Polishing Narcissus’s Mirror

this was originally posted on @Ayrshirehealth on 18 September 2013

One does not have to go far to find concerns being raised about our Health Service. Over the last 2 decades there has been a procession of headlines: Bristol Children’s, Alder Hey, Shipman, Mid Staffs, Vale of Leven, Morecambe Bay.

Each of these represents a myriad of disappointments, of betrayals of trust. Over this time the professionals, the professions and the institutions have been called to account. The climate has changed. The unquestioning acceptance of decisions has gone. It is clear that arrogant and overbearing professionals are not acceptable.

At the root of the change in professional culture is the expectation of reflection. Individual professionals are expected to be open and above all to reflect on the quality of their interactions and outcomes. The expectation of the appraisal and re-validation process is that it will deliver this open reflective practice.

As it is for the individual clinicians and their teams, so for the systems in which they work.
Health systems function at the macro, meso and micro levels. The micro level is that level of individual clinicians and their teams. This is where the rubber meets the road, where all the important clinical interactions occur, where the effectiveness or otherwise of the system becomes apparent. It is the level at which Quality Improvement is demonstrated.
No one would, or should accept clinicians being anything other than frank, open and candid about their processes or outcomes. The importance of this professional integrity cannot be overstated. That breaches of probity cannot be tolerated is self evident: at least as important is that the assessment of Quality and Effectiveness and attempts at its improvement are rendered unreliable without complete candour.

The Meso level is the level of the Institutions and groups of Institutions. These are the august institutions in which we all work. They engender a potent collective identity and the practices and standards which pertain define the culture of that institution. That culture is apparent to everyone, be they patient, carer, staff or visitor, who crosses the doorway. All staff are concerned about reputation of the institution. It perhaps bears consideration how best to bolster that reputation, enhance that culture. Many of the institutions named in the opening paragraph fell for the idea that accentuating the positive, minimising the negative was a short cut to an enhanced corporate image, that declaring excellence would make it so. The truth is that the institutions that have truly attained excellence, that have built a culture of, and a reputation for excellence, have done exactly the opposite of that. Institutions, such as Cincinnati Children’s, declaimed perfection, took responsibility for, and ownership of their shortcomings and mistakes. They took their weaknesses and crafted them into their strengths. They did not waste effort in trying to redefine success, to mistake mediocrity for excellence. To claim that one’s results are no worse than anyone else’s is not a mission statement of which anyone can be proud. Even if one does feel that criticism is unjustified, is it not better to put effort into trying to improve rather than into defending what may be an untenable position? Quite rightly that would not be acceptable in a clinician or clinical team; corporate reputation does not render it any more so.

The Macro level represents the state or country. Political or leadership ambition may similarly be attracted to that temptation to minimise bad news or over-egg achievements.
My plea is simple: Irrespective of the level at which one works, be it Micro, Meso, or Macro there is nothing equivocal about who we all serve. There is no place for serving the corporate master. The patient is the only proprietor. Ergo: the same imperative applies for open, transparent reflection irrespective of whether working at Micro, Meso, or Macro level.

It is to the great credit of your Board that concerns with data have been dealt with head on. It is the standard expected of us all. Organisational Hubris is not a driver of Quality. None of us should be wasting effort polishing Narcissus’s mirror.