DESIGN & CONSTRUCTION


infection with this organism. Prior to the trigger in Belfast, neonatal deaths from Pseudomonas went unquestioned. The airline and nuclear power industries might well be regarded as exemplars of how to implement a safety culture successfully. Air travel is the safest form of travel, despite the consequences of something going wrong being potentially calamitous – and in a way this is a major driver. If a plane crashes it is obvious to everyone, not just those with an immediate connection, but usually to the whole world, as it makes headline news. Another factor fundamental to airline safety culture relates to the Heinrich ratio, illustrated in Figure 2. It may appear innocuous, but it contains an extremely powerful message. For every 330 accidents, there are 300 no injury accidents, 29 minor injuries, and 1 major injury. The airline industry focuses on collecting data on the near misses – the 300 ‘no injury’ accidents.


The Hackitt report and the New Hospital Programme – the trigger event for occupant safety The new build process is very much dependent upon guidance and compliance. Guidance and compliance alone have a strong track record of failure across many industries. A building may be compliant, but it does not mean that it is safe for the occupants. The challenges with healthcare


construction need to be seen in the context of a background of problems across the construction industry. The Building a Safer Future report was published in May 2018, in response to the Grenfell Tower fire. It went beyond this unfortunate incident to look at the construction industry, which is described ‘as a race to the bottom’. An extract from the publication is shown in Figure 4. The Hackitt report lists some of the key changes required to deliver safe buildings, which include: n competent individuals. n a risk-based approach. n no longer blindly following guidance. n responsibility and accountability. n safety to the forefront.


The Hackitt report has thrown down the gauntlet to the New Hospital Programme – implement the right change or the outcomes will remain the same. The current approach to safety within healthcare construction might be seen as the antithesis of the airline industry. There is no learning from one new build to the next; in fact post-occupation reviews, if they do occur, are rare. A publication from 2005 surveying the early wave of PFI hospitals confirms this when it says: ‘Some problems encountered were unique to a particular building project, but most were common to all’. Thus, most of the readily identified problems were repeated from


Figure 4: ‘An outcomes-based framework requires people who are part of the system to be competent, to think for themselves rather than blindly following guidance, and to understand their responsibilities to deliver and maintain safety and integrity throughout the life cycle of a building’.


(Taken from page 6 of the foreword to ‘Building a Safer Future’ – a personal view from Dame Judith Hackitt 1 (pictured).


one hospital to the next. Additionally, each new build project tends to be bespoke – there is no honing of design to improve from one new build to the other. The New Hospital Programme is in a prime position to utilise and build upon all these learnings, thereby becoming the trigger event for major change to occupant safety, through: 1. Creating the first healthcare facilities to be designed around patient safety.


2. ‘Front-loading’ projects at concept stage with risk identification and consideration.


3. The first healthcare facilities to be designed to mitigate antimicrobial resistance.


4. Introducing innovation in process across the construction industry.


5. Changing the relationships with stakeholders, and thereby revolutionising product design.


6. Instituting a supportive learning and accountability governance process where risk can be identified and shared, rather than loaded onto the contractor. Fundamental to all of these outcomes is changing the culture to a patient safety risk-based approach.


How and where is risk introduced? ‘Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.)’ The quote above is taken from a


letter from Don Berwick (a champion of patient safety) to NHS staff produced in response to the failure at North Staffordshire Hospital. One of the findings from the Francis Inquiry was how North Staffordshire Trust had placed compliance ahead of patient safety. The key performance indicators used by the Trust (developed by the Healthcare Commission) had no bearing on patient safety. Almost every failure in healthcare can be traced to where patient safety was not at the forefront. Where is risk introduced in a new-build project? The stakeholders in such a project


are numerous, and might be perceived as being at quite a distance from the project site. At the centre of the image in Figure 5 is the healthcare facility, with its complement of doctors and nurses. Damage to patient safety may traditionally be thought of as originating from the staff in the immediate environment. What this image is demonstrating is that the further away a stakeholder is from the healthcare facility, the greater the harm that can be inflicted. This is because unlike a doctor and nurse – who may only affect a small number of patients – stakeholders at a distance can influence the outcomes of all the patients, not just within a healthcare facility, but in healthcare countrywide. Simultaneously these distant stakeholders can readily lose sight of their impact on patient care. Due to space constraints, Figure 5 does not show all the stakeholders involved.


Placing patient safety ‘front and centre’ A risk-based approach places occupant/ patient safety at the front and centre of the project; no longer do time and money become the primary drivers. A risk-based approach will not only be safer, but also more cost-effective, as there should be no unwanted surprises during the project or after occupation of the building. The new Queen Elizabeth University Hospital in Glasgow hospital opened £500,000 under budget. However, the cost of remedial actions to date is estimated in the first few years to be between £20 m and £30 m. Anyone involved in a new-build project


– even at a distance – can inadvertently make a decision which results in a patient contracting an infection. Informed governance describes a situation where everybody understands the consequences of their actions on patient safety. This is more readily achieved when there is a supportive learning environment. What follows are some examples of how


stakeholders at various distances can have an impact on patient safety.


March 2024 Health Estate Journal 31


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