Hello, it's Anthony Chadwick from the webinar vets, welcoming you to another episode of the UK's leading veterinary podcast, Vet Chat. I'm so pleased to have Mark Turner with me today. Mark is a Liverpool graduate and he has done a masters in patient safety, and we're wanting to talk about that whole area of quality improvement in practise, but before we do that, Mark, maybe tell us a little bit about your journey after leaving the best city in the UK.

I thoroughly enjoyed my, my time there, I have to say, after graduating. I got a job in West London in a small animal practise, with a very good reputation. I was there for a couple of years and have been in the, in the London area ever since in small animal practise, .

And then, a couple of years ago, I, well, more than a couple of years ago, about 8 years ago now, I got interested in, in patient safety and quality improvement. And, that led me to, do a master's, degree, a research master's degree at the RBC, looking at patient safety in the veterinary profession. And from there I've, I've continued having a, almost a love affair, if you like, with, with patient safety and its role in, in the veterinary profession, now and in the future.

Yeah, it's such a an important area, isn't it, and I suppose the first question that I would say is, you know, what was the journey that got you interested in in patient safety and and quality improvement in that practise? Yeah, yeah, I, inevitably in my, in my career, I've, I've made some mistakes. In practise, a, a couple stand out in particular.

One was a cat, that, that came in for a routine, operation, and unfortunately didn't make it through the anaesthetic. And the second one was a little bit later in my career. A dog, and, both of them inevitably, left, almost a, an indelible, mark, if you like.

And, I got, I got more and more interested in patients' safety and, . What, what I could do in the future to prevent a similar mistake, happening for myself. But the research that I was doing online led me to the formalised discipline of patient safety in the human medical profession.

And what they have learned through many, many, research papers about the things that make, patient harm more likely, and equally those things that help teams give a better service and make, patient harm much less likely. And that's a, as I say, a formalised discipline and, and obviously now the veterinary question is, is really on board with it. And understanding more, more about patient safety, in the veterinary profession.

I know, you know, I had the same experience as you, fairly newly qualified, going out to see a cow that had an abscess on its jaw and put a. Scalpel blade into there, and it was draining beautifully, decided I wanted to see if there was anything else going on. So put the scalpel blade in again and obviously hit a major vessel and, and the poor cow bled out.

And of course, it's really devastating, I think, for a young graduate, probably for any, you know, veterinary surgeon, because, you know, our, our primary aim is not to do any harm, and there it was that we'd, you know, I'd, I'd killed this cow. And I suppose it sort of feeds into the disease that a lot of vets have, if you like. It's, it's a good thing but it's also a bad thing and that's perfectionism, we, we really want to do everything perfectly and, and yet we are human.

We make mistakes. And I suppose part of. Of that is is learning from mistakes, you know, you often learn more from the difficult times in life than when everything is very successful, don't you, when those difficult cases occur or in, you know, general life as well, so I, I really get that and I suppose it is, is that.

Is it going to be endemic because we are perfectionists, or does that really make it less likely that we're gonna have accidents because we are so, so careful, but is there a damage to ourselves then, because we are, you know, not. Cavalier and we are so careful about things. How does that work, do you think?

Yeah, yeah, it's, it's a really interesting area, isn't it? And I think, I think what's important to say is that, so much of the time, what we do in practise does go well. And that is in no small way down to our perfectionism, our conscientiousness, our, ability to.

Multitask and, and work effectively in sometimes really high pressure environment. So, I think it's important that we acknowledge, you know, the positive side to, to perfectionism, along with our, technical expertise and the training that we've done at, at. At university, all these things make us, make us, professionals, and I, and I, and I don't think we should shy away from, from all of those aspects of, of our professional selves, but equally it can make us, it can make it difficult for us to.

Accept, when we do make a mistake, that's just all part of being human. And even though we have all of this expertise, we have all of this knowledge, and we are very good, as I say, at doing our jobs out in the real world, there are inevitably going to be occasions where, where we make mistakes because of our cognitive limitations as human beings, and that's just the fact of, of life, and, you know, as Homo sapiens, we're, you know, we're incredibly evolved. And of course sometimes things go wrong, you know, I'm thinking about a bitch bay where a ligature slips, and that may not be really a fault of the surgeon, it may just be, you know, it's a very fat bitch, it's been very difficult to do the operation, very deep chested, dog or whatever.

And, and I suppose the danger is then that we avoid doing things as well, so that, you know, there is a, you know, a kind of story going around that maybe newer graduates are less confident about trying things that perhaps 30 years ago vets would have had a go at. But I suppose also against that is they want to do them really well and if they don't feel they can do them really well, they're much more likely to refer those cases as well, aren't they? But obviously the basic stuff like bitchbas.

We have, if we're in a small animal practise, we, we have to do that, so sometimes it's also pushing yourself to put yourself into difficult situations, cos again that's how you learn, isn't it? Yeah, yeah, it's, it's, it's difficult balancing our desire to be perfect from day one, while at the same time developing, developing our experience and our, our knowledge base, once we're out in practise, I think, inevitably, you know, as we, as we learn on the job, there are things that we we might, in hindsight, think we could have done, better, but again, it's, it's, it's part of the learning process which, which individuals and practises go through all of the time. It's, it's almost, .

An integral part of working in the, in the medical professions that you know, things aren't always gonna go right and . I, you know, because we're working with, with animals, sometimes very, very rarely, hopefully, the consequences can be quite serious, but there are always opportunities to learn, and, you know, I, I for one can, can, speak from experience, you know, I, like we've said, I, I've made some, made some mistakes which hopefully have made me a better clinician, now than I was then. And what would you perhaps say were the main findings of the, the masters that you did?

What, what were the maybe two or three take home messages that. Are useful for us in in practise to reflect on and take on board. Yeah, so the, the research project was, a questionnaire that we, sent out to vets, nurses and practise managers to complete.

It was quite a lengthy questionnaire, so we're really grateful for, all those people that did complete the whole thing. We got 335 complete responses, so we were quite happy with that. Yeah, we, yeah, we, we.

Developed a, a, a list or a summary, if you like, of the main findings. I think one of the things that, that stood out for me was our, our lack of understanding in the best possible sense of the word, our, lack of understanding of some of the principles of quality improvement and the principles of patient safety, that, you know, as we've already touched on, that people simply make mistakes and, and even. Even the vets, even the best vets in practise will occasionally make mistakes.

So, once you have a better understanding of, of that principle, from that point, it's, it's a really good jumping off point to start investigating the, the events that, that happen in your, in your practise, to understand the underlying causes of those, of those accidents. So. For every, for every medical accident, there'll be a, there'll be a human error, but there'll be a, a series of events that led up to that, to that human error.

And those are the things that we, focus on, in significant event audits. So, so, . Maybe a lack of understanding of those basic principles hinder, hinder us when it comes to performing effective significant event audits.

It also, personally, I've found that that principle a really encouraging way to think about, to think about my day. They practised, you know, but if I do make a mistake, you know, there may be, learnings for me, personally, but there'll always be a, a, a, a sequence of events that led up to that. If I can better understand it, better understand those events, then, you know, we can all move forward as a practise to, to prevent that from happening again.

One of our value words, Mark, iss Kaizen. Which is very much er from the Japanese car industry which said right we've built a car that's not working very well, we're gonna stop the conveyor belt and we're gonna sort this problem out because we don't want to create more of those Friday afternoon type cars. Yeah that's the same thing if you don't learn from a mistake which often is more you know, across the whole business, it's not just one person, often there are other people involved in a, you know, in an anaesthetic or whatever.

And even in things like if we're, you know, sometimes it can be something that's happening a lot, can't it, like postoperative infections, if we're seeing a lot of postoperative infections, there's probably something wrong in the system of anaesthetics or sterilisation or the way that we scrub up for an operation. So some of them will be, you know, won't be single event items, will they, and then you've got to look, I suppose. More culture, I know we, we spoke about this and culture can be, is often, or it should come from the top in the sense of if it's a positive one, but a negative one often comes from the top or from the lowest common denominator in the business, and if, if, if the leader of the business is.

Not open to positive critique, then it makes life really difficult to do some of this patient safety and quality improvement. If, if I think I am perfect and do nothing wrong, I've actually stopped that ability to be continuing to learn, haven't I? Yeah, yeah, so, obviously, another interesting finding from our, our research was the, the role of, the organisation in developing a culture in which people, not just the time to sit down and, and investigate, the accidents in practise, but also have that, that inclination, to, to sit down and, and to want to improve.

And yeah, there are so many things that sort of feed into culture in a practise, aren't there? I mean, you know, there are, profession-wide cultural influences. There are sort of societal influences.

There are also personal influences on a, on, on the culture within a practise, but there are also organisational level, influences, on a culture. And I suppose at a very practical level, those are the ones that are most easy to change when we're looking to, institutionalised quality improvement and patient safety in our, in our practise or in our organisation. So, some of the things that we can, can do is, is, develop, develop people's confidence in speaking up when they, when they do see a mistake, develop their confidence in, in reporting those accidents, so they, so they can be investigated.

And that is, it is of course, where quality improvement starts. Did you know the webinar vet has a public community Facebook group? We want to ensure veterinary professionals have a place to stay in the loop with everything that's happening here at the Webinar vets.

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I remember a story about South Korea Airlines were crashing planes very often and it was because the junior pilots never felt that they could criticise the senior pilots, even if they saw he was doing something really wrong, so wrong that they were probably going to die, but they still couldn't er question that authority, and I, I suspect the same thing happens with consultants in hospitals and why you sometimes also get cover-ups because not so much in the . In the airline industry, but we obviously still see evidence in some of the reports that come out about particular trusts that just haven't seemed to do a good job in a particular area, and that might have gone on for years and years and decades. So we're all learning on this process, where none of us again are perfect at quality improvement either, are we?

No, that's right. And, yeah, one of the, one of the events in the airline industry that really transformed their, their understanding of, of safety and, and the causes of accidents, the causes of plane crashes, was the, and I forget which island in, in the. Canary Islands, but 2 747s crashed into one another, and I think it was 580 people died, and they, they, having, listened to the black box flight recorders, they built up this picture during their investigation of crew members being scared to speak up to the captain of the Dutch airliner.

As he decided to set off down the runway to take off, when he hadn't had explicit permission from the control tower, to do that. It was also foggy, so he couldn't really see what was going on at the other end of the runway. And, and that's how the crash happened.

So they, they started to understand that this, inappropriate hierarchy in The cockpits was actually the cause of a, a crash, which, you know, at first sight, might have been, might have looked like it had been due to other causes. And that was another finding from our research that, not everywhere, but in some practises, there's the potential for hierarchies that are too steep. So, you know, veterinary nurses, patient care assistants, see something go wrong, but don't feel.

Comfortable speaking up to, to a vet when they see him making an obvious mistake, and we have to, I think as vets. You know, I, I'm very much into a flat structure, nobody's better than anybody else that we can learn from, you know, the new graduate that's just come in with some new ideas. We have to be open to those.

Obviously we're not necessarily going to change the whole practise structure because a new graduate comes in because. You know, for me with systemization, it's about that there is a webinar that way of doing things, and if we have 10 people all doing webinars in a slightly different way, that's when, you know, we'll have failures of webinars and so on. So somebody may come up with a better idea, but the way to do it is to bring it into the meeting and say could we think about trying this, and then if there's 4 or 5 people who say, oh what a great idea.

You bring it into the business, don't you, so it becomes cultural, you know, there is a way of doing things in your practise or, you know, in any business, but it it's been decided by the group rather than necessarily foisted on people from above. This is the way we're now going to do things. It can create, create resentment as well, and I suppose that's again another place where perhaps er problems and and mistakes can come in.

Yeah, I mean, a, a really interesting, another really interesting field within, patient safety is, is psychological safety. So a slightly confusing, term perhaps, but psychological safety is, . Basically can be defined as the sense that it's OK to to say what you see, and that's irrespective of your, of your role in the practise.

Psychological safety, is an incredible part of developing a culture, within practises. Whereby, safety, for, for patients, can be improved, because simply teams are more effective at delivering high-quality care than individual, clinicians. Because individual clinicians, irrespective of their experience, expertise are capable as human beings to make mistakes.

The beauty of, psychological safety within a team is that other members of the team, if they, if they see that, that vet, or nurse potentially making a mistake, they feel able to speak up and say, well, hang on a minute, you've just drawn up, you know, 2 meals instead of 0.2. And, it's, it's a sort of.

Again, a, a massive cultural shift, but something, hopefully, that we're, we're already starting to, understand a little bit better within the profession. The idea that, not dismissing other people, not ignoring our members of the team when they, when they say something that's potentially significant or, or relevant. To the, to the animal that we're working on.

And, and I think I witnessed that firsthand. I'd just had an eye operation about two months ago. I didn't stop it going slightly wrong and I got a corneal abrasion, but that's another story.

But actually, the number of people who ask me exactly the same questions and also hearing, right, we've got X amount drawn up, right, we've got X amount drawn up in the syringe. A lot of communication, which was very verbal communication. Where you know, there was a right, are we operating on the right eye, you know, etc.

Etc. Because of course we hear of errors where people have, you know, kidneys taken out that they shouldn't or all sorts of things. So it, it is this comms is really important that you can have that free communication that you can chat through things as you know, before things start but obviously during as well.

Yeah, and it's, it's, it's also about slowing down to speed up, isn't it? It's sort of, stopping at the beginning of a, of an operation before you, you know, although, you know, with a, with a busy ops list, maybe your first instinct is just to crack on, induce the animal, but it's, it's stopping, maybe just for 60 seconds. A couple of minutes, worked through our checklist.

So it's slowing down to speed up, because we're then, much less likely, particularly on those busy days, to make a mistake, which would, would potentially then extend, the time we have to stay at work. And it is also about, like you say, systems and, institutions. Instituting systems, within the practise again, which are gonna lead to, to better quality services potentially.

So the classic example being, you know, checklists, but it could be many other things as well. I, I know, obviously, you know, you've done the masters and, and still working in practise, but also, have, have, have developed a real passion obviously for quality improvement and patient safety. Tell us.

A little bit about the, the website that you've developed, VetIt and perhaps how people can have a look at that and how they can get in contact with you if, if they need some advice on, on these areas. So, so is VettIt now up and running, can we, can we go on and and have a look at this website if we want to after the podcast? Yeah, so, FET QIT, is, is up and running.

It, yeah, as you say, it's, it's evolved from my passion for patient safety and quality improvement in practise, and the idea behind that. Behind the website was to give vets in practise, just a, a taste of, of what QI is and how it can benefit them and their teams. Of course, QI is, immensely helpful when it comes to .

Providing a, a, a really good standard of, care in practise, but, there's a lot of evidence now that QI tools and behaviours can, can drive up levels of engagement in practise as well, reduce, rates of burnout amongst staff members. So the, so the, the benefits, of using QI in practise are sort of, multi-level, if you like. We, we have developed a, basic training course, which introduces teams to, the essential, QI tools and behaviours that will help them, institute, some of the, QI principles in, in their practise.

QI can be a pretty Scary, scary area, I think sometimes, and, some of the, some of the words seem a bit dry and, and perhaps off-putting, and, and there seems to be a lot of work involved, and, but, but actually, we can make, we can make really significant progress by using just some really, particularly team-based behaviours, can help us start, start introducing some of these QI principles in our, in our practise. And when we, when we talk about quality, quality improvement, we're not talking about, quality, being poor now in practises. I mean, the standard of, of practise, in, in veterinary clinics up and down the country, of course, is, is, is incredibly high.

But it, but the idea behind quality improvement is just simply looking for every little gain that we can make. Every time we, we perhaps, observe a mistake or, or even just a near miss, it's, it's understanding that those are valuable lessons for us to, to investigate, so that in the future we can, we can provide an even better standard of service. To our, our patients and our clients, and the, and the payoff is that, teams feel even more engaging and excited about coming to work.

And and as you say, it's, it's involving everybody in the team and so they feel more valued in their role and, and obviously there's a training element, they get better, don't they, by, you know, it's, it's CPD on, on, on the job really, isn't it? Yeah, that's right. Yeah.

So, I mean, the the beauty of, QI is that, the, the evidence that we're using are the incidents and, near misses in practise that we can, that we can learn from. And, and, some of those, some of those learnings are, are really quick. I mean, you know, I think sometimes significant event audits sound like they're very sort of convoluted.

rather, rather scary events, if you like, in themselves. But, some of the learnings, you know, can, can literally be made within a small team in 10 minutes. Yeah.

And, and, you know, the old phrase is that an, an intelligent person learns from their mistakes, but a genius learns from other people's mistakes, and there are consistent mistakes that are probably made in veterinary practise, you know, I, I have to say I'm in the club of, you know, going and being told that it was a female cat and operating and not finding anything and then finding the repair of testicles or it was a, you know, it was a castrated male. And, and that is a training thing, you know, that's a nurse who obviously has prepped the animal, but also the vet hasn't double checked. So if you have that process which says, you know, with every case that we do, the vet as well as the nurse will check that the animal is.

A female and you know, of course we may not know if it's been spayed or not, we can check by looking at flanks, but of course we can miss a stitch. But at least we're not gonna try and spay, you know, a a an intact male cat, which obviously, you know, is gonna be difficult from the flank, isn't it? Yeah, yeah, yeah.

And, you know, I mean, I think, I think some of the mistakes are particularly likely to happen on a, on a busy day, inevitably. Those are the days when, in a sense, . Accidents and near misses are more likely to, to happen.

But to go slow, to go fast is, you know, a great comment that you made, because it, it really is important to be, it's all around mindfulness, isn't it, and to actually be in the moment, take time, make sure that you have a cup of coffee, because if you're operating for 5 hours solid and you don't even have time to urinate or have a cup of coffee, then clearly you're going to make mistakes when you get tired, probably more so than if you're very fresh. And I think, I think, yeah, mindfulness is a, is a really inevitably, it, it, so relevant to so many parts of our lives, but it, it, it is genuinely relevant to this, this conversation as well. And, and being, mindful and also compassion, compassionate, for ourselves throughout the day, and for others throughout the day, and understanding that, none of us are, are perfect and.

If we feel like we need to take just 2 minutes, to, to knock back a glass of water, that, that is OK before we, we see our next client. And also being respectful that, you know, if there are errors made, it's never right to shout and ball at, you know, another vet or a nurse, because again I. You know, I remember when we did the mindfulness course for the Royal College, the number of lovely testimonials I got from people who said things as simple as I've stopped shouting at my nurses, I mean that's so basic cos it shouldn't happen.

But the fact that, you know, they were also a victim in it, they were very busy, you know, they didn't feel like they were getting any breaks, something terrible goes wrong, they realised that's gonna add another hour to their day as they explain all of the aftermath of that to clients and so on. But actually that respectfulness to team members is, should just be a given, you know, nobody should get shouted at at work, should they? Yeah, and that, that was another finding from our research, to be honest, you know, .

Traditionally, there has been a bit of an, a, a bit of a blame culture in the profession, which, which obviously doesn't, doesn't help anyone. Not only do we not learn from, from these accidents, because we, we believe that the, that the proper outcome from this accident is just to blame and, and sanction somebody within the team who's made the obvious error, so we're not, so we're not learning, more about the systemic causes of that event, but, we simply. A bit more of a miserable place to, to be.

And it, and then the third, the third consequence of, of a blame culture is that it stops people from speaking up in the, in the future when they know things are going wrong. So you sort of institutionalise the opposite of a learning culture. Cover-ups.

Yeah, yeah. Cover-ups and, and also not speaking up in the moment when if somebody had felt confident enough to speak up, then maybe that mistake might not have an, an impact on, on the patient, because they've seen you draw up the 2 mLs of, of ACP and they've told you it should be 02. But, you know, in a, in a culture where, where blame is a, is a predominant factor, then they just simply don't speak up.

And, and then, you know, . Somebody may or may not end up giving the the wrong pre-med to an animal. So the, the, the consequences of a blame culture are sort of multi, multi-factorial as well.

And that, that was a, that was a finding from our, from our, research and, you know, it's probably a historical, it's, it's got historical antecedents and . And profession-wide anti-s students, but if we can, we can reverse that, it's gonna take time, but if we can reverse that, then the profession will inevitably become an even higher quality profession. Yeah.

Mark, it's been great to chat, . You know, I think it is such an important area. If people want to chat to you about vet QIT vet kit, or to talk more generally about patient safety, is there a way of getting in contact with you on LinkedIn or an email or?

Yeah, yeah, all, all my contact details are on the, on the website, so info at vetQIT.co.uk.

I'm more than happy to, talk about, this subject, in, in whatever, context. Yeah, it's just, it's just fun to, to discuss it, yeah. Yeah, Mark, thank you so much.

It's a really important area, we've always got to learn, we've always got to kaizen, thanks for reminding us about that. So thank you so much. Pleasure.

Thanks, Anthony.