• organisational failure
• patient safety
• change management

Every healthcare system has its disasters—high profile failures of care in which many patients are harmed, perhaps seriously, and lives are often lost. In the UK such tragic circumstances have come to light with alarming regularity in recent years,¹ and there has been a series of public inquiries into, for example, avoidable deaths in paediatric cardiac surgery in Bristol, negligent clinical practice in gynaecology in Kent, inappropriate post-mortem tissue removal and retention from children in Liverpool and, most recently and horrifically, the murder of over 200 patients in a period of 23 years by a general practitioner in Manchester.² The cumulative effect of this litany of misadventure is hard to judge, but it has certainly contributed to reducing the willingness of the public and the media to place their trust in clinical professionals and healthcare organisations, and has fuelled calls for more regulation and oversight of clinical practice and the performance of healthcare organisations.

Although the anatomy of these disasters is largely clinical—botched surgery, negligent diagnosis or treatment, errors in prescribing or administering drugs, clinical incompetence, and so on—subsequent inquiries and investigations suggest that their pathology is almost always organisational.³ These problems seem to happen in organisations with inadequate or weak leadership; organisational or geographical isolation and an inward looking closed culture; a lack of basic management systems and processes such as performance review and management; poor internal and external communication and a lack of openness or transparency; and disempowered groups of staff and patients who are unable to voice their concerns.⁴ Armed with this knowledge, one might expect that we could identify those organisations (or parts of them) which are prone to failure and prevent future failures from occurring. But the dismal repetitiveness with which such organisational failures happen suggests that this is far from straightforward. For example, in social care we have seen a succession of inquiries into the deaths of children at the hands of their parents or carers over the last 30 years,⁵ culminating most recently in the case of Victoria Climbié discussed in the accompanying editorial by Marcovitch.⁶ After each inquiry, social workers, healthcare professionals, educators, the police, and other public services have been castigated for failing to spot the obvious signs that children were at risk and failing to act to protect them in time. In each case a picture has emerged of organisational failure—poor communication, inadequate systems for record keeping and case management, unrealistic workloads, weak or absent middle and senior management, and a lethargic culture of learned helplessness in which unacceptably poor standards of care become the norm. Each inquiry or investigation makes many recommendations but they are either not implemented or they do not work, for the tragedies keep happening.

There may be three reasons for this, related to (1) the way that instances of organisational failure are identified; (2) our approach to investigating and understanding their causes; and (3) the mechanisms for using that understanding to bring about changes which would make future recurrence less likely.⁷

Firstly, it is almost wholly a matter of chance whether an instance of organisational failure is brought to the surface and exposed, or lies concealed. Healthcare organisations and the healthcare professions have traditionally dealt with such problems informally and secretively,⁸ and it seems likely that there are many more instances of such disasters which never attract widespread public and media attention and are never subject to a formal inquiry or investigation. In some countries the process of medical negligence litigation reinforces this tendency to concealment through the use of non-disclosure agreements and out of court settlements, and market pressures among competing healthcare providers mean there are strong disincentives to honesty and openness. The responsibility for identifying major organisational failures and initiating an investigation is often fragmented between professional regulators, healthcare providers, and government authorities. A better and clearer definition of the circumstances or instances which should trigger a formal investigation of organisational failure is needed, alongside more robust and coherent systems for initiating and managing such investigations or inquiries.

Secondly, the techniques used for understanding and learning from the causes of organisational decline and failure in healthcare organisations are rather limited. In the UK we rely too much on the reports of individual, ad hoc inquiries and investigations which are effectively single case studies of instances of organisational failure. These are often conducted by an inquiry panel led by a lawyer, which takes a quasi-judicial approach to finding out what happened and may be more effective at describing the events with forensic accuracy than at prescribing effective organisational changes which would prevent them happening again. The process of investigation is often slow and costly, but still lacks rigour and sophistication. Moreover, we have no mechanisms for accumulating investigatory expertise and building up a cumulative understanding of organisational failure across a series of such events.

Thirdly, there are few—if any—mechanisms for following up inquiries and investigations and ensuring that other healthcare organisations have learned from past mistakes and made changes which would make their recurrence less likely. Once an inquiry report has been published, public and media attention is short lived and the boring but crucial process of implementing its recommendations and making changes happen is often not followed through, or is left up to healthcare providers and professionals to do with little support or oversight. Unsurprisingly, some are better than others at this, and it seems reasonable to hypothesise that those organisations which are least effective at making such changes happen may also display more of the common characteristics or determinants of organisational failure which were outlined earlier.

If healthcare systems had better mechanisms for identifying, investigating, and learning from major organisational failures, they would almost certainly be better at preventing such failures in the future, and so would avoid the considerable harm that often results for patients, clinical professionals, and healthcare organisations. At the same time, more research is needed to develop a better, theoretically informed, and empirically grounded understanding of the causes and determinants of organisational failure and how they can be prevented.

This editorial draws upon current research into major organisational failures in health care which is supported by the Commonwealth Fund, a New York City-based private independent foundation. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its director, officers or staff.