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21 Nov

The Lessons We Can All Learn From Mid-Staffs

The Lessons We Can All Learn From Mid-Staffs

Tuesday 19 November was a landmark in the Dias household as the date of my daughter, Nicky’s nursing graduation ceremony at Sheffield Hallam University. Those who have been to these events know that the joy and pride in seeing your child’s success acknowledged is usually countered by the sheer tedium of seeing hundreds of other people’s success also being acknowledged so by the time the Vice Chancellor delivers the closing speech, the audience is usually more than ready for the proverbial sharp exit.

However, on this occasion, at around 8.00pm Professor Philip Jones, Vice Chancellor of Sheffield Hallam, stood up and addressed the graduates and their proud families on nursing, the NHS and, in particular, the Stafford Hospital scandal. Professor Jones’ short speech reminded the graduate nurses that the media regularly criticised standards of care whilst NHS management was in constant change. He then turned to the Stafford Hospital scandal, and, in particular the findings and recommendations of the Berwick Review.

For those not familiar with the events at Stafford Hospital or the response by the Mid Staffordshire NHS Foundation Trust, in essence, because of substandard care between 400 and 1,200 more patients died between 2005 and 2008 than would be expected in this type of hospital. The numerous enquiries and reports that resulted, in particular the Francis Report of February 2013, highlighted the managerial failures but often differed in their final recommendations. It wasn’t until the Berwick Review into Patient Safety, published in August 2013, and commissioned by the government, that the various recommendations and lessons to be learnt were pulled together. Professor Don Berwick, an American expert in patient safety and a Republican renowned for his criticism of publicly funded health, was highly mis-trusted by the medical establishment to begin with but the final report is now acknowledged as a landmark for future patient care.

So, where is all this going and what links my daughter, Professor Jones and Professor Berwick? Their primary link is a passion in caring for the vulnerable - my daughter practices it, Professor Jones facilitates it and Professor Berwick analyses it but where this is going is to ask whether the lessons in poor management revealed by the Review can be applied to other sectors?

The short review can be easily downloaded at https://www.gov.uk/government/publications/berwick-review-into-patient-safety and is certainly worth reading as the executive summary alone is worth the effort as the identification of the problems faced and the managerial system necessary to address these are largely universal and applicable to any organisation.

So, with due acknowledgement and apologies to Don Berwick, here’s a few samples, slightly altered to be more universal in their application to all organisations:

• Place the quality of customer care above all other aims.

• Engage, empower, and hear customers at all times.

• Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

• Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

• When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.

• Make sure pride and joy in work, not fear, infuse the organisation.

• Abandon blame as a tool and trust the goodwill and good intentions of the staff.

So, thank you Nicky for graduating and introducing me to the sage advice of Professors Jones and Berwick - if the lessons learnt from the health tragedy that was Staffordshire Hospital can be applied to companies, who knows, the Government’s spin on imminent economic recovery may well prove correct.

John Dias

Managing Director, Silver Bullet Marketing Ltd


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