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Medical professionalism matters

Exploring the real life challenges experienced by today’s medical professionals and providing support that doctors want and need

Francis, Keogh, Berwick… Quo Vadis?

Primum non nocere: do no harm is widely known as the Hippocratic Oath; which has been at the heart of medical practice for centuries. The last century has seen some amazing scientific and technological advances which have increased the life span of the population while making the practice of medicine more difficult.

The practice of medicine is well known to be a very risky business, being compared to other high risk businesses i.e. aviation, nuclear and the shipping industry; but medicine has its very own complexities and challenges.

Health care organisations are large complex “structures” with intricate delivery systems. In this unique environment the science of patient safety cannot be delivered optimally without the art of human touch, as all the health care delivery systems are merely conglomerates of human beings with minds of their own, values, beliefs and assumptions culturally embedded within them.

The last decade of the last millennium has seen some colossal tragedies in our practice of medicine at home. The story of Beverly Allit, Harold Shipman, Bristol Paediatric Cardiology practice

While we were coming to terms with these tragedies; trying to make sense and learn from these devastating incidents, on the other side of the Atlantic, the Institute of Medicine published a report. It conservatively estimated that 98,000 people die a year from medical errors that occur in hospitals. This report sent shock waves around the world. The US department of health and IOM set out robust steps to reduce the mortality by 50% in the 5 subsequent years.

This report helped us to understand that medical errors are often the result of a problem in the system, rather than the fault of a single individual. The importance of teamwork in patient safety and quality improvement emerged as a more fundamental need; as the focus shifted from the health care professional to the operating system i.e. the organisation (microsystem + mesosystem).

Consumers Union in the US; a non-profit publisher of consumer reports, in May 2009 articulated their despair by shouting “To Err is Human – To Delay is Deadly Ten years later, a million lives lost, billions of dollars wasted.” It has been widely accepted that, despite some robust interventions, policies, procedures, alterations of processes and even a health care law, in the US the desired outcome of 50% reduction of mortality of preventable causes was not achieved. On the other hand Patient Safety and Quality Improvement have both been, quite deservedly, recognised as domains of scientific practice.

Back in the UK

The medical profession and the Department of Health have been making every effort to cross our own quality chasm.

In December 1997, the Government published a White Paper “The New NHS”. The Chief Medical Officer, Liam Donaldson, in July 1998 published an article that proposed a robust framework of a high-performance system where healthcare professionals and managers will be working together towards a common goal of delivering safe & high quality of care to our patients.

An organisation with a memory; report of an expert group on learning from adverse events in the NHS was published in the year 2000. It stated that in NHS hospitals alone around 10% of all admissions (or at a rate in excess of 850,000 per year) adverse events occur in which harm is caused to patients. We saw, during this time, the establishment of CHI & NICE to safeguard patient care.

2013, more than 12 years have passed. Multifarious efforts have been made by various parts of the NHS quangos and other patient safety organisations to make a significant difference in our aspirations for patient safety and quality improvement. Patient safety still seems to be a real hard nut to crack!

2013 has seen a tsunami of government funded reports into some atavistic failures of healthcare delivery systems. The second cycle of the Francis report made 290 recommendations over 1782 pages. Patients’ families and friends, citizens of the country had questions. A lot of them still remain unanswered!

A review of mortality figures in 14 hospitals in England was the next revelations to hit us in the face. This was followed by Don Berwick’s review.

Quo Vadis!? We ask with respect. Have we lost our memory? Are we really lost? Have we gone passed caring? Have we lost our passion for care, empathy and compassion, the Hippocratic zeal in doing no harm? Why are we not getting there yet?

Perhaps the answer lays in our shared culture- the invisible glue that binds us together in psychological contracts. A culture that allows individuals to thrive, feel supported and have the ability to express their beliefs, values and assumptions without fear. A culture that binds us all together as a family and allows us to do our best for our patients.

Recently a fair amount of attention has been given to understanding the organisational culture of the NHS. But whilst there are many tools for assessment of the cultural milieu of an organisation, none seem to be adequate for assessing the fundamental tenet of a highly successful health care practice.

It might be interesting to define the success paradigm by using ethnographic tools to analyse the social anthropology of the clinical systems of hospitals, the ‘clans in clusters’. This could help define their relationships with the system around them and help us understand hierarchical chain that connects the leadership structure in a healthcare delivery system. This understanding could help fix the apparent paradox of dyspraxia and execution paralysis.

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