Jane Carthey: Responding to patient safety incidents – lessons from a South African hotel chain

Could the CEO of a South African hotel chain help the NHS improve how we respond when things go wrong? At last week’s Risky Business 2012 conference, Arthur Gillis, CEO of the largest chain of hotels in South Africa, gave a presentation about embedding an excellent customer service approach among employees working in his hotels. He outlined seven steps that underpin excellent customer-focused culture when things go wrong:

1.    Run to the problem and apologise
2.    Take responsibility
3.    Fix it
4.    Have resource in reserve
5.    Minimise inconvenience
6.    Follow up
7.    Evaluate

Now think back to the last patient safety incident that occurred in your hospital or practice. Did the people involved run to the patient or carers and offer a timely apology? Or was the initial psychological response one of distancing and denial? The experience of many patients who describe how healthcare teams responded when they were harmed by their healthcare treatment suggests that the latter type of response is common. And the research on open disclosure has identified a mismatch between what patients expect to happen after an incident and what doctors think patients want and are willing to provide (Gallagher et al, 2003; Iedema et al, 2011).

The second point that resonated in Arthur’s presentation relates to the need to “have resource in reserve.” That is to say, hotel chain employees are taught to recognise that they need back-up when dealing with a serious customer service issue. Translated to the context of responding to a serious incident, the NHS needs to recognise that the healthcare team involved are the second set of victims. Also, the healthcare professional leading the communication with the patient or carer needs to be supported too. How many doctors, nurses, and allied healthcare professionals work in a hospital or practice where good support mechanisms exist?

Perhaps the most interesting lesson for the NHS is that “evaluate” is the seventh step in Gillis’s customer-focused culture framework. It comes after the apology and provision of support for both customers and hotel staff. This is strikingly different to the NHS’s approach for responding to serious incidents. It is in fact the exact opposite of what usually happens when a serious incident occurs.

In healthcare, we have a tendency to jump to the “evaluate” step first. We have conversations among ourselves about what happened and why (sometimes charged with assumptions about blame and causality). Our scientific and analytical nature, professional culture, and drivers in the healthcare system all combine so that jumping straight to the “evaluate” step is the norm.

Furthermore, once a serious incident investigation process has been initiated, healthcare teams can become so fixated on evaluating causality that the patient and healthcare team involved do not always receive the attention and support they need. Obviously, learning when things go wrong is vital; having robust incident investigation processes in place is an essential part of developing a learning culture in the NHS.

But as long as the NHS springs to the “evaluate” step first, are we in danger of not providing appropriate support to patients, carers, and colleagues involved in serious incidents?

Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003 Feb 26;289(8):1001-7.

Iedema R, Allen S, Britton K, Piper D, Baker A, Grbich C, Allan A, Jones L, Tuckett A, Williams A, Manias E, Gallagher TH. Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ 2011 Jul 25;343:d4423. doi: 10.1136/bmj.d4423.

Jane Carthey is a human factors specialist with 16 years NHS experience. Her research interests include measuring how human factors impact on surgical outcomes, improving patient handover, being open, and understanding the systems causes of non-compliance.