Openness, watchfulness and an appetite to continuously improve are the hallmarks of safe healthcare systems, according to Mr Terry Symonds, Deputy Secretary, Department of Health and Human Services. In this special feature, Mr Symonds says people working in integrity agencies, particularly those in the health sector, can learn from the leadership and values of so-called high reliability organisations.
The health sector has multiple levels and lines of oversight – for good reason.
Most healthcare jurisdictions around the world have had their share of failures, sadly at the expense of patients and families who have suffered avoidable harm or loss as a result of poor quality care.
External oversight for patient safety (such as that provided by accreditation or the Australian Health Practitioner Regulation Agency) complements internal systems for:
- safer care, including professional standards and peer review
- the use of data for benchmarking and analysis
- rigorous quality improvement methodologies
- engagement of patients and families directly in their own care.
Above all of those levers is the role of boards in ensuring safe systems and a culture that values openness and continuous improvement.
Without that culture in place, organisations might respond to oversight with ‘compliant’ behaviour – seemingly endless forms for an audit trail, beautiful policy that is never implemented and seasonal bursts of activity to meet reporting deadlines or onsite inspections. It also encourages fear and silence – the opposite of what is needed to diagnose and improve unsafe care.
The best healthcare combines external oversight with strong, values-driven leadership from clinicians and boards. These ‘high reliability organisations’ have learned from aviation and other industries the importance of a just culture, to be watchful for near misses, small failures and counter-factual evidence, to encourage and protect staff who call out problems, and to learn and adapt their systems constantly through measurement and improvement.
External bodies – such as aviation authorities and inspection agencies – make important contributions to this process, speeding up and sharing practice improvements and protecting communities when local systems go wrong.
The links between safety and integrity are not hard to see. The cost of corruption is not only a waste of resources that could be spent on more and better care, but also loss of public confidence in our institutions and sector. Eventually, that confidence is critical to enable good public policy, and it must be treasured.
Clinician, CEO and board leadership is key to integrity in healthcare as much as it is key to safety. The values and behaviours required to address both are the same: openness, watchfulness and an appetite to learn and improve. Boards model and drive those values and behaviours from the top and senior clinicians do the same in clinics and operating theatres, in their supervision of trainees and in meetings with their colleagues. CEOs model and reinforce the culture in all their communications with staff and teams across the organisation and in their own practice.
Oversight bodies such as IBAC play a critical safeguarding role when local systems are weak or potentially compromised. They can also play a more strategic and advisory role to strengthen internal systems, cultures and behaviours.
IBAC’s analysis of corruption risks in the health sector, for example, includes a snapshot of reports and investigations conducted in health services, but also discusses more general risks for the public health sector.
Our sector has some structural features – such as the interwoven and interdependent public and private health sectors (not unique to Victoria) – which bring great benefits for patients and communities but also poses risks that need to be managed to ensure that public and private interests are appropriately and transparently managed.
The IBAC report explains the importance of positive workplace cultures in encouraging open discussion and reporting of potential problems. This issue has long been recognised in the field of safety.
IBAC is not the only oversight body; its report refers to a crowded space of regulators and investigators and some reports that potentially overlap in jurisdiction (for example, a cover-up of malpractice which might trigger both a workforce regulator notification and a corruption notification). I believe the onus is on the regulators not the reporters to get this right, through sharing reports where appropriate and allowed, and proper cross-referrals.
IBAC’s report is an important contribution to better governance in our sector and is required reading for leaders and regulators of public healthcare in Victoria. Our vision for public healthcare necessarily includes both high reliability and high integrity, and our community expects nothing less.