This article is a reproduction of an article published in HindSight magazine issue 32 in July 2021 on the theme of ‘The new reality’ (all issues available at SKYbrary)
Healthcare is perhaps the most complex safety-critical sector, and the challenges have only increased throughout the COVID-19 pandemic. Increasingly, human and organisational factors have come under the spotlight. Manoj Kumar is a consultant general surgeon with a background also in safety, human factors, and training. In this conversation with Steven Shorrock, Manoj provides insights and perspectives on the realities of work in healthcare, and the team’s role in improvement.
- The ‘new reality’ in healthcare has most elements of the ‘old reality’, in terms of leadership thinking and organisational culture.
- Those in positions of senior leadership need to be as adaptable and agile in decision making and learning as other professionals.
- Teams can resolve most problems and realise most opportunities, given the time, freedom and resources.
- Team-based quality reviews link reporting directly to regular team discussions, and feed the team’s learning back into training and the governance process.
- Focusing only on learning from adverse outcomes or snapshots of work can result in a lot of lost learning.
- Reducing unnecessary bureaucracy can enable horizontal communication and adaptability in an organisation, making it more effective.
- Issues of wellbeing and diversity are now issues of active reflection and discussion.
Steven: Thanks for making the time to talk, Manoj. I’m wondering how you got into the profession of surgery.
Manoj: I’m a general surgeon with an interest in benign upper gastrointestinal surgery and abdominal wall hernia. I perhaps came to this profession through a different path to most of my colleagues. I come from a far less privileged background and certainly there were no doctors in my family.
Steven: How did that influence your work?
Manoj: Well, when I got my medical degree and started my first job as a of
junior doctor, the first thing I noticed was that I was in a smaller minority in terms of background, but also in terms of my insight and my perception of this whole career. Then when I joined surgery, you can imagine it became even more evident. Very early in my career, I was also a patient in the NHS [National Health Service], so that also gave me that opportunity to see things differently from some of my colleagues, which I certainly found to be an advantage. I suppose I knew what it was like to be in a vulnerable position and to have anxieties that go beyond passing or failing an exam.
Steven: And you are also involved in human factors. How did that come about?
Manoj: I did my masters in the subject in 2009 at Aberdeen University. That again set me off in a slightly different path than most of my colleagues, which was great because this was definitely much needed in healthcare. I eventually got onto this role as the National Clinical Lead for the Scottish Mortality and Morbidity Programme which has since evolved to ‘team-based quality reviews’. So my current role is really split between being a consultant surgeon, focussing on elective and emergency work and that of my national role based primarily with NHS Education for Scotland.
Steven: What are the main challenges and trade-offs that come up for you in working with patients?
Manoj: I always wish I had more time to spend with the people I meet or see. I think most of us come into this profession knowing that delivering good care and building trust, especially with those who are at their most vulnerable when they meet you, requires spending a reasonable amount of time listening to their concerns, anxieties and hopes. What little time that we have, either on a ward round or in clinics, involves a constant battle between receiving vital information and providing the necessary information. And whether we like to admit it or not, something has to give if more or less time is spent with a patient. More time with a patient will impact on available time for something or someone else, often resulting in less time for ourselves, rest, families, home, etc. Less time spent with a patient can, and unfortunately does from time to time, result in near misses, ‘incidents’, or indeed harm. It can be difficult to get the balance right.
Steven: I was about to ask what a typical day looks like, but I’m aware that there probably isn’t one and I know you’re in surgery today, unexpectedly.
“Most folks don’t realise that ‘good’ and ‘bad’ often have the same origin story”Manoj Kumar
Manoj: This is where it gets interesting. I was not meant to be in theatre today. It has been a busy morning, having had to take a patient to theatre as my colleague got caught up with another clinical commitment. There’s an element of unpredictability in this work. And it happens fairly regularly, especially in the current climate. Most healthcare systems have been designed to run to get the most out of them, with finite resources. So everything has to fall into place on a daily basis. When something doesn’t fall in its place, then you see workarounds or trade- offs, which fortunately often result in a good outcome. But if someone forgets something or something unexpected happens and the right filter is not there to capture this, you can get a poor outcome. Then, it is not uncommon that this can evolve into blame of the person at the sharp end, or worse. Most folks don’t realise that ‘good’ and ‘bad’ often have the same origin story.
Steven: So it’s kind of running with very little spare capacity and few degrees of freedom. How does the pandemic change things? Is there a new reality for you?
Manoj: There is certainly a new ‘awareness’, though in a sense there isn’t a new reality as such. You have the same people running the same organisation and perhaps sometimes applying the same thinking to try and resolve a new challenge. Perhaps you will tell me it’s the same in other industries. The National Health Service is the best thing we have in Scotland and the UK, and it’s an amazing resource that we should all be so proud of and it can and will continue to improve. We do have to be aware that Sometimes the the culture can be ingrained with the same thinking or traditions that can hamper progress.
Steven: Are you talking about leadership?
Manoj: Yes, in part. There is always that risk of being trapped in an echo chamber where individuals may inadvertently surround themselves with like-minded folks who are likely to resist challenging the status quo. And sometimes, it is easier to get onto that ladder to these leadership posts if you fit that description. It can result in a rather exclusive club that naturally becomes detached from the ‘messy reality’ that you have written about previously. Those outside that exclusive circle may struggle to get a seat at that table – never mind get their voices heard – and those who do challenge may be viewed as a troublemaker or be ‘spoken to’.
Most in leadership roles are well- intentioned individuals trying to do the right thing. But it’s that issue of applying 20th century thinking that “this is what worked or did not work for us before” to resolve current complex challenges. We should reflect on past experiences but that should not paralyse our ability to take on new challenges.
I think ‘leadership’ is sometimes overhyped to the point where we see significant resources being spent on leadership programmes, etc. This, once again, is focussed on the few. And we are sometimes still left with command- and-control thinking.
Steven: Can you give us an example?
Manoj: Early in the pandemic, I noticed one hospital that came up with this concept of ‘gold’, ‘silver’ and ‘bronze’ leadership levels. And there would be emails noting that silver leadership has asked bonze leadership to do something. In a way, it made some of the staff ask where their position was – seat 38A at the back of economy class?
You can see the thinking: good individuals trying to do good things but with perhaps a misguided sense of what leadership is about. It perhaps can be described as this heavy-loaded goods train going on this one track, and you can get on it and get to where they think you should go, or you get off. But the reality is, things still function on the ground level.
Steven: So on the ground level, where do staff come into this in healthcare?
Manoj: You have this brilliant group
of people who regularly go beyond reasonable expectations to make a significant positive contribution to their workplace and care that is offered. We have to be conscious that some of these brilliant people do get left behind, sometimes because they are not given the opportunities to progress for unfortunate reasons and biases. Or they are viewed as ‘difficult’ because they have challenged the status quo. They naturally become withdrawn and disengage. And so you do lose that diversity in thought amongst other things.
I have always believed that the focus of any organisation should be on teams – that collective will or sense of shared purpose. This is what we should be investing in. Give people the opportunity to get together and figure things out themselves and support them with the required resources and time to resolve these challenges.
And that’s what we’ve seen in the pandemic. It was those teams working day in, day out – cleaners, nurses, porters, doctors, and so on, working collaboratively under intense pressures – actually making a real difference, and they could do that because they were able to support each other, adapt and overcome problems. We have seen some countries that continue to be amazing because of the people, and not because of the leaders, at times. It can be similar in organisations.
“You have this brilliant group of people who regularly go beyond reasonable expectations to make a significant positive contribution”Manoj Kumar
Steven: You mentioned earlier about the heavy goods train metaphor for leadership and culture. How do you personally respond to that? Do you choose to get on the train and try to switch it to another direction, or do you stay on the sidelines?
Manoj: That’s interesting. The reality is it’s so complex that it’s a bit of both. Soon enough, you realise the wins that you can make. The key things that helped us are clearly articulating the ‘why’, showing there is a problem, and trying to demonstrate the pathway to how we can actually get there. This is why I’m so focused on these team- based quality reviews.
Steven: Can you tell me a bit more about the team-based quality reviews? What’s the thinking behind them?
Manoj: In the health service, there is a reactive approach to ‘harm’, which is to wait for a tragic event and then spend a huge amount of time and money on reviews trying to understand what went wrong. And these reviews may be led by individuals in senior positions who may not necessarily have had the support or training in concepts of human factors. There is also the added challenge of what ‘safety’ actually means to different people in different roles. And these reviews are often conducted with little input from those who were involved in the event, such as next of kin or the team delivering care. So there is that significant risk that the output of these reviews may be incomplete delayed, or, worse still, flawed. And their recommendations can have little impact in preventing another ‘event’.
If we can support people to get together to sit regularly and participate in a somewhat structured social process of inquiry to ask those questions, then we are on a start towards improvement. This means listening to patients’ and carers’ perspectives in these discussions.
One of the other things that is evident in review processes in healthcare services, perhaps more so in the NHS, is that they can be outcome-driven. We often look at a single snapshot in what is essentially a complex journey for the patient. The reality is that not all people who die in hospitals have had poor care, while there is a significant number of people who don’t die, but did have poor care. So, if we just focus on deaths, we’re missing a huge amount of learning and areas that require improvement, which if addressed in a timely manner could potentially prevent such terminal events. We need to expand the review processes.
Steven: What you do in the team-based quality review? What is the process?
“Traditionally in healthcare, whether we acknowledge this or not, reporting has been used to blame people. We are seeking to change that”Manoj Kumar
Manoj: Essentially, a team-based quality review is about having an informed workforce that have the time, tools and training to come together regularly and look at what has gone well and not so well in the care they provide. A significant element is bringing in the patients, families and staff perspectives into these reviews. The process starts with having the right systems in place to capture relevant information. Specifically, this is a reporting or learning system that can be accessed and used easily, but also one that can function as a learning resource. This information is then shared with the team who can use appropriate tools or frameworks that are grounded in HF principles to carry out the required analysis of why things worked well or why they did not. Traditionally in healthcare, whether we acknowledge this or not, reporting has been used to blame people. We are seeking to change that.
We saw an improvement in engagement and more openness in reporting when people understand the purpose of reporting, the benefits of a ‘systems’ approach to analysis, and work collectively as a team to find solutions to complex challenges. And this feeds back to the organisation’s governance process, to those who are ultimately accountable to ensure relevant changes are made or teams supported.
Steven: So, instead of the data going into a black hole where you don’t see it again, it comes back to you in a sense.
Manoj: Exactly. There are, of course, challenges, including how do we change the perception that reporting systems are synonymous with punitive repercussions. We need to change this thinking of reporting of adverse events as negative and reporting of ‘excellence’ as positive. The reality is that both are positive measures to help us improve the care we can offer. If we create a safe space and have right tools, right structure, right systems and processes, people actually speak up. And in complex systems, you need this to happen regularly in a manner that results in timely positive change. Otherwise, we will continue on this never-ending journey of waiting for something catastrophic to happen before we initiate expensive reviews and decide on change.
Steven: You’ve heard, of course, about all of the ways in which aviation could benefit healthcare. I’m keen to hear about the reverse – what front line operational staff in aviation and elsewhere can learn from healthcare. So that’s one example. Do you have any other examples of practices individually, as a team or as an organisation?
Manoj: One thing is that in NHS Scotland, we can call anyone from any speciality, in any hospital, and get their help without any significant barriers. Yes, there may be disagreements on the specifics of management plans, but this is good because it allows everyone to give our patients the best management plan possible. Whether it’s specific patient care or helping with training or reviewing organisations systems or processes, there’s a great spirit of cooperation.
Steven: On the pandemic, have any key lessons emerged, in terms of how it was before and how it is now…perhaps any changes you’d like to keep?
Manoj: There was, and perhaps still is, this situation that, if a wrong decision was made, it was on one healthcare professional alone. There was little understanding of the complexities behind decision-making, especially in healthcare. I think there is a greater recognition of the complexities that we all work in, why decisions make sense at a particular time and more and more you see an interest in understanding of human factors science and its significant relevance.
One other thing that the pandemic has forced us to look at closer is on wellbeing, especially stress, burnout, and dissatisfaction. People sometimes forget that those working in the health service also have lives outside of work and they have challenges like everyone else.
In the last year or so, we have also seen an increased awareness of issues around diversity. It may not be obvious to some, but this is also a significant safety issue.
These problems and challenges were always in existence and will perhaps continue to be there. But, interestingly enough, the pandemic has forced most of us to pause and reflect, and because now there’s more conversation on wellbeing, people are at least talking and continuing to raise awareness about it. And we are seeing changes, thanks to the masses who are pushing for change. I think people are looking within their teams and at themselves, asking, “how can we be better?”
Steven: You mentioned wellbeing and stress. Many are suffering in different ways. What kinds of things do you do to manage your own wellbeing? What kind of self-care strategies do you have?
Manoj: That’s a really good question. We asked ourselves this recently and a lot of us, me included, fall into this trap: you work and you go home. Unfortunately, the pandemic didn’t really shift much of that routine for those working in health and social care. I don’t play golf like most of my peers do. I’ve got two young girls of eight and ten years old. And if you ask me what keeps me sane and grounded, it’s them. We go on bike rides, walk and really enjoy doing those kinds of things. That’s what keeps me sane. It’s family.
Manoj Kumar is a Consultant General Surgeon and Associate Director of Medical Education at Aberdeen Royal Infirmary. He is an Honorary Senior Lecturer at the University of Aberdeen, Hon Clinical Tutor at University of Edinburgh and Fellow of the Royal College of Surgeons of Edinburgh. He has completed a Master’s degree in Patient Safety: A Human Factors Approach from the University of Aberdeen as well as the Scottish Quality and Safety Fellowship. He is the National Clinical Lead for Team Based Quality Review Programme with NHS Education Scotland which aims to improve safety reviews and processes in health and social care. He is also a committee member of the Law Society of Scotland’s Health and Medical Law Subcommittee and an ambassador for the Clinical Human Factors Group.