and trades unions. There was a patient safety officer role created in each NHS trust to reassure staff and to ensure that the policy was followed.
The training was multi-dimensional . The one day programme for all clinical personnel included trained actors to create opportunities for medical staff to practice different scenarios. There were deeply affecting videos of real patients and family members explaining how a simple apology would have really, really helped in the aftermath of a systemic failure or staff oversight. There was an eLearning programme and a training process – and additional resources - for more than 30 trainers and 50 professional actors to enable the roll out to take effect. There was even an online ‘dating agency’ which enabled NHS trusts to find a local, approved trainer/actor team to deliver the programme. Above all there was a link between the programme and the NPSA’s National Recording and Learning System – a tool used to capture the reasons for patient safety incidents which could be interrogated to identify common issues and to inform future learning and the sharing of good practice.
The initial information and feedback was universally positive. Staff who may have been wary of the approach soon realised that the majority of incidents which caused patients harm were systemic – it was about the organisation’s policies and procedures rather than individual error. This was never intended as a blame game. The programme rolled out – slowly at first – but soon reaching most of England and Wales.
So what on earth happened? Why more than 10 years later is this initiative to say sorry, bound about by new rules and new commitments from the General Medical Council, needing to be re-launched? Why did it take the report into the Mid-Staffordshire care scandal to cause people to look again at the simple, human act of offering an apology?
The answer is implementation. There were three issues which I believe had a negative impact on that implementation and which meant that an excellent initiative with (though I say so myself) pretty good resources and learning design failed to effect much change.
1. The problem was cultural. Quite simply, although the programme was very, very clear that this initiative was not about identifying the guilty and punishing them, the culture of some elements of the NHS was then and – apparently still is – about blame and punishment for errors. The NHS is a political football. When things go wrong, someone will always need to be blamed, hung out to dry and tried in the court of media scrutiny. Although the programme was good – a one day course, however impactful, was never going to shift that culture in an organisation employing almost a million clinicians.
2. Personnel changes. Despite the NHS being a huge organisation, in fact only about three or four people had the performance objective of ensuring that the programme was rolled out and adopted by the various trusts and hospitals. When two of them left – interestingly because they wanted to become freelance trainers responsible for rolling out the initiative – no one was maintaining the necessary momentum. Creating a large buzz about the programme initially but then not following it up with subsequent communication, new insights and success stories meant that it faded from view and consciousness. In 2012, the NPSA itself was subsumed into the NHS Commissioning Board and in 2013 that body became NHS England. Rearranging the deckchairs on the Titanic has become the valued skillset in our modern healthcare system.
3. Overtaken by events. The NHS is constantly being asked to introduce new initiatives. ‘Improvements’ are ten a penny and several per week. Once the focus had gone off the programme - once it was no longer the newest, shiniest thing in the Health services HR armoury – it became very quickly yesterday’s initiative. It was ignored as another welter of politically motivated reforms became the focus of attention. The change in personnel exacerbated this. The new person in the role needed to make their mark. The initiative championed by their predecessor was hardly going to enhance that individual’s career. Better to make a statement by starting something new, something that would be undeniably theirs, something that would get them noticed.
Responding to these issues one by one produces an interesting object lesson for those of us in L&D who want to effect meaningful and long-lasting change through our work (and if we don’t why are we in the job at all?)
Sort out the culture first. We can’t simply change culture by running courses, setting up collaboration spaces and designing some eLearning. We need a role in the organisation questioning why the ‘way things we do things around here’ is as it is. We need support at the top and energy throughout the organisation. Unhelpful cultures, toxic cultures and day to day, business as usual activities which would work contrary to the change we wish to see will squeeze our initiatives and make their impact negligible.
Give somebody the responsibility for driving the initiative forward. Assuming you’ve sorted out the culture, simply launching any change initiative and hoping it will be implemented is bound to fail. It needs continuous work over a long period to ensure people are using the resources, sharing their good practice and learning collectively from the experience of everyone.
Maintain the importance of the initiative in the light of changing circumstances. Periodically, those involved in managing and driving the initiative should take time out to reflect on whether it is still relevant or necessary or whether the world has moved on. What’s more a plan – like the cycle plans used to promote products from major companies – needs to give appropriate and ongoing marketing push to the initiative so that it doesn’t drop down or completely off the radar. In fact, we can learn much in prolonging L&D initiatives by looking at the work of fast moving consumer goods companies. In those companies, which supply the kinds of products you buy in the supermarket, each brand has an internal team responsible for the brand’s health. However, these teams may move on and seek new challenges. In these cases, the momentum behind the brand’s strategy is maintained not by the employed brand team, but often by their advertising and marketing agencies. In many of the FMCG companies with whom I have worked, the agency rather than the marketing team are the guardians of the brand. On the Being Open project, my team and I were employed to produce the materials and train people in their use. After that stage, we were thanked, paid and sailed off into the sunset. Perhaps organisations commissioning programmes from outside agencies should consider a longer relationship, keeping the creative team behind the programme’s design on board for a while longer to support roll out and implementation.
But the abiding lesson is this. For all the people whose care has been affected by lessons not learned and apologies not offered; for all the staff who have felt unable to offer an apology or to address problems in their workplace; for all the people who have felt their only redress was to take legal action – I am truly sorry.
Robin Hoyle is a writer, trainer and consultant. He is the author of Complete training: from recruitment to retirement. His new book: Informal Learning in Organizations; how to create a continuous learning culture is published by Kogan Page on September 3rd. Robin will be speaking at Learning Live on September 10th and Chairing the World of Learning Conference at the NEC on 29th and 30th September, 2015.
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Robin Hoyle is a writer and consultant working with organisations large and small to implement change through people development. He has a long track record of strategic L&D leadership and materials development and design - working for a wide range of organisations in private, public and voluntary sectors in the UK and throughout the world...