Can healthcare organisations ever reach zero harm?

Stream: Safety | André Tomlin Mark Brown

At this year’s International Forum on Quality and Safety in Healthcare, taking place at London ExCeL in London’s docklands, there was a sense the discussions and presentations were taking place in a context where discussions of equity, harm, and the need for change took on a renewed urgency.

In a very narrow view of safety in healthcare, all risks of harm to patients, to staff and to organisations require mitigation and where possible improvement work to reduce or remove their occurrence. 

At the forum this year, the discussion of safety included more than reduction of clinical harm and error. A strong focus on equity and working with patients and communities as partners drew attention to the ways that healthcare services and healthcare systems can and do cause harm through the enactments of prejudice, the omission and under-representation of different groups in the data that guides clinical decision making and through the perpetuation of broader societal inequities. Lack of environmental sustainability was offered as another way in which healthcare organisations can cause harm by omission, brought clearly into focus by Daze Aghaji and Anthony Costello’s keynote.

As many presentations and talks across the three days in Newham stated, systems are perfectly designed for the outcomes they produce. The structure, processes and culture of healthcare organisations will, even if all error is removed, still create harm if the way in which they function is not equitable.

Poor care, variation in care, inappropriate care or care based upon assumptions and prejudices removes dignity from those that experience it and the communities to which they belong. 

Patient Safety Learning Chief Executive Helen Hughes said in March 2024’s We are not getting safer: Patient safety and the NHS staff survey results: “It is vital that we create a culture in healthcare that supports raising, discussing and addressing the risks of unsafe care. Results of this year's and previous years' staff surveys, coupled with evidence from patient safety scandals and whistleblower testimonies, show that in too many parts of the NHS this is simply not the case.”

This year the forum hosted a debate exploring the question ‘is zero harm a useful concept for patient safety’?

Eric Thomas, Professor of Medicine and Associate Dean for Healthcare Quality at the McGovern Medical School; University of Texas Health Science Centre, shared the opinion that idealistic goals, such as zero harm, encourage people and organisations to game the system, fudging outcomes or operating shadow waiting lists. This gap between what is known and what is expressed reduces motivation. For Thomas, major changes in healthcare emerge from marginal gains over time.

Henrietta Hughes, NHS Patient Safety Commissioner, speaking in favour of the motion, told the audience that attitudes in health and care are fixed on the past, on doom and gloom.  Hughes asked the question ‘how much avoidable harm would you like for your loved one?’ calling for a shared vision of zero harm such as set out in Martha’s Rule.

In 2021, Martha Mills was admitted to hospital with a pancreatic injury after falling off her bike. She died in hospital after developing sepsis. Staff did not respond to Martha’s family’s concerns about her deteriorating condition. In 2023, a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.

The three proposed components of Martha’s Rule, the first phase of which is rolling out across NHS England sites from April 2024, are:

1. All staff in NHS trusts must have 24/7 access to a rapid review from a critical care outreach team, who they can contact should they have concerns about a patient.
2. All patients, their families, carers, and advocates must also have access to the same 24/7 rapid review from a critical care outreach team, which they can contact via mechanisms advertised around the hospital, and more widely if they are worried about the patient’s condition.
3. The NHS must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least daily. In the first instance, this will cover all inpatients in acute and specialist trusts.

Harm persists because of behaviour within systems, and incentives to leave it unchallenged. A simple exciting vision, Hughes argued, allows for the sharing of power in achieving it with patients and colleagues.

Speaking against the motion Carol Munt, Patient Partner and Advocate, drew attention to the morale of NHS staff, already suffering from exhaustion, distress and ill-health. For Munt, zero harm is infeasible, impractical and harmful. To make an NHS, or healthcare system that is safe, risk must be understood and staff should not be overburdened and exhausted, putting them at risk of making mistakes.

Speaking in favour of the motion Jason Leitch, National Clinical Director; Scottish Government said that systems should at least aim for zero harm, giving the example of the aim for zero central line infection in surgical units in Scotland. Some clinicians opposed this aim, but NHS Scotland pressed ahead and succeeded. The zero harm aim did not achieve this alone, but it did contribute in setting a vision. People change systems, said Leitch and goals motivate people. Carbon net zero as a goal has led to quicker decarbonisation than a more conservative target.

Leitch, in defence of the motion, pointed out that it is a goal to which we have already agreed. The World Health Organisation’s number one objective is zero avoidable harm to patients.

Speaking against the motion, Aidan Fowler, National Director of Patient Safety in England,  said that everyone wants to see harm in healthcare minimised but zero is neither measurable nor achievable. Real incidents of harm get tied up in a debate about whether the harm was avoidable or not, increasing moral distress and feeding a blame culture. This means we miss opportunities to improve. We should be the best at getting better.   

Comments from the floor ranged from the opinion that Key Performance Indicators are not inspiring to the opinion that zero harm is a poor target, while zero harm culture is a better one. Another commenter said that the idea of zero harm suggests a condition of aiming for zero error in healthcare, which is unrealistic and creates huge barriers to learning and to speaking up and owning the mistakes that do happen. An attendee from Norway claimed that while its services have an aim of zero harm, harm still occurs. Another raised the NHS Ombudsman’s opinion that NHS organisations can have a culture of covering up, and the adoption of such an emphatic goal would encourage such culture and behaviours. Another commenter suggested that a moonshot goal and focusing on current challenges as they are presented to us is not an either/or proposition. One attendee raised the question ‘would you buy a car that has a defect?’

Voting on the arguments presented, an audience on X/Twitter and the audience in the room voted against the motion, deciding that zero harm is not a useful concept for patient safety.

If the goal of zero harm is considered to be too much of a stretch for healthcare, what then should be the approach when harm has occurred?

Kathryn Turner of Metro North Mental Health in Queensland, Australia presented to the forum on the topic of Restorative Just and Learning Culture.

Turner began by stating that “Metro North acknowledges the Traditional Custodians of the land upon which we live, work and walk, and pay our respects to Elders past, present and emerging.”

Talking about what restorative culture means, she said: “Aboriginal and Torres Strait Islander communities and other First Nations people have a long history of using Restorative approaches to respond to conflict and harm. Concepts of responsibility and accountability to community, relationship repair, family and community decision-making are part of First Nations processes used to resolve conflict and respond to incidents of harm. Restorative processes create the opportunity to understand the impact on families and community relationships, the hurt involved and who needs to be involved to acknowledge and repair harm to the extent possible.”

Turner told the forum that the way in which we respond to harm, compounds harm.  Compound harm emerges from the procedural responses that follow a harmful event or experience. She quoted Wailling et al, 2022: “Compounded harm arises when these human considerations are not attended to, resulting in shame, contempt, betrayal, disempowerment, abandonment or unjustified blame, which can intensify over time.”

Turner said it was important to foreground acknowledgement of the harm caused to patients and their families and to avoid presenting arguments that the complexity of systems removed responsibility for their failure

Restorative Just and Learning Culture is a development in Safety Culture thinking that addresses the importance of people, relationships and trust and applies a complex adaptive systems approach to system improvement. 

Turner shared Nick O’Connor, Kathryn Turner and Jo Wailling’s definition of Restorative Just Learning Culture (RJLC) as one that merges a range of restorative approaches with a continually developing understanding of learning and improvement applied to complex systems of healthcare. As defined “RJLC is a deeply accountable, forward-looking process that recognises that we work in complex adaptive systems and that we need new systems approaches to leading, learning and improving following harm. 

“Restorative practice is a ‘voluntary, relational process where ideally all those affected by a harmful event come together in a safe and supportive environment, with the help of skilled facilitators, to speak openly about what happened, to understand the human impacts and to clarify responsibility for the actions required for healing and learning’.

“A Restorative approach emphasises the central role of our interconnectedness through a web of relationships and the central importance of equity and respect. It requires us to balance the perspectives and concerns of all parties to support the dignity of each person and to restore it when it has been diminished.

“Restorative health organisations are guided by the principles, values, practices and priorities of a restorative framework. As well as handling conflicts, complaints and harm in a restorative manner, they develop policies and practices that recognize the needs of patients, families and staff as whole persons, exhibit a distributed style of leadership and inclusive decision-making, and proactively develop a culture of belonging and respect throughout the organisation.”

Restorative practice introduces healing as imperative that goes alongside learning and improvement.  In exploring what happened, it also asks ‘who has been hurt and what are their needs?’ and rather than asking who is culpable in a safety incident, asks ‘who is responsible and what are their obligations to people?’ Restorative approaches ask ‘how can harms be repaired and relationships be made right again?’ and ‘how can we mitigate the risk of harm? What would it look like to be free from this harm in future?’

The journey to a Restorative Just Culture came from, said Turner, an acknowledgement that their organisation’s approach to suicide prevention was not working, especially in the process of investigating when such an event took place. Even in a ‘no blame’ culture, processes still focused on working out exactly who was not to blame and excluded second victims from the process. In the time between 2014 and 2022 working with lived experience leaders, co-designing with carers, staff, patients and family, arrived at a restorative and just culture framework for dealing with such sad events.

In this framework, the needs of patients, families and carers, clinicians and the organisation are all given respect to the hurt tragic events cause.  

Patients, carers and families need support, healing information, engagement in review and learning. To meet this obligation, staff were trained in clinician disclosure. A postvention support structure was set up for clinicians to refer to. Families are engaged in the review process, being interviewed to get their perspective and to identify lessons they think should be learned. The organisation uses an Open Disclosure format to communicate the findings of the review to family, patients, and carers. They are also asked for their feedback to help evaluate the post incident process.

Clinicians need support, healing and learning. Metro North makes available an ‘always there’ trained peer support programme. Staff are actively involved in review processes, rather than feeling under investigation. They are also engaged in dissemination of findings and there is a weekly triage meeting to explore a broader range of incidents including near misses, suicide attempts and developing themes across incidents.

The organisation needs learning and support. They implemented a six step post Incident process that incorporates multiple perspectives (family, clinician and leadership); a forward-looking review of 'the clinical care pathway' rather than looking back from an incident; considers review against best practice, considered exploration of Human Factors, and view of systems through the Constellation Diagram. Involvement of team ensures work-as-done is understood; involvement of Leadership ensures work-as-understood is understood. They also consider what was done well, use SMARTER to assist with the development of high-quality recommendations and use a hierarchy of hazard controls tool to guide strength of recommendations. All learnings of relevance are incorporated into Recommendations, not just those deemed 'Contributory Factors'.  There is also overt support of staff following adverse incidents.

Turner says that everyone involved in a tragic event like suicide will focus most on the elements of Restorative and Just Learning culture that resonates most with their needs.  What is important is to maintain the focus on healthing first, then learning.

This focus on repairing relationships and healing harm presents an interesting step on from safety as the successful application of rigorous standards. In conditions where trust in healthcare has been impacted by scandals, falling capacity and historic exclusion and poor outcomes, a focus on holding and growing relationships between healthcare services and those they serve and actively addressing with compassion and organisational commitment the reality of harm seems vital. 

If zero harm is not possible, then healthcare systems may need to explore what it means to patients, to families and carers, to staff and to organisations when things inevitably go wrong.