In the first half of a two-part article, Consultant Medical Microbiologist, Dr Michael Weinbren, head of Estates Risk and Environment at Belfast Health and Social Care Trust, George McCracken, Susanne Lee of independent microbiology consultancy, Leegionella, and Consultant Microbiologist at NHS Greater Glasgow and Clyde, Dr Teresa Inkster, argue that ensuring patient safety in new healthcare facilities requires a markedly different approach to design and construction. They advocate ‘no longer blindly following guidance’, designing with patient safety uppermost, heeding lessons from past projects – and especially unsuccessful ones, and ‘front-loading’ projects at concept stage with risk identification and consideration.
While dangers are recognised on the construction site, a safety culture for occupants about to enter a new building is conspicuous by its absence. The risks emanating from design, construction, and commissioning of a new healthcare facility where the occupants are particularly vulnerable is causing death and patient harm on a scale of magnitude higher than on the construction site, yet this largely goes unrecognised. This is evidenced by the multitude of reports documenting patient infections from the built environment. The situation is further complicated by the very fabric of our hospital buildings driving antimicrobial resistance – the legacy of which threatens the future existence of many of the modern developments in medicine.
Building occupant safety resides in a bygone era lacking a health and safety culture, although perversely the concept of the built environment affecting occupant safety dates back to Florence Nightingale. When projects go wrong it is very easy to blame a particular group of individuals, but in most instances, this would be totally incorrect. Understanding the basis for the failures is key to improving patient safety. The New Hospital Programme (NHP) is in a privileged position to implement unprecedented change to improve patient safety and change the way the construction industry works. This article examines why this should be the case, and the requirement for change.
Big headline stories
Recent issues with new hospitals making headline reading (Glasgow, Edinburgh, Papworth, Belfast) are too common, especially given that the number of new facilities under construction at any time is relatively small. The cost to society includes loss of life (largely due to avoidable infection), and financial (remedial actions, increased length of stay, litigation), the latter becoming a drain on NHS resources for the lifetime of the building. However, there is a much bigger problem (largely unrecognised) affecting every hospital, causing patient harm including deaths, and driving antimicrobial resistance. Whilst preventable, it first requires there to be recognition of the problem. History shows that major loss of life can occur in a variety of arenas – which either goes unnoticed, or is in some way accepted until a triggering event occurs driving change
The built environment and patient (occupant) ill health
Florence Nightingale is credited as being the first person to make the link between the built environment and patient illhealth – in her book ‘of notes on hospitals’ published in 1859. The first paragraph reads: ‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large, crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect.’
Some 170 years later it is even stranger that within days of opening new hospitals, such as the The Hôpital Européen Georges-Pompidou in Paris, and the Royal Papworth Hospital in Cambridgeshire, patients are contracting avoidable infections from the built environment, many of which prove fatal. A speaker at the Healthcare Infection Society Spring 2023 meeting detailed how Florence Nightingale’s hospital design provided better ventilation for patient areas than their new hospital, which failed to meet the ventilation requirements necessary to protect patients during the pandemic. While on the one hand Florence Nightingale is rightly revered, with her life being remembered each year, on the other it would appear that most people celebrating fail to understand what she taught us. Mitigating the risks from the built environment should by now have become a highly developed science.
Instead, most individuals remain oblivious to the risks. Hospitals may look more advanced, but this belies the fact that they are still harming the sick.
Developing a safety culture – the requirement for a triggering event
Florence Nightingale possessed several attributes essential to her success. While everyone else entering a Victorian hospital could not see the risk from the built environment, she alone not only did, but, being a statistician, was able to provide data to demonstrate the harm. Additionally, she used this to good effect to drive change. Her ability to recognise risk and provide supporting data were key to implementing change – the triggering event. Where such events have occurred in other sectors the nature of the trigger can vary.
The Woodhead railway tunnel between Manchester and Sheffield was completed in 1845, having taken six years to construct. Over that period 60 workers died, and over 140 were seriously injured. It was only after project completion that the true magnitude of harm was realised. A campaign by social reformer, Edwin Chadwick, highlighted that it was safer for an individual to have fought at the battle of Waterloo than to work on the railway tunnel. This shocked the public, and led to a government enquiry and changes within the industry – ‘big data’ being the triggering event. Despite the injuries and deaths being in plain sight to those working on the project, this alone did not generate change.
A high-risk occupation
This was 178 years ago. Such events surely are relics of the past? Not so. Until relatively recently, working in construction was a high-risk occupation. Deaths and injury were a regular occurrence, although across numerous sites, unlike the tunnel. Even so, they were accepted without question. Analysis of injuries and deaths across industries collected by the Health and Safety Executive identified the construction industry as a major outlier, driving the relatively recent culture change on construction site safety. The trigger for the culture change was ‘large data’.
Healthcare – where a strong safety culture would be expected to be inherently embedded – is not exempt from such striking incidents. In 2011/2012 neonates in Belfast died from overwhelming infection with an organism known as Pseudomonas aeruginosa. Avoidable neonatal deaths from Pseudomonas were not new. What was different about Belfast was that the number of infant deaths attracted sufficient media attention nationally and internationally to become a triggering event. As a result, HTM 04-01 was published, which – for the first time – recognised the role of water (the built environment) in transmitting 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
competent individuals.
a risk-based approach.
no longer blindly following guidance.
responsibility and accountability.
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 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
Manufacturers
Products need to be safe, reliable, readily decontaminated, installed correctly, and readily maintained. This may sound simple, but when dissected, is complex. Any product going into a water system must be free of contamination – the practice of water testing components is highly dangerous (nearly bringing cardiac surgery globally to a standstill), and must be stopped or mitigated against in a demonstrably effective manner. Product safety is complex – and while manufacturers’ instructions may appear exhaustive, they do not highlight the ‘critical control points’ which are essential to get right if the equipment is to be installed correctly and safely for the patient. The provision of training material which aids the correct installation of equipment should also be evaluated as part of the product. The role of manufacturers in this process should not be seen in isolation from that of procurement.
Procurement
Procurement has a pivotal role to play in driving improvements in equipment design, and thereby patient safety, but to date in many areas this is mostly lacking. Avoidable harm is currently allowed to compromise patient safety. From discussions with manufacturers it is clear that they rarely receive feedback on what works and what doesn’t with their products. The NHS is in a unique position to drive the change. The uniqueness comes from the NHS – in contrast to most other healthcare models – being a network, with the potential to harness feedback on products on a large scale. Additionally, not only does the NHS require better, safer designs, but it also needs new, innovative products in response to recently recognised issues.
The role of procurement in delivering patient safety is greatly misunderstood. Supplier and supply chain engagement at an early stage are vital to ensure that everyone understands the importance of their contribution to patient safety. This engagement is also important to ensure that projects are ‘de-risked’ – by helping those involved know how they will be supported in delivering a safe environment. This greater understanding will provide a substantial element of cost control to each project
Producers of guidance
A key question for the producers of guidance is what is their goal? Is the goal to produce guidance for the sake of producing guidance, or to inform the audience sufficiently to achieve the requisite goal? Guidance does not preclude the need for training. Issuing guidance without ensuring that the relevant training facilities exist has, and will continue to, affect patient safety. For example, when the update to HTM 04-01 was produced in 2012, no one would dispute the role of Infection Control as part of a multidisciplinary team to ensure water safety. However, no prior or subsequent training was available to Infection Control teams. Consequently, many infection control specialists are part of Water Safety Groups, but bring no added value to the table, because through no fault of their own they have not been able to acquire the necessary training. The way guidance is used, as already highlighted, needs to be rapidly addressed – it is an adjunct, not something to be followed blindly, and does not replace the need for a risk-based approach, combined with assembling the requisite expertise to deliver patient safety.
The NHS
An organisation with a memory was a report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer first published in 2000. In many ways this report was ahead of its time. A similar safety culture needs to be developed in recognition of the risks posed within and from the built environment. The NHS is responsible for building large numbers of healthcare premises, perhaps more than any other body globally. The current cost of failure relating to the built environment is unknown, but is likely to be in the order of billions of pounds. This does not consider the unnecessary loss of life, increased length of stay, avoidable use of antibiotics, and spread of antimicrobial resistance within healthcare facilities. The NHS has the opportunity to develop a unique safety culture for healthcare construction and maintenance which operates off the near misses; to date this approach has never been harnessed within this sector, unlike the airline industry
Not straightforward
A hospital new-build is described as a ‘once-in-a-lifetime opportunity’ for individuals. The working life of a hospital is around 30 years, so rebuilding a new facility is likely to only happen once during a career. Few, if any, therefore, are prepared for the process, which is nothing less than an onslaught. As a Chief Executive one might expect the process to be analogous to purchasing a new car, i.e. one simply needs to get a company in which designs and builds new hospitals. This is far from the case. While ratings exist for items costing only a pound, there is little to guide the purchaser who is about to spend the best part of a billion pounds on a new healthcare facility. The best one gets is that these companies have built hospitals beforehand, but there is often no way of establishing if these were successful.
It is essential that the NHS Trust’s Chief Executive and Board understand how risk is readily introduced into a project, which can destabilise a safe outcome. The Board needs to move from facilitating such a project to taking control. Architects, design teams, and construction companies will do whatever they are told, and equally want a successful outcome. However if instruction/guidance is not specific, they will proceed in their own way often unaware of the risk. Why should they be aware of the risk, when most others involved in process are not?
Reference
1 Building a Safer Future: Independent Review of Building Regulations and Fire Safety: Final Report. May 2018. http://tinyurl.com/ybywvrdm
April’s HEJ will include the concluding part of this article