In the November 2024 issue of the British Medical Journal there was a controversial article discussing plans to regulate NHS managers, following an announcement from Health Minister Karen Smyth’s part of the turnaround of the NHS saying that we need a “culture of transparency that keeps patients safe.”
Time and time again, opaque practices and the manipulation of data and decisions have been central to failures in the NHS; Mid Staffs, East Kent, the list goes on. The lack of transparency erodes trust in the NHS, with patients and staff alike relying on open access to data and decision making to assess the quality of care, monitor patient safety and advocate improvement. When management, at Trust, through to NHS England level, obscures key information, the opportunity to identify and rectify systemic issues is lost and the public confidence in the NHS as a safe and reliable institution is undermined. This is often seen alongside a culture of defensiveness which can exacerbate the issues. By prioritising institutional reputation over transparency, leaders create an environment where errors are hidden rather than addressed, and that can lead to the perpetuation of unsafe practices. Even now, there are ongoing examples of this within the NHS. The lack of openness diminishes morale, inhibits improvement, and ultimately harms patients.
Regulation is not straightforward though, or may not even be the most appropriate tool for achieving the desired outcome. As Louella Vaughan outlined on X, there are numerous practical reasons and barriers to regulation that would need consideration. As Louella highlights, what we’re really looking for is accountability in decision making and making organisations stick to existing legislation and good HR processes.
The key is in transparency of decision making that results in accountability.
There are many key decisions made around operational planning and delivery. The balance of finances and safe (let alone optimal) service delivery is a tricky one to manage, and no one is saying there is an easy answer to this. Unlike where there is a clear decision in medical notes from a named consultant around a medical plan, what is often less clear is who has made certain decisions that impact ED crowding for instance, which we know now can have a direct impact on patients safety but rarely makes it into an individual patient’s notes. They can be difficult decisions, but they have an impact and it should be clear who made the decision and when it was implemented.
An example that we might see regularly is when an employee calls in sick and cannot make their shift, which reduces the numbers of staff (medical or nursing) in the ED to a minimum. Decisions are made, financial controls are applied, and shifts are (or are not) advertised at an enhanced rate. Shifts go out at the standard rate, which we know from experience will not get filled. It then takes 5-6 hours to authorise enhanced rates, by which time it is too late for anyone to realistically pick up a shift at such short notice. The decision-making behind this is often opaque and nameless.
The question is, could this be done? Who is accountable when the shift is understaffed, below the minimum staffing for the number of patients in the department, with the safety risks that follow? It doesn’t tend to be an individual patient safety risk, because most patients will eventually be seen, but we know both first-hand, and through ONS data and RCEM data, the cumulative effect of waits in the ED and the risk of mortality to the population of patients present at that stage. This is what we are looking for regarding decision-making and operational management of NHS sites.
CEMBooks can help with this as its key aim is to deliver operational excellence through transparency and visibility of decision-making from board to ward at all stages of the process – it is effectively like showing your working out in an exam. It shows how, at a silver command meeting, the actions were requested, who they were assigned to, the timeframe for delivery, the results of those actions, and how the closed feedback loop around communication was made to work. Rather than keeping this behind a closed distribution email wall our system gives transparency across the organisation about the decision making process.
This is what we are examining, and this is how a system like CEMBooks can help. Meetings and outcomes are not hidden away on closed distribution email lists, instead they are visible, open, and transparent for everyone to see. They are searchable for historical context, and decisions around the operational management of an organisation become as clear as the decisions around the care plan for an individual patient.
This is the future, and this is how using a system like CEMBooks can provide operational excellence and support the delivery of a safe and accountable operational system.
#operationalexcellence #cembooks #transparentdecisionmaking