Can cross-industry principles help NHS mental health services?

by TheEditor

Categories: Investigative, Management, Mental Health

For this post and all others (past and present), by psychiatry I also mean mental health services. Whilst psychiatry is a medical discipline it sits within and is normally closely linked to other aspects of mental health services. 

Introduction

In this post I explore how mental health services can learn from disaster management, mistakes, and failures across other industries. I will be thinking about what can be learned from the perspective of NHS psychiatric services. I often study many videos on airline disasters, nuclear events, tsunamis, situations from aerospace, in addition to the usual from the NHS.  Some common themes tend to cohere when trying to manage chaos e.g.

  1. keep the plane flying which is analogous to keeping the patient alive (from suicide);
  2. ensure basics of procedures are followed;
  3. avoid information overload;
  4. do good communication and much more.

I am not trying to re-invent ‘clinical risk management'[CRM], though many of the principles explored will overlap with CRM. The focus will be more on organisational matters.  I gather some cross-industry principles (C-IP) examples then dig deeper into which have not fitted easily. Then I explore the concept of HRO.

Cross-Industry Principles – relevance to psychiatry

Industry / ConceptPrinciple or Insight from C-IPApplication in Psychiatry (for example)
AviationPrioritisation and FocusSuicide risk assessment before other therapeutic goals
AviationStandardised CommunicationUse of standardised protocols in crises
Nuclear PowerLayered Safety MeasuresMulti-disciplinary reviews for high-risk cases
Nuclear PowerRigorous Incident AnalysisIn-depth analysis of incidents for future improvement
Emergency ResponseCommand and Control StructureClear leadership in crisis interventions
Emergency ResponseRegular Drills and Scenario TrainingTraining for psychiatric emergencies
HRO ConceptPreoccupation with FailureEncouraging reporting of minor issues; learning from near-misses
HRO ConceptReluctance to Simplify InterpretationsAvoiding oversimplification in patient care complexities
HRO ConceptSensitivity to OperationsMaintaining awareness of front-line patient care
HRO ConceptCommitment to ResilienceDeveloping adaptive responses to challenges in patient care
HRO ConceptDeference to ExpertiseUtilising multi-disciplinary expertise in decision-making
Challenger Disaster InsightAttention to Minor AnomaliesMonitoring and addressing small signs of patient deterioration
General Disaster ManagementUnderstanding Cumulative Effect of Small ErrorsRecognising and acting on subtle changes in patient status

The above table is not meant to be exhaustive. It is a basic summary of some ideas. 

Previous struggles to graft on the NHS from elsewhere

The NHS has attempted to adopt various principles and methodologies from other industries to enhance efficiency, quality, and patient care. However, not all of these have seamlessly integrated or achieved the desired outcomes due to various factors like cultural differences, organisational complexity, and resource constraints. Here’s a list of some principles and concepts from other industries that have faced challenges in their adoption within the NHS:

  1. Lean Principles (Toyota Production System): Aimed at minimising waste and maximising efficiency, Lean principles from the manufacturing sector have sometimes struggled in the NHS context due to differences in organisational culture, the complexity of healthcare processes, and the need for a more patient-centric rather than process-centric approach.

  2. Six Sigma: Originating from Motorola, Six Sigma’s intense focus on reducing process variability and defects has not always translated well in the NHS, where patient care often requires flexibility and adaptability that rigid process control might hinder.

  3. Total Quality Management (TQM): TQM’s emphasis on long-term success through customer satisfaction has been challenging to implement due to the NHS’s multifaceted stakeholder landscape and the difficulty in defining and measuring ‘quality’ in healthcare as opposed to manufacturing.

  4. Theory of Constraints: This management paradigm, which focuses on identifying and managing bottlenecks, has been difficult to implement due to the dynamic and unpredictable nature of healthcare demand and the complex interdependencies within the NHS.

  5. Get It Right First Time (GIRFT): While this concept aims at reducing clinical errors, its translation into the NHS has been challenging because of variability in clinical practices, resource limitations, and the complexity of cases.

  6. Balanced Scorecard: While used for strategic management and performance measurement, the balanced scorecard has faced challenges in the NHS due to difficulties in quantifying healthcare outcomes and balancing financial, customer, internal process, and learning/growth perspectives.

  7. Benchmarking: The practice of benchmarking, common in business for comparing performance against industry standards, has been problematic in the NHS due to the diversity of services and the complexity of healthcare delivery, making direct comparisons challenging.

  8. Business Process Reengineering (BPR): BPR’s focus on radical redesign and overhauling of processes for dramatic improvement has often clashed with the incremental change culture in the NHS and the sensitive nature of healthcare services.

  9. Agile Methodology: Borrowed from software development, Agile’s iterative and flexible approach can conflict with the regulatory and compliance requirements of healthcare, along with the need for more predictable and stable processes in patient care.

  10. Just-In-Time (JIT) Inventory: Originating from manufacturing, JIT’s emphasis on reducing inventory levels and increasing responsiveness has been difficult to apply in the NHS due to the unpredictability of healthcare demands and the need for immediate availability of a wide range of medical supplies.

These principles, while successful in other sectors, often encounter unique challenges in the NHS, reflecting the complex, dynamic, and highly regulated nature of healthcare delivery. The successful adaptation of these principles requires not just the transplantation of methodologies, but also a deep understanding and modification to suit the healthcare context, particularly the unique aspects of patient care and the public health sector.

Enter High Reliability Organisation (HRO)

The term “High-Reliability Organisation” (HRO) first emerged in the 1980s. It was coined by researchers at the University of California, Berkeley, particularly in the work of Todd LaPorte and Karlene Roberts, who were studying organisations that operated in high-risk environments but had managed to maintain a remarkably good safety record. Their initial studies focused on organisations like air traffic control, nuclear power operations, and naval aircraft carriers, which despite their inherently hazardous and complex operations, demonstrated a high degree of reliability and safety. There was recognition that certain industries operate under conditions where the potential for error and disaster is high, yet they maintain an exceptionally low failure rate. This paradox intrigued researchers, leading to the exploration of practices within those sectors.

Early research laid the foundation for what would become a significant field of study in organisational theory and management, focusing on understanding how these organisations achieve such high levels of safety and reliability, and what practices and principles can be applied to other organisations to enhance their reliability, especially in high-stakes or high-risk environments.

At the heart of the HRO framework is an understanding that in complex and high-risk environments, the avoidance of failure is not just a matter of good fortune. Instead, it reflects deep-rooted organisational characteristics and practices that actively foster reliability and safety. These organisations are defined by their collective preoccupation with the potential of failure, no matter how small, and a commitment to learning from mistakes.

One of the foundational aspects of HROs is their relentless focus on potential errors. They operate on the premise that no error is too trivial to be ignored, and even the smallest anomaly could be a symptom of a larger problem. This philosophy drives a culture of vigilance, where risks are constantly identified and addressed before they escalate.

Another key trait of HROs is their approach to complexity and the refusal to oversimplify interpretations. They recognise that in complex systems, problems are rarely caused by a single factor. Instead of seeking convenient explanations, HROs delve into the nuances and intricacies of issues, understanding that simplification can mask underlying risks.

Sensitivity to operations, another cornerstone of HROs, ensures that those at the frontline, who are closest to the action, have a clear understanding of the current conditions and operational realities. This sensitivity enables quick detection and response to emerging issues, ensuring that potential problems are addressed promptly.

Resilience is also fundamental to HROs. They understand that despite the best plans and precautions, things can still go wrong. Therefore, they invest in developing the capacity to adapt and recover from unexpected challenges, ensuring continuity and reliability of operations under all circumstances.

Finally, HROs practice a deference to expertise, where decision-making is informed by the knowledge and experience of those with the most relevant expertise, rather than strictly adhering to a hierarchical structure. This approach ensures that the most informed and contextually aware decisions are made, especially in critical situations.

The HRO concept, therefore, is not just about the avoidance of errors, but about creating systems and cultures that are inherently designed to anticipate, recognise, and effectively manage the unexpected. It is about an organisational commitment to continuous learning and improvement, where safety and reliability are woven into the very fabric of the organisation. This framework, while developed in the context of industries with extreme risks, offers valuable lessons for any field, including mental health services, where the stakes are high and the margin for error is small.

Adapting HRO Principles in Mental Health Services

Adapting High-Reliability organisation (HRO) principles to psychiatric services in the NHS presents several challenges, particularly given the complex, multi-faceted nature of public sector healthcare. These challenges stem from the inherent differences between the environments where HRO principles originally evolved (such as aviation or nuclear power) and the unique landscape of NHS psychiatric services.

ChallengePotential IncompatibilitiesPotential Adaptations for NHS
Resource LimitationsHRO implementation can require significant resources not readily available.Prioritise cost-effective HRO strategies; seek incremental improvements.
Cultural ShiftExisting hierarchies and practices may resist HRO’s open, learning culture.Develop training programs focused on cultural change; incentive openness.
Complexity of Mental Health CareStandardisation is challenging due to individualised patient needs.Tailor HRO principles to allow for flexibility in patient care.
Interdisciplinary CoordinationDiverse professional groups may have conflicting approaches.Establish interdisciplinary committees to guide HRO implementation.
Political and Policy InfluencesFluctuating political and policy landscapes affect stability.Advocate for policy support of HRO principles; adapt to policy changes.
Measurement and EvaluationDifficulty in measuring complex, subjective mental health outcomes.Develop specialised metrics for psychiatric care; use qualitative feedback.
Training and Continuous LearningHigh workload limits time for training and development.Integrate HRO training into existing professional development programs.
Managing External ExpectationsPublic scrutiny and transparency demands can conflict with internal focus.Engage public and stakeholders in understanding HRO benefits and processes.

If HRO principles were to be implemented in NHS mental health services it would probably struggle with the range of incompatibles and potential adaptations to be made. 

Models and principles developed in other industries often face significant challenges when transposed onto NHS mental health services. This difficulty primarily arises due to the distinct nature of healthcare, particularly mental health care, which encompasses unique challenges, complexities, and demands that are often not present in other industries. Here are some key reasons why these models might struggle or achieve only partial grafting:

  1. Complexity and Unpredictability of Healthcare: Unlike manufacturing or other service industries, healthcare, especially mental health, deals with human lives where outcomes are less predictable and highly individualised. This complexity makes it difficult to apply models that rely on standardation and predictability.

  2. Cultural and organisational Differences: The NHS has its own deeply ingrained culture and organisational structure. Models from industries like manufacturing or aviation often require a cultural shift that can be challenging to implement in an established system like the NHS.

  3. Resource Constraints: The NHS operates under significant resource limitations, including staffing and funding constraints. Models from other industries often require investments in training, technology, and process re-engineering, which may not be feasible within the NHS’s resource framework.

  4. Patient-Centric Nature of Healthcare: The primary focus of healthcare is patient welfare, which sometimes conflicts with models that prioritise efficiency or cost-effectiveness. The patient-centred nature of healthcare requires flexibility and personalisation that may not align with the more rigid frameworks developed in other sectors.

  5. Regulatory and Ethical Considerations: Healthcare is heavily regulated, and ethical considerations play a significant role in decision-making. This regulatory and ethical landscape can limit the applicability of certain industrial models that do not account for these aspects.

  6. Interdisciplinary Nature of Mental Health Services: Mental health care involves a wide range of professionals, including psychiatrists, nurses, social workers, and therapists, each bringing different perspectives. Integrating models that do not accommodate this interdisciplinary approach can be challenging.

  7. Public Sector Dynamics: Being a part of the public sector, the NHS is influenced by political factors, public policies, and societal expectations, which can impact the implementation and success of models borrowed from the private sector or other industries.

  8. Need for Tailored Approaches: Mental health services require approaches that are tailored to individual needs, which can be at odds with standardisation and uniform processes characteristic of many industrial models.

In conclusion, while there is potential value in learning from other industries, any adaptation of these models to NHS mental health services requires careful consideration, customisation, and often a significant transformation to align with the specific realities and nuances of healthcare delivery. The goal should be to integrate the beneficial aspects of these models while preserving the core values and priorities of patient-centred mental health care.

Conclusion

The exploration of adapting principles from High-Reliability organisations and other industrial models to NHS psychiatric services reveals a landscape rich with potential, yet fraught with complexities. These models, while successful in their respective fields, encounter unique challenges when transposed onto the nuanced and unpredictable terrain of mental health care within the NHS. The inherent nature of healthcare, particularly mental health, with its intricate interplay of biological, psychological, and social factors, resists the straightforward application of principles designed for more predictable and controllable environments.

Central to this discussion is the recognition of the NHS’s distinct culture, operational framework, and the multi-faceted nature of mental health care. Principles like Lean, Six Sigma, and Total Quality Management, successful in manufacturing and service industries, confront significant hurdles. These include the necessity for flexibility in patient care, the complexity of mental health conditions, and the resource constraints endemic to the public healthcare sector. The NHS’s commitment to patient welfare often clashes with models prorating efficiency or standardisation, highlighting the need for a more patient-centric approach.

Moreover, the integration of models from high-stakes industries such as aviation and nuclear power into NHS psychiatric services cannot be straightforward. The High-Reliability Organisation model, for instance, emphases a preoccupation with failure and a culture of safety, which, while beneficial, demands a significant shift in organisational culture and attitudes within the NHS. Mental health care’s unpredictability and individual variability further complicate the application of standard procedures and metrics.

At first blush it may appear that HRO principles may grate against development of a no-blame culture. However, adopting HRO principles can actually support the development of a no-blame culture. By focusing on systemic issues and promoting open communication about errors and near-misses, NHS psychiatric services can create an environment where staff are not only encouraged but also supported in reporting mistakes. This approach aligns with the ethos of a no-blame culture, where the goal is to learn from errors to improve patient care and prevent future incidents.

My exploration also underscores the importance of considering the NHS’s unique regulatory, ethical, and interdisciplinary context. Models that succeed in other sectors often require adaptation to fit the ethical considerations, regulatory frameworks, and the collaborative nature of mental health services. Additionally, the influence of political factors and public policy on the NHS cannot be overlooked, as these external pressures shape the feasibility and implementation of any borrowed models.

In summary, while there is undoubtedly value in examining and learning from other industries, the successful adaptation of their models to NHS psychiatric services necessitates a careful, measured approach. It requires not just the transplantation of methodologies, but a deep understanding and modification to suit the healthcare context, particularly the unique aspects of patient care and the dynamics of the public health sector. The goal should be to judiciously integrate the beneficial aspects of these models while preserving the core priorities and values of patient-centred mental health care.

Further Reading and Resources

For a more comprehensive understanding, here are some suggested readings and resources:

  1. Managing the Unexpected: Sustained Performance in a Complex World” by Karl E. Weick and Kathleen M. Sutcliffe – This book provides an in-depth look at managing complexity and unexpected events in HROs.

  2. High Reliability organisations: A Healthcare Handbook for Patient Safety & Quality” by Cynthia Oster and Jane Braaten – A handbook that translates HRO principles into practical strategies for healthcare settings.

  3. Evidence Brief: Implementation of High Reliability Organisation Principles

  4. Journal of Healthcare Management: “High-Reliability Health Care: Getting There from Here – An article that discusses the journey towards high reliability in healthcare organisations.


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