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Corporate Manslaughter HSJ

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Corporate Manslaughter HSJ

  1. 1. Adapting organisational behaviour to safeguard against the threat of corporate manslaughter Stuart Emslie BSc MSc CEng MIHM FIOSH Healthcare Governance director & Visiting Fellow, Loughborough University Business School Former Department of Health Head of Controls Assurance for the NHS in England
  2. 2. Outline….. <ul><li>Ensuring compliance and implementing safeguards to minimise the risk of corporate manslaughter cases </li></ul><ul><li>Evaluating services and processes to reduce systemic risks </li></ul><ul><li>Providing effective risk management training to engage all staff in their responsibilities </li></ul><ul><li>Promoting good management and the flow of decisions into policy </li></ul><ul><li>Balancing the need to rewrite policies and procedures with day-to-day compliance </li></ul><ul><li>Managing financial constraints and associated risks to sustain Act requirements in the long term </li></ul>
  3. 3. 1992: Compliance with Health & Safety Laws & Regulations <ul><li>Around 500 safety related statutes in UK </li></ul><ul><li>Approximately 60 of day-to-day concern </li></ul><ul><li>>100 authoritative codes of practice </li></ul>
  4. 4. Safecode……. <ul><li>Issued to all UK NHS organisations 1994 </li></ul><ul><li>Audit compliance against 60 key H&S statutes </li></ul><ul><li>Comprehensive module for setting investment priorities for safety/risk management </li></ul>
  5. 5. 1994
  6. 6. 1999 Controls assurance H&S standard 38 pages…..
  7. 8. 2004 Standards for better health “ While Standards for Better Health will synthesise a large number of existing rules and guidance, NHS bodies will continue to be subject to the wider regulatory framework, such as health and safety legislation.”
  8. 9. Organisational behaviour – a function of organisational systems Systems make things happen – people make it work Adapting organisational behaviour to safeguard against the threat of corporate manslaughter
  9. 11. r=.73, p<.001
  10. 12. Quality of job design (r=.59) Job satisfaction (r=.53) Intention to leave job (r=.53) Positive feeling with organisation (r=.62)
  11. 16. Norfolk and Norwich University Hospital NHS Trust <ul><li>Male, mid-forties dies due to air embolism during routine cardiac angiogram </li></ul><ul><li>Injected with air rather than radio-opaque fluid </li></ul><ul><li>No ‘safety check’ carried out </li></ul><ul><li>Trust successfully prosecuted under Health and Safety at Work etc. Act 1974 for not having a ‘safe system of work’ </li></ul><ul><li>Poor management……. </li></ul>
  12. 19. The Scotsman 14 October 2007 - http://news.scotsman.com/index.cfm?id=1641252007
  13. 20. ‘ UK: blunders by doctors kill 40,000 a year’ Sunday Times, 19 Dec 1999 “ Medical error is the third most frequent cause of death in Britain after cancer and heart disease…….kills four times more people than die from all other types of accidents.” NB – USA approx. 98,000/year; Australia approx. 10,000/year
  14. 21. www.jcaho.org
  15. 22. Failure Mode and Effects Analysis FMEA HFMEA TM SFMEA Failure Mode and Effect Analysis Failure Modes and Effects Analysis
  16. 23. FMEA Steps… <ul><li>Select a process (topic) </li></ul><ul><li>Assemble your team </li></ul><ul><li>Describe the process steps </li></ul><ul><li>Identify the ways in which each process step can fail (failure modes – e.g. drug maladministration; performing wrong site surgery; clinical mis-diagnosis; etc.) </li></ul><ul><li>Identify the root cause(s) of failure (Why?) </li></ul><ul><li>Identify the most likely effect(s) (i.e. consequence of failure) of each identified failure mode </li></ul><ul><li>Assess risk associated with each failure mode (consequence and likelihood – from risk matrix) </li></ul><ul><li>Identify additional controls required (actions to effect improvement) </li></ul><ul><li>Implement additional controls </li></ul><ul><li>Test process improvements </li></ul>
  17. 24. 1 2a 2b 4b 3b 3c 5 4a 3a
  18. 26. Ten steps to compliance? <ul><li>Ensure that you have in place an effective health and safety/risk management system, e.g. see OHSAS 180001:2007; HSG 65, Successful Health and Safety Management (HSE); AS/NZS 4360:2004 risk management (See also IoD/HSE guidance). </li></ul><ul><li>As part of the management system, ensure that a robust health and safety policy is in place. Within that policy all health and safety roles and responsibilities should be articulated. </li></ul><ul><li>Job descriptions of staff should reflect their role in health and safety management, particularly at a senior level. </li></ul><ul><li>Senior managers should be trained to ensure they understand their role in the effective management of health and safety. Reflect upon the competencies of existing senior managers with respect to health and safety management. Provide additional developmental opportunities to address any deficiencies. </li></ul><ul><li>Line managers should receive training to enable them to manage health and safety within the part of the organisation for which they are responsible. </li></ul>Adapted from Local Government Employers - www.lge.gov.uk
  19. 27. Ten steps to compliance?…..cont… <ul><li>Board members should receive awareness training on their role and responsibilities within the health and safety system. This is particularly important for non-executive directors. To help ensure adequate representation of health and safety issues, consider designating an executive director with responsibility for the management of health and safety. </li></ul><ul><li>Ensure that health and safety performance, including compliance with health and safety legislation, is regularly considered at board level. Remember that health and safety law applies to everyone , including patients! </li></ul><ul><li>Mainstream health and safety into decision-making processes and ensure proper scrutiny of the health and safety implications of policy decisions. </li></ul><ul><li>Ensure health and safety (including patient safety) is firmly part of an integrated approach to risk management across the organisation. </li></ul><ul><li>Adopt a robust and transparent approach to prioritising investment in improving the management of health and safety and other risks. </li></ul>Adapted from Local Government Employers - www.lge.gov.uk
  20. 28. THANK YOU! [email_address]

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