The Patient Safety Movement has taken place on a background of required governmental changes to Healthcare. The speed with which these required governmental changes have taken place may be interfering with efforts to ensure safety within the NHS. published December 2015

1. Divisions C and F
J Spencer
December 2015 Slide 1
Organisational Management Theory and the
Patient Safety Movement
Not enough time for change
Dr Jennifer Spencer MB BAO BCh BMedSci BA,
Dual CCT (RCPsych), CAMH and Adult ID Psychiatry
Healthcare Fellow and Consultant Psychiatrist,
Neurodevelopment and Mental Wellbeing
University of Cambridge Departments of Psychiatry and Engineering (Div C and F)
Collaboration for Leadership in Applied Health Research
and Care East of England (CLAHRC EoE) at
Cambridgeshire and Peterborough NHS Foundation Trust
In deep gratitude to Dr Terry Dickerson and Professor Peter Jones

2. Divisions C and F
J Spencer
December 2015 Slide 2
The original project

3. Divisions C and F
J Spencer
December 2015 Slide 3
Methods
• Safety awareness and safety culture were measured at
different hierarchical levels within the management structure
of a mental health crisis team.
• Major changes in leadership and organisational structure took
place during the data collection phase of the project

4. Divisions C and F
J Spencer
December 2015 Slide 4
What we learned
Managerial versus Frontline Staff Perceptions
• Both Managerial and Frontline Staff perceived Safety culture to be
predominantly Bureaucratic.
• They perceived Individual Teams to be more Proactive and less
Reactive than the Organisation as a whole (p<0.01)

5. Divisions C and F
J Spencer
December 2015 Slide 5
What we learned - Systemic descriptions
• Frontline staff were aware of interconnected nodes where communication occurred
between different teams. They were aware of safety concerns that were occurring and
being addressed within the confines of the frontline staff communication network.

6. Divisions C and F
J Spencer
December 2015 Slide 6
What I did next.
I read a lot.

7. Divisions C and F
J Spencer
December 2015 Slide 7
The Framework
The Sociotechnical system
A set of processes that embrace the actions of a number of
individuals interacting with relevant technologies

8. Divisions C and F
J Spencer
December 2015 Slide 8
“Managers are not confronted with problems that are
independent of each other, but with dynamic situations that
consist of complex systems of changing problems that
interact with each other…
Managers do not solve problems, they manage
messes”
-- Russell Ackoff, Journal of Operational Research Society, 1979

9. Divisions C and F
J Spencer
December 2015 Slide 9
RTI (h)(s) Health Solutions: Market Access Planning Across the Product Lifecycle
https://www.rtihs.org/services/market-access-and-outcomes-strategy/market-access-
heor-and-pricing-strategies
We know these kinds of analyses take time.
• Most industries spend a lot of
time and resources thinking
about things before making
changes
• Time to market (TTM) is the
length of time it takes from a
product being conceived until its
being available for sale.
• A tacit assumption is that TTM
and product quality are
opposing attributes. Skipping
steps of the development
process compromises product
quality.

10. Divisions C and F
J Spencer
December 2015 Slide 10
Example of Satisficing Prospective vs Retrospective
Safety assessment in terms of Cost (internet industry)

11. Divisions C and F
J Spencer
December 2015 Slide 11
Best Practice Change Management
within a Sociotechnical system

12. Divisions C and F
J Spencer
December 2015 Slide 12
How do you identify what is missing from a Sociotechnical system?
(Sometimes Systems Engineering really is Rocket Science)
Maslow’s Hierarchy of
Needs (1943)
· Self Actualisation
· Esteem
· Social
· Safety
· Physiological
Bronfenbrenner’s
Ecological Systems
Theory (1979)
· Individual
· Microsystem
· Mesosystem
· Exosystem
· Macrosystem
· (Mega-macrosystem)
· Chronosystem
Temporal Plane
Bottom-Up View/Drivers/
Influencers/Enablers/
Perspectives
Side View/Drivers/
Influencers/Enablers/
Perspectives
Top-Down View/Drivers/
Influencers/Enablers/
Perspectives
SUPPLY-DEMAND
EQUATION
(SINGLE
TRANSACTION/
ITERATION)
SUPPLY
(AVAILABILITY/
ACCESSIBILITY)
ASPECT
DEMAND
(CONSUMPTION/
RECEPTION)
ASPECT
IN SPIRALS/IN
CIRCLES ETC.
(OVERALL
CONTEXT)
THE ‘NEED’ (N)?
Overall Need
Contextual
Model Diagram
∑_x^(x+n)
〖F(Nx)=Outcomes(Nx+n) 〗
Defining the Need that is to be addressed during a system change (Goodger 2015)
Economic
theories
Human Resources
(Change Management) theories
Continuous Improvement
(Systems Science) theories
Mathematics

13. Divisions C and F
J Spencer
December 2015 Slide 13
Information fed into the decision
making process
Figure 23: The FinalisedMMSpreadsheet Model Navigation Interface

14. Divisions C and F
J Spencer
December 2015 Slide 14
Why am I worried about these things now?

15. Divisions C and F
J Spencer
December 2015 Slide 15
How has the ultimate outcome of mental illness been
affected by changes to Healthcare over the last 20 years?
0
5000
10000
15000
20000
25000 1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
UK total deaths
attributable to mental
ill health
UK female deaths
attributable to mental
ill health
UK male deaths
attributable to mental
ill health
UK total deaths
caused by Intentional
self-harm
UK male deaths
caused by Intentional
self-harm
UK female deaths
caused by Intentional
self-harm
Care in the Community
is implemented
Sir Liam Donaldson publishes
"An organisation with a Memory"
Deloitte, Monitor and Parliament
implement the Foundation Trust programme

16. Divisions C and F
J Spencer
December 2015 Slide 16
At the same time, the overall amount spent on healthcare in the
UK has risen rather than fallen
2,036
2,457
3,300
0
500
1,000
1,500
2,000
2,500
3,000
3,500
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Per capita Total expenditure on health

17. Divisions C and F
J Spencer
December 2015 Slide 17
Are we making changes to the healthcare system too quickly
Is not enough time being spent on the design processes

18. Divisions C and F
J Spencer
December 2015 Slide 18
Questions for discussion
• Is the current healthcare reform process damaging to our desired
outcomes?
• If we ensured healthcare change was appropriately paced, would
outcomes improve?

19. Divisions C and F
J Spencer
December 2015 Slide 19
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University of Cambridge
Department of Engineering
Engineering Design Centre
MPhil in Engineering Report
A SYSTEMS BASED APPROACH TO TRANSLATE
FROM ‘NEED’ TO STARTING POINT
31st
July 2015
Amanda C Goodger
Supervisors: P John Clarkson, Nicholas H M Caldwell,
Industrial Supervisor: Adrian Davis