I recently had a conversation on Twitter about a national campaign called ‘Sign up to Safety’, which aims to reduce avoidable harm in the NHS. Now, avoidable harm is clearly something worth tackling. The sticking point for me was that they have a numerical target to reduce avoidable harm by 50%.
What I can’t understand is why anyone would aim to reduce avoidable harm by 50% – if it’s avoidable, we should avoid it! Not just some of it. Why would you want to be ‘half-safe’?
It’s like deliberately planning to retain the other 50% of harm! Which, of course, sounds silly – because it is silly.
There’s a lot that’s silly (and harmful) about such targets, such as the assumption that a target is necessary to make people want to reduce harm in the first place. If they know that reducing harm is important (i.e. a priority), then the target is irrelevant. It might even be possible to measure some types of harm reduction, so that’s good too, because then you have measures to help you understand how your harm reduction efforts are going. The target is still irrelevant though.
Anyway, why is the target 50%? How was this determined? Why not 55%, or 70%, or 81.648%? If it was set at 50% because it was deemed attainable, then what’s the point of the target, because you’re gonna attain it anyway, right?
Why is a 49.999% reduction a failure, whereas a 50.001% reduction a success? These invisible dividing lines between ‘good’ and ‘bad’ simply don’t exist in the real world. If you could reduce more harm than 50% then you would, wouldn’t you? If so, the target is irrelevant. If you wouldn’t, then why not?
How about if you reduced all the harm you possibly could, but this only amounted to 35% less harm? Have you failed? Why? What about if you had it within your gift to reduce harm by around 80-90%, but only reduced it by 55%? You’ve exceeded the target, but is this good?
Then there’s the stuff about method. How does a numerical target set at any level help you identify and address harm reduction opportunities? It doesn’t, because targets don’t provide a method.
Also, as I’ve said before, it’s better to aim for 100% (i.e. perfection) than just a fraction of your true goal. You’d then measure, learn and improve as you go along. Yes, in many domains (such as harm or crime reduction) it may not ultimately be possible to completely eradicate the object of your reduction efforts, but this shouldn’t stop anyone from trying.
Let me give you a few examples using the Stick People, to try and demonstrate why numerical targets like the 50% target for avoidable harm are pointless (not to mention arbitrary and prone to causing dysfunctional behaviour).
Here’s Stick Doctor. Today, Stick Doctor encountered two opportunities to reduce harm in her hospital. Guess how many she addressed? (Clue: It wasn’t one).
This is Stick Cop. Stick Cop currently has four investigations in his in-tray. He’s decided to investigate all of them to the best of his ability. Not just two.
Here’s Stick Child. Stick Child saw one opportunity to help a group of under-10s get their heads around some basic performance management concepts. He didn’t stop half way through.
Get it now?
If you have a worthwhile priority, just focus on that. Measure your progress, using the right measures in the right way. Learn and improve. You don’t need the target.
Reduce avoidable harm by reducing numerical targets!
By 100%.
InspGuilfoyle 
I think you’re thinking too two-dimensionally – this isn’t a target, it’s an ambition.
If we could reduce harm in the immediate patient encounter, we would of course avoid it. This campaign is about the harms that aren’t currently avoided prospectively, but on reflection could have been avoided if things had been done differently.
Let’s say stickchild had a friend with a rare disease. This patient has a routine blood test which shows they’ve suddenly been cured and they don’t need their medicine any more. A week later, that disease is back and they’re very poorly from not having that medicine for a week. Sounds like there was an accident with the blood test, however no-one involved wanted to harm this patient.
We could have a culture that seeks out someone to blame and mercilessly strikes them down with wrath (i.e. a zero tolerance of harm) or we could seek out learning opportunities from the incident to reduce the chance of this harm happening again. We don’t know if this “avoidable” harm could ever have been avoided – sometimes slips and lapses happen – but it could be something a simple as ensuring the person taking the blood sample only deals with one patient at a time.
So it’s not a case of deciding whether to stop this harm happening, it’s seeking to change things so that less bad things happen. Which 50% do we stop happening? Whichever ones we can.
Sometimes we have to accept that avoidable things can’t be avoided. Sometimes we can’t have the right people in the right place to make the things right things happen, sometimes the systems we use to keep us safe are overwhelmed. Healthcare is by definition the management of failed situations. We’d be permanently healthy if our bodies never failed to cope with what our happens to us. Healthcare is also an environment of considerable uncertainty, where the correct and most harm-free answer may never be known.
We’d all love healthcare to be zero-harm. There’s a boggling number of processes in place which invisibly prevent a huge number of harms occurring, but it’s an inverse exponential curve. The avoidable harms we can’t yet prevent are the really tricky ones to prevent.
You’re also confusing an initiative intending to be an open, collaborative quality improvement venture with a central imposed target culture. In the FAQ you’ll find this campaign “transcends organisational boundaries and will align the whole system to achieving our shared ambition. There will be no targets or ‘performance management’ from the centre – the energy, ideas and expertise will be found deep inside the NHS and within your organisation. ”
The 50% is an ambition will anyone be sacked if it doesn’t get there? I really hope that as long as we tried then the answer is no.
All valid Kev but I’m not sure they necessarily address the original point? In my experience the institutions which have arbitrary targets are the ones which also tend to embrace a name and shame culture. “The Emergency Department only achieved a 35% reduction in avoidable harm this quarter, causing XYZ NHS Trust to miss its target” – sound familiar? We all want to eliminate avoidable harm as much as possible: the more the better, no arbitrary cutoffs.
But is this a target? I don’t think it is and they’re saying it’s not (http://www.england.nhs.uk/signuptosafety/faqs/#three). Individual managers could turn it into a target.
We shouldn’t confuse ambitions with demotivations.
Thanks for your comments Kev. I agree with all you say in respect of tackling all opportunities to avoid harm, how difficult it is to measure, the probability that 100% will never be attained, and so on. In these respects we seem to be on the same page.
The only bit I disagree on is that the 50% target cited seems pretty explicit to me- despite the assertion in their FAQs that there will be no targets, there clearly is this one. Also, they talk of saving 6000 lives – how can anyone know how many lives will have been saved? That’s probably even more difficult than measuring harm reduction.
I’m with you 100% in supporting the aims of the campaign and I don’t doubt there will be some benefits, but I maintain there’s nothing to be gained from throwing that arbitrary 50% into the mix.
Whatever it is called, new measuring will only work if all the workforce are totally committed to any improvement. I think this is unlikely given the way medical staff have been treated. They will do their best to deal with the problem in front of them but instances of going above and beyond will be limited
#facepalm moment?
They’ve picked something which seems quite emotive, and very, very tricky to measure.
As for no targets, performance measures. Err well NHS England, CQC and the TDA (Trust Development Authority) all live and breath arbitrary numerical targets. One organisation notably absent from the list on their FAQ is Monitor (who licenses hospital to treat patients).
Guess what they use targets and performance management to run hospitals.
Great idea in principle, and actually pretty easy to start reducing avoidable harm, and like Simon says, why the hell would you only want to reduce it by 50%?
Which brings me back to #facepalm
I once heard a senior manager in my organisation say in a meeting (without an apparent trace of irony) “my target this quarter was 90% and I’ve hit 88%. So you could say I’ve hit 98% of my target.”
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