Patient safety and junior doctors: are we missing the obvious?

To cite: Lemer C, Moss F. BMJ Qual Saf 2013;22:8–10. Doctors in postgraduate training posts are essential for delivery of acute care in the NHS. Arguably, amongst the most engaged and energetic in the health care workforce, they occupy an organisational space that lets them see good and bad practice and experience first hand both what happens when an organisation works well and the failings that all too often line up to cause harm to patients. And yet, these doctors are only marginally involved in the running of the organisations in which they work. Failure to involve such a key sector of the health care workforce in quality improvement initiatives does a disservice to doctors in training and the patients they care for so ubiquitously. Leading quality improvement therefore requires not only clinical knowledge of effective interventions but also a clearly defined set of organisational skills and an understanding of organisational behaviours. Sir Donald Berwick articulated these skills two decades ago 2 and the NHS institute for Innovation and Improvement now includes some of them in its Medical Leadership Competency Framework: demonstrating personal qualities, working with others, managing services, improving services, setting direction and demonstrating personal qualities. The Medical Royal Colleges and the General Medical Council, who set and approve speciality curriculums, recognise the importance of these skills which are referenced within curriculums and within guidance for practice. Most doctors in postgraduate training programmes do not formally acquire these skills as part of their clinical experience and training. A few work with clinical supervisors who are also clinical managers and so do learn about the skills for organisational change. For many, learning about this aspect of medical practice is concentrated within a single ‘management courses’ set apart from their clinical work and usually at the end of their training programme. Not surprisingly, many newly appointed consultants undoubtedly feel ill prepared for the organisational aspects of their work and are not equipped to lead quality and safety improvement initiatives. By separating learning about the clinical care of individual patients from learning about the care of the organisation and teams whose effective functioning underpin effective clinical care, the education system seems designed to produce precisely the results it delivers. That is, doctors who are relatively well prepared to look after individual patients but poorly prepared to make and support organisational changes crucial for continuous improvements in the quality and safety of care. So, there is has been a clear gap between what we provide and what is needed. Recently, a number of discrete initiatives and projects have demonstrated the significant benefits of engaging doctors in training in quality improvement and change management within the hospitals or practices in which they work. A systematic review of the literature identified a numbers of educational programmes aimed at various levels of clinicians and which may improve clinical processes. In a recent survey, junior doctors who had taken part in such programmes reported a greater likelihood of improvement projects succeeding. However, these programmes are not universal and many doctors in training are still not able to access them. Furthermore, a recent review of training on improvement, by The Health Foundation suggests that few data exist to identify which sort of programme is most effective and indeed, at whom this should be aimed. The study reported by Durani et al highlights the degree to which attitudes to quality improvement and patient safety EDITORIAL