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Implementing 'Whole Systems' Change


Jo Cumming Outlines Miscommunication Disasters to Highlight that Organizations Need to Implement 'Whole-systems' Approaches to Change

Challenging Beliefs and Changing Behaviours

It can be hard to change behaviours when the task is one which people view as easy, think the required behaviours are obvious and believe they are doing them well.

An example is handing over information from one shift to the next. The belief being that if I have told the person what needs to be done the person knows what needs to be done. If it was this straightforward, handovers would not result in disasters across safety critical sectors.

What are the Potential Consequences?
The potential hazards of miscommunication are highlighted by the fact that 60% of 'stuck-pipe' incidents on oil platforms offshore happen within two hours of shift handover, mainly due to inadequate passing on of information.

Following the Piper Alpha Disaster, the Cullen Report concluded that one of the many factors that contributed to the disaster was failure of transmission of critical information at shift handover. This led to the incoming shift taking actions that initiated the disaster. The report concluded that there were no written procedures for shift handover, the type of information written as notes, and communicated at shift handover, was left to the discretion of the operator and there was no categorisation of important items to include in the handover.

In the nuclear industry, information passes over more than one shift and the potential for error grows - as happened at BNFL's Sellafield works when highly radioactive material was discharged to sea.

Clinicians are also concerned at the potential risks of ambiguity and poor communication, especially when trying to maintain continuity of care across shifts. Much time is wasted dealing with information that is not conveyed clearly. As it is likely that at least 80% of the working day is spent communicating in one form or other, the opportunities for misunderstandings and error are always present.

There are two aspects to this communication. First, identifying what needs to be communicated. The second is how this information is communicated. Is it clear and free from the miscommunication and misunderstandings that can result in a failure to carry through medical instructions, with potentially lethal consequences? The 'Death of a Child' case catalogues a trail of communication errors. Poor delegation and handover of task responsibilities and inadequate notes were highlighted throughout the fatal sequence of events.

Implementing 'Whole Systems' Change
While well-designed procedures can reduce sources of error, real and sustained improvement is only achievable through a 'whole-systems' approach which addresses attitudes, beliefs and skills plus the tasks, structures and systems.

Working with groups of junior doctors we found they started off being sceptical about needing to learn anything. We first encouraged them to come with examples of effective handovers where they went into to the next shift knowing what was expected of them. We then invited examples of when this had not happened and the consequences for them and the patient. An important question we asked was 'who has a stake in a quality handover?' The doctors identified patients, parents, administration, medical defence and other professional staff. They began to appreciate how better quality information would give them more confidence in a range of situations. Only after this, were they prepared to change their beliefs and be open to exploring and learning about best practice. One had a 'Eureka' moment - "Just because I have told someone they may still not know what I know!" Another realised that "The only important thing is the message the receiver ends up with."

What is Best Practice?
The goal for medical handovers is to identify concerns and flag up potential problems through the transfer of prioritised information that is pertinent to the ongoing care of the patients. Case notes provide the opportunity to record critical data and review and capture the effect of past events. Both are at the heart of medico-legal responsibility and the ethics of good clinical practice. In addition to making sure the junior doctors understood these differences, the hospital had to adjust some systems and structures so handovers could take place.

Whatever the sector, and whether or not inadequate handovers between shifts have potentially serious consequences, ensuring the ‘givers’ of information know what they need to impart is the first step. The next step is improving the two-way process by building in insightful questions. Finally, the ‘giver’ needs to check if he or she has explained things clearly by asking the ‘receiver’ to confirm the priorities for the next shift.

While the clinicians’ project started with a focus on improving handovers, it quickly uncovered other issues. We found ourselves visiting change and learning, case notes and consent. We encapsulated the project in the title "That's not what I meant!", so named because we found people thinking they had made themselves clear, only to find that they had not, with potentially fatal consequences.