World Patient Safety Day 2019: creating a just culture across healthcare

Tuesday 17 September 2019

Cicely Cunningham is a clinical oncology ST6 trainee based in the west of Scotland. She is currently on a training break and is working as a Scottish Clinical Leadership Fellow in the Royal College of Physicians and Surgeons of Glasgow. Dr Cunningham is also a passionate campaigner for reflective learning and cultural change within the NHS and is the founder of the Learn Not Blame awareness campaign. 

Here, Dr Cunningham explains the importance of today's inaugural World Patient Safety Day and why hospital leaders and clinicians should all work to promote and sustain a 'just culture' in healthcare. 

What does 'patient safety' – as an advocacy topic – mean to you? 

Patient safety is one of the most important issues for me as a doctor. It is estimated that there may be 11,000 avoidable patient deaths a year in the UK, which to me is a shocking figure.

It is a privilege to work as a clinical oncologist and we know that radiotherapy is one of the safest areas of healthcare in the UK. But we should be ambitious in getting the very best outcomes for patients with cancer, whether that’s with advances in radiotherapy, new systemic treatments, or improving all aspects of our processes and teamworking so that our care overall is safer.

Why is it important to recognise patient safety through an awareness raising event like World Patient Safety Day (WPSD)?

The truth is that 'patient safety' as a term has been degraded. For many doctors they associate this term either with finger-pointing and blame or as a pointless tickbox exercise which add no value. But having a global awareness day is an opportunity to showcase a different approach to safety, which is more meaningful to clinicians. Patient safety should be about a forensic curiosity about how we do all our work – examining how and why things go well most of the time. Then, when they don’t, to focus that same curiosity on why, on that occasion, things went wrong.

What do you think are the key areas for improving patient safety in your specialty?

There are many areas where improvements in patient safety could happen, for example, strengthening the reliability of how test results are reported and acted upon, improving systems for systemic therapy prescription and addressing variations in the management of neutropenic sepsis. Which are the priorities for action will depend on the local situation.

Why should clinical oncologists and radiologists care about the WPSD message of “speak up for patient safety” and how can they help?

Involving patients is absolutely vital if we are to improve patient safety. After all, they are the only ones there all the way through it! Clinical oncologists will be familiar with the data from Basch et al showing an overall survival benefit for those patients using a web-based symptom reporting system. We need to see our patients and their families and carers as part of the wider healthcare team, and work together for the best outcomes for them.

Two other big themes of today’s WPSD are promoting a transparent culture in hospitals and encouraging 'blame-free' reflective learning – what does this mean for daily practice?

This can be summed up in the idea of a 'just culture' in healthcare. To me, a just culture is one that treats all humans equally, fairly, and with dignity, whether you are a patient, clinician, medical support staff or administrator or a hospital porter or cleaner. In a just culture, we create psychological safety where all individuals involved in healthcare can speak up.

On an individual level, this means being conscious of my behaviour at work – really listening to colleagues and patients, trying to use non-judgemental language, reducing hierarchies by establishing relationships, and always examining and questioning how I and my teams work – not just when things have gone wrong.

How can and should the NHS improve its hospital culture?

The NHS has been renowned for having a blame culture where the person closest to the lapse in patient safety has been blamed for things going wrong – as was the case with doctors who historically administered intrathecal vincristine in error, when the issue was finally resolved by changing the design of the administration device.

Changing the culture requires a better understanding of the human factors at work within healthcare – put simply, we are all flawed human beings who make mistakes. With that as a starting point, we can look for how we get the best performance out of these flawed humans. Acknowledging the importance of human emotions, of the need for autonomy and control in the workplace – and just how powerful human kindness can be – are all part of the answer.

How can reflective learning from events and the fostering of a just culture make a difference to the provision of clinical oncology, as well as radiology and other healthcare services?

It is a challenge to get meaningful learning in the NHS. But oncology has great opportunities for embedding learning in its practice both through regular multi-disciplinary team meetings and through our morbidity and mortality review processes. In radiology, there are similarly opportunities through the “Learning from Discrepancies” review process.

Creating a psychologically safe space for different professions working together on a regular basis provides a great opportunity for constructive learning. In my view, it’s also really important for us to regularly engage with those receiving the care – what did they feel could be improved?

How can health workers and the NHS engage patients in the concept of a just culture and the need for open, reflective and constructive learning by clinicians?

When things go wrong, what people want and need is a truthful and full explanation, an apology, and to know that this won’t happen to other people. They want meaningful accountability. This becomes more possible with the creation of a more just culture in healthcare. As doctors, we need to be advocating for this for our patients.