The curious incident of the Chief Executives in the night time
Yvonne Sawbridge, Senior Fellow (HSMC)
With the launch last week of NHS Improvement – the new regulator of healthcare providers - my thoughts have turned to regulation and inspection in terms of the value they add to a system.
It has reminded me of a story I heard a few years ago, at the height of the Mid Staffs crisis, when there was a palpably raised level of anxiety in the system. Boards were all (rightly) concerned about whether they could be confident care given in their Trust was good; PCTs were anxious whether they had been rigorous enough in their analysis of Trusts to identify any early warning signs; and regulation and inspection activities were burgeoning across the system.
Against this backdrop of anxiety, one PCT CEO told me about their public board meeting where a member of the public angrily raised the fact that in their local hospital he had seen a yellow (clinical waste) bag in a general purpose bin - the implication being that if they couldn’t even get the bin liners managed correctly, what else was going wrong? The PCT Board instructed their CEO to take action and immediately after the meeting, the PCT CEO called the Trust CEO and they agreed to walk around the hospital together later that evening, checking the bins.
When this story was shared with me at the time, I initially thought this seemed like a poor use of senior executives’ time, and an indicator of how extreme anxiety can distort perspectives and potentially create dysfunctional responses. However I have just been reading “The Checklist” by Atul Gawande, and he cites the story of a rock star who famously insists (it is even in the contract) that he has a bowl of M and Ms in his dressing room but with the brown ones removed – a painstaking task for some poor member of his entourage. On one occasion, the bowl did contain some brown M and Ms and the rock star refused to go on stage - reflecting the clause in the contract. Prima donna behaviour? Or was there something else going on?
Gawande excuses this rock star on the basis that because he presides over a complex production involving numerous technical processes and safety aspects his behaviour was entirely rational. Because if a simple, albeit tedious, instruction has not been followed, then what else might have been overlooked?
On the infamous occasion of the offending M and Ms, the show was postponed and everything for the performance was re-checked. As it turned out, the stage was found not to have been properly equipped and so a potential collapse and ensuing disaster was averted. So maybe not a prima donna after all, but more a full blown safety champ?
Back to the bin roving Chief Executives – and while checking bin liners should not be a routine task for Senior Management, seemingly trivial things can be the canary in the mine. When procedures are not followed - such as a clinical waste bag finding its way into a general waste bin - exploring what lies behind such oversights is an important task for senior managers. But in order to do this constructively, rather than creating a climate of fear and anxiety, a particular set of skills and understanding is required. So, how do we create a just culture in which curiosity is valued and oversights are acknowledged and explored?
This is the key – will this new regulator help develop a culture of curiosity and just acknowledgement of error, or will it create further panic and anxiety and knee jerk reactions? Time alone will tell.