1. THE GP THE CONTRACTOR & THE EMPLOYER Marion Foster March 2011

2. GP Partner as a Contractor and Employer UNDERSTAND: The duties, rights and responsibilities The RISKs OBJECTIVES

3. ABRIDGED PRESENTATION — FOR ILLUSTRATIVE PURPOSES ONLY © 2009, Clifford & Garde Major Malfunction “”

4. CAN GENERAL PRACTICE LEARN FROM THE CHALLENGER DISASTER?

5. THELEGACYOFCHALLENGER THE LEGACY OF CHALLENGER The Rogers Commission, which investigated the incident, determined: both o- rings The SRB joint failed when jet flames burned through both o- rings in the joint recurrent damage to o- rings NASA had long known about recurrent damage to o- rings tolerated Increasing levels of o-ring damage had been tolerated over time “nothing bad has happened yet” - Based upon the rationale that “nothing bad has happened yet” - Complacency

6. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture KEY ORGANIZATIONAL CULTURE FINDINGS – What NASA Did Not Do

7. MAINTAINING A SENSE OF VULNERABILITY “can do” NASA’s successes (Apollo program, et al) had created a “can do” attitude that minimized the consideration of failure Near-missessuccesses near-failures Near-misses were regarded as successes of a robust system rather than near-failures weak sense success grantedgreater risks A weak sense of vulnerability can lead to taking future success for granted… and to taking greater risks can do” say “this can’t be done.” “we must succeed” “we could fail.” NASA’s “can do” attitude often made it hard for individuals (even groups) to step forward and say “this can’t be done.” The imperative of “we must succeed” had overwhelmed the consideration of “we could fail.”

8. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture Key Organizational Culture Findings – What NASA Did Not Do

9. COMBATING NORMALIZATION OF DEVIANCE “This history portrays an incremental descent into poor judgment.” Diane Vaughan, The Challenger Launch Decision reinforced unavoidable acceptable risk. Each successful mission reinforced the perception that foam shedding was unavoidable…either unlikely to jeopardize safety or an acceptable risk. normalized Foam shedding, which violated the shuttle design basis, had been normalized tolerance of damage tolerance of failure tolerance of damage DISASTER Challenger parallel… tolerance of damage to the primary o- ring… led to tolerance of failure of the primary o-ring… which led to the tolerance of damage to the secondary o- ring… which led to DISASTER

10. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture Key Organizational Culture Findings – What NASA Did Not Do

11. ESTABLISH AN IMPERATIVE FOR SAFETY “When I ask for the budget to be cut, I’m told it’s going to impact SAFETY on the Space Shuttle … I think that’s a bunch of crap.” Daniel S. Goldin, NASA Administrator, 1994 prove were unsafe Burden of proof The technical staff for both Challenger and Columbia were put in the position of having to prove that management’s intentions were unsafe. ssume existed to prove did not exist The traditional approach - to assume that a problem existed, then seek the sound technical evidence and analysis necessary to prove (if possible) that the problem did not exist. reversed This reversed their normal role of having to prove mission safety.

12. ESTABLISH AN IMPERATIVE FOR SAFETY International Space Station deadline 19 Feb 04 Desktop screensaver at NASA As with Challenger, future NASA funding required meeting an ambitious launch schedule Conditions/checks, once “critical,” were now waived A significant foam strike on a recent mission was not resolved prior to Columbia’s launch Priorities conflicted… and production won over safety

13. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture Key Organizational Culture Findings – What NASA Did Not Do

14. PERFORM VALID/TIMELY HAZARD/RISK ASSESSMENTS “Any more activity today on the tile damage or are people just relegated to crossing their fingers and hoping for the best?” Email Exchange at NASA “… hazard analysis processes are applied inconsistently across systems, subsystems, assemblies, and components.” CAIB Report, Vol. 1, p. 188 lacked identifying NASA lacked consistent, structured approaches for identifying hazards and assessing risks subjective, not addressed Many analyses were subjective, and many action items from studies were not addressed risk assessments acceptable In lieu of proper risk assessments, many identified concerns were simply labeled as “acceptable” “green” analysts Invalid computer modeling of the foam strike was conducted by “green” analysts

15. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture Key Organizational Culture Findings – What NASA Did Not Do

16. ENSURE OPEN AND FRANK COMMUNICATIONS I must emphasize (again) that severe enough damage… could present potentially grave hazards… Remember the NASA safety posters everywhere around stating, “If it’s not safe, say so”? Yes, it’s that serious. Memo that was composed but never sent not a concern not open Management adopted a uniform mindset that foam strikes were not a concern and was not open to contrary opinions. The organizational culture “bad news” Did not encourage “bad news” 100% Encouraged 100% consensus “chain of command” Emphasized only “chain of command” communications trump Allowed rank and status to trump expertise

17. 1.Maintain Sense Of Vulnerability 2.Combat “Normalization Of Deviance” 3.Establish an Imperative for Safety 4.Perform Valid/Timely Hazard/Risk Assessments 5.Ensure Open and Frank Communications 6.Learn and Advance the Culture Key Organizational Culture Findings – What NASA Did Not Do

18. LEARN AND ADVANCE THE CULTURE persisted The organizational dysfunctions that had been identified in the Challenger incident, and which persisted through the Columbia incident, strongly suggest that NASA had not learned from its mistakes… not learned NASA had not learned from the lessons of Challenger still existed Communications problems still existed getting heard Experts with divergent opinions still had difficulty getting heard Normalization of deviance Normalization of deviance was still occurring Schedules dominated Schedules often still dominated over safety concerns shallow Hazard/risk assessments were still shallow Abnormal events Abnormal events were not studied in sufficient detail, or trended to maximize learnings

19. What is Safety Culture and Why is it Important? Safety Culture is the critical barrier that protects workers, the public, and the environment from the inherent risks or dangers in the organisations’ work.

20. What is Safety Culture and Why is it Important?

21. WHAT IS RISK?

22. Chinese word for Risk Wei Ji Danger Opportunity

23. REMEMBER RISK HAS AN UPSIDE!

24. PRIMARY CARE STRATEGICOPERATIONALFINANCIALREPUTATIONAL SECURITY HEALTH & SAFETY INSURANCE / INDEMNITY REGULATORYLEGISLATIVE CLINICAL GOVERNANCE PEOPLE WHAT ARE OUR HIGH RISK AREAS?

25. System Failures negligence claims Over ¼ of 200 cases settled  Repeat prescribing –11.5%  Dealing with results –7%  General office systems –3.5%  Cervical cytology –1.5%  Recall / protocols / referrals 5% MDDUS Statistics

26. EXAMPLES OF LEGISLATION  Freedom of Information Act. 2002  The Medicines Act, 1968  The Misuse of Drugs Act 1971  The Children’s (Scotland) Act 1995  Health and Safety at Work Act 1974  Data Protection Act 1998  Access to Health Records 1990  The Misuse of Drugs Act 1971  The Children’s (Scotland) Act 1995

27. Business Continuity Planning Low likelihood Very High impact

28. BUSINESS CONTINUITY MANAGEMENT CIVIL CONTINGENCY ACT 2004 Loss of premises - Fire / Flood Loss of staff - Key People / Mass sickness / Flu Loss of IT / Patient Records / QoF Data / Key documents Loss of power Restricted access to building Partnership split Loss of telephones

29. Corporate Governance Business Continuity Management Site Recovery planning Business Continuity planning Work Area Recovery planning Human Resource planning Technology Recovery planning Crisis Management planning Managing the crisis Essential staffStaff relocation Business as usual Site salvage / restoration Context

30. Senarios