In his latest blog post, GP Hein Le Roux reflects on the differences between strategy and culture when it comes to patient safety.
In patient safety, an academic definition for strategy is a plan that takes you to your long-term safety goal, whilst the culture is more about people; the practice’s personality or ‘the way we do things around here’. So for me, strategy is about talking the talk, whereas culture is about walking the walk. Clearly strategy and culture are both important, but often there is a gap between the two. Leadership attitudes and behaviours, particularly on honesty, form a crucial bridge in the quest to connect a safety strategy to the generative patient safety culture that we are all trying to build.
If our leadership is able to create a supportive environment, then it is so much easier to talk about an error or near miss in an open and just way. Whilst system and process factors are very important, my firm belief for what underpins the culture we are trying to create revolves around the mind-set of people. Medicine traditionally has been very hierarchical, often with power and thus decision-making based on tenure rather than merit. In my experience, this can inhibit openness and learning.
One recognised antidote is a move to a flatter organisational structure where leadership is distributed to the frontline; this is where the real clinical responsibility lies and is to be welcomed. Often this is where the safety and quality challenges occur, but it is also where much of the determination to change things for the better lies.
I feel attitudes are changing and in my view leaders need to continue to foster a culture of honesty particularly by exhibiting more versatile leadership, based less on command and control and more on coaching and visionary leadership styles. These behaviours can empower and liberate the front line to make things much better for patients.
“Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic”
We regularly talk as a practice about our individual significant events which provide powerful learning. Encouragingly, we are also talking more about the systems and processes which underpin our work, with an appreciation of the impact of a decision or behaviour on other parts of the practice. A recent example was where one of my nursing colleagues came to me saying that she had given an incorrect vaccine to a patient and what should she do? She could have kept quiet and no one would probably have been the wiser, but she actively chose to be open and honest. We discussed the incident and she phoned Public Health England, finding out that there was a low risk of harm. She then phoned up the patient to let them know what had happened and to say sorry. They valued her candour. Furthermore, she reported it on the National Reporting and Learning System.
As is often the case, our internal practice significant event analysis revealed more of a system and process error and some ‘human factor’ issues – in this case, a busy clinic. We have all learned from this and the nursing team are developing a vaccine check list to reduce the chances of such errors occurring again. On a personal level I found my colleague’s attitude to be both brave and inspiring. In particular I noticed her feelings of anxiety, which made her honesty in coming forward even more of an act of ‘bottle’. Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic.
So why can it be difficult to come forward with an error or near miss? What psychological factors can bring out our defensive feelings? The themes contained in a book that I read recently called ‘Difficult Conversations’ by Stone, Patton and Sheen seems very relevant to this particular blog. Whilst it is dangerous to generalise, an observation I would make about myself and some GP colleagues is that we can cling to a purely positive identity of ourselves, which leaves no place in our self-concept for negative feedback.
If I think of myself as a super-competent person who never makes mistakes, then feedback suggesting that I have made a mistake presents a problem. The only way to keep my identity intact is to deny the feedback – to figure out why it’s not really true, why it doesn’t really matter, or why what I did wasn’t actually a mistake. If we are going to engage in honesty and candour then we are going to come up against information about ourselves that we find unpleasant.
We all make mistakes
The bigger the gap between what we hope is true and what we fear is true, the easier it is for us to lose our balance. One way to get around the overly simplistic all-or-nothing thinking is to be aware that we are all probably more complex than just ‘I am perfect’ or ‘I am worthless’. Just because something is missed or goes awry does not mean that I am a bad person. We all make mistakes and if we can’t admit that to ourselves it becomes harder to learn, improve and move on because we spend all our time and energy defending ourselves.
One reason people are reluctant to admit to a mistake is that they fear being seen as weak or incompetent. Paradoxically, from my experience, it is generally competent people who take the possibility of mistakes in their stride and are seen as confident, secure and ‘big enough’ not to have to be perfect.
Bridging the gap
In summary there is a saying that ‘culture eats strategy for breakfast’. In other words, it is easy to talk the talk on honesty at a superficial level, but walking the walk is psychologically much more complex. Leadership attitudes and behaviours are crucial in order to bridge this gap. What I would say about our practice is that whilst we readily acknowledge that we are not perfect, we actively try to be open and reflective, so we can learn and improve the service we offer. Honesty has obvious benefits for our patients and also to our colleagues both within the practice and across the wider health and social care community.
As everyone already knows it is tough in general practice these days, but the esprit de corps that this honest culture generates is immeasurable.