Timely recognition and resolution of concerns
Reasons for the difficulty
Questioning surgical practice is a professional and social challenge. For example, it can be daunting for team members to draw attention to the practice of their clinical peers, or more junior team members (such as trainees or nurses) to highlight concerns about their senior surgical consultant colleagues.
Medical managers also face a dilemma when dealing with responses. This type of scenario often presents with complexities that they have never encountered. This is exacerbated by the fact that they may lack formal training in – or induction to – their role.
One example is where a medical manager has no direct clinical experience of specialised or technical areas in surgical care. The only individuals with the expertise to make a judgement about the individual under scrutiny may be close colleagues, who are neither independent nor objective.
Our experience
The standard of response to concerns being raised about surgery is highly variable. Potential issues with an individual or team can be known about for some time in 'informal' hospital networks, yet a resolution has not been achieved. This is prevalent where concerns relate to poor standards of individual or team behaviour rather than clinical outcomes, or situations where behaviours are poor but clinical outcomes appear to be good.
Other situations include where deficiencies are recognised and attempts are made to address them, but any improvements are short-term. This can be exacerbated by changes of personnel at Medical Director, Clinical Director, or Service Manager level, all of which affect continuity of purpose and consistency of approach.
The sample of reviews here is a 'self-selected' group involving cases where a hospital has not been able to improve the circumstances without assistance. It involves situations where problems have persisted for some time. A core characteristic of our sample, however, is where issues have existed, they have done so for a long time and have not been resolved.
Therefore, a lack of early resolution means that the problems become far more entrenched and difficult, increasing the risks to quality of care.
Conducting discussion about surgical practice
It is our experience that discussion by surgeons (or other clinicians) about other surgeons can be strong and emotive, which in turn generates equally strong and emotive responses.
A small number of reviews showed that an individual may make unsubstantiated assertions that reflect a personal agenda. This leads to an extremely sensitive situation. In any dialogue that could become contentious, it is vital that distinction is made between issues that warrant further investigation and problems stemming from personal interactions between individuals.
The next stage
A delayed response to concerns can escalate to a situation where a discussion about surgical practice becomes confused with an interpersonal or organisational grievance or grudge. This leads to the response to concerns becoming procedural rather concentrating on patients and the quality of their care. Organisations over-focus on process and fail to ask the key question: how is this situation affecting the quality of surgical care being provided to our hospital’s patients today?
How this can improve
More effort should be made to improve the quality and frequency of discussions about surgical performance. Timely discussion of these challenges should be normalised, before they become more serious.
Organisations should seek external advice and support at an earlier stage so they have a better chance of resolving problems before they affect the safety of patients.
