How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
 
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

© HEMADRI

 
Follow me on twitter @HemadriTweets




PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.

ROBOTIC SURGERY: THE FUTURE BECKONS...

ROBOTIC SURGERY: THE FUTURE BECKONS...

Guest Blog by

Dr. Soumyadeep Bhaumik MBBS 

GP, Independent Researcher and Medical Correspondent

 

In 1921 Czech playwright Kapel Clark introduced the concept of robots (and in the process coined the term robot too) in his science fiction epic Rossum’s Universal Robots. Domin, the lead character of the play describes the future of robots as, “all work will be done by living machines. Everybody will be free from worry and liberated from the degradation of labour. Everybody will live only to perfect himself.” Ever since then robots have captured the imagination as well as the reality of humans. Robots are used nowadays in specific, precise, speedier and often hazardous work in domains ranging from industries to research to warfare. The entry and progression of robots however has been comparatively slower in the field of medicine.¹

Robotic surgery is a new and emerging field that has taken the medical and particularly the surgical community by storm. Robotic surgery is a technique which in the simplest term can be described as a surgeon performing surgery using a computer that remotely controls very small instruments attached to a robot with multiple arms.

History of Surgical robots:

The background of development of robotic surgery is inherently intertwined with the development of minimally invasive surgery (MIS). MIS has various advantages like smaller incisions, lesser infection, shorter hospital stays, quicker discharge from hospital, decreased pain, better cosmesis, and better postoperative immune function^2-4  An inherent problem with current laparoscopic equipment is the loss of haptic feedback (force and tactile), natural hand-eye coordination and dexterity¹. Moreover laparoscopic instruments have restricted degrees of motion (usually 4) whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization (which is essentially two-dimensional). Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult ⁵. Most surgeons harped over these limitations and argued the supremacy of traditional surgeries but biomedical engineers collaborated with a handful of surgeons and developed the Puma-650 which was first used in precise neurosurgical biopsies² and then in Trans-urethral resection of prostate (TURP)⁶. Robotic surgery gained rapid strides with the development of the PROBOT, ROBODOC, NeuroMate, PAKY-RCM, AcuBot and AESOP ^1,7.The da Vinci Surgical System ultimately made the robotic surgical system popular globally. More than 1752 da Vinci systems are already installed in across 44 countries of the world.⁷

Pros and cons:

Robotic surgery promises to overcome the traditional obstacles of surgery¹. They have better geometric accuracy, remain stable and do not get tired, can scale motion and offer more degrees of freedom than the human hand. They are precise and can access spaces or areas which a human hand cannot--thus making micro-anastomoses possible. Unlike humans, robots are not susceptible to radiation/infection or fatigue. Robots eliminate the fulcrum effect and also physiological tremors of the surgeon. Having fewer surgeons in the operating room and allowing doctors the ability to operate on a patient long-distance (tele-surgery) would also lower the cost of healthcare in the long term.⁷ More over because the surgical cuts are essentially smaller it provides all benefits of MIS, albeit in a greater dimension.

The prime disadvantage as of now with robotic surgery is not technology (which is bound to improve further in the future) but the costs involved. Robotic systems cost a whooping US $ 1 million to procure and recurring costs of $100,000/year. Such huge sums mean a lot if viewed in the light of public health measures in resource-poor developing and underdeveloped nations. Other concerns that have been raised are the requirement of extra staff to operate, steep learning curve and it’s yet to be proven cost-benefit ratio. A major cause of concern is the fact that robots do lack the capacity to earn the trust implicitly assumed in a surgeon-patient relationship⁸.What would be the psychological state of the patient peri/post operatively when he knows that his body parts is being handled by a machine made of ‘tins and oils’ ? What if the robot malfunctions? What if it is fed with the data for a wrong patient or for that matter even a wrong surgery? Who will be to blame in case something goes wrong?

What the future holds?

In spite of the fact that robotic surgery is fast spreading globally it is important to note that it is still in its infancy. The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, vision beyond the magnified eye, robot accessibility with a reduction of entry ports and miniaturizing the slave robot.⁷ In the near future robotic systems are expected to integrate various other technologies and modalities that are currently being used in the operating room. Efforts are already on to relay touch sensations from the robots to the surgeon and develop better suture less anastomoses⁷. Diagnostic modalities like USG, CT scan and MRI will soon be merged with robotic surgical equipments and guide the surgeon in better dissection and pathology identification. Nano-robots too are being developed across the world. Surgical training is also expected to radically change with robotic systems being used to rehearse procedures before doctors actually operate on a patient. Eventually tele-robotics will develop thereby enabling super-speciality surgeons to operate at inaccessible rural location without them being physically present in the operation theatre.

Evaluation of its safety, efficacy and long term effects vide randomised controlled trials is the need of the hour. Efforts to bring down costs should be specifically attempted. Unlike in industries or warfare clinical judgement is way too complex process which takes into account various factors beyond the operation table. The patient's socio-economic background, physico-intellectual status, his aspirations from life, emotional state, and cultural factors are issues which are taken onto account by the surgeon. Owing to the very nascent stage in which artificial Intelligence is currently the view that the automation age in robotic surgery has arrived and " it’s only a matter of time when it will run our lives for us” ⁸ is but a vision of the very distant future.

--------------------------------------------------------------------

Soumyadeep Bhaumik is a blogger and his blog Caffeinated Works & Random Musings is one of the largest healthcare blogs in India

You can get in touch with him via

in.linkedin.com/in/soumyadeepbhaumik
www.soumyadeepb.wordpress.com
https://twitter.com/DrSoumyadeepB

----------------------------------------------------------------------

References:

1. Lanfranco AR, Castellanos AE,Desai JP,Meyers WC.Robotic surgery: a current perspective. Ann Surg 2004;239:14-21
2. Kim VB, Chapman WH, Albrecht RJ, et al. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using DaVinci. Surg Laparosc Endosc Percutan Tech 2002;12:34–40.
3. Fuchs KH. Minimally invasive surgery. Endoscopy 2002;34:154–159.
4. Allendorf JD, Bessler M, Whelan RL, Trokel M, Laird DA, Terry MB et al. Postoperative immune function varies inversely with the degree of surgical trauma in a murine model.. Surg Endosc 1997;11:427–430
5. Prasad SM, Ducko CT, Stephenson ER, Chambers CE, Damiano RJ Jr. Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up.Ann Surg. 2001;233:725–732.
6. Davies B. A review of robotics in surgery. Proc Inst Mech Eng.2000;214:129–140.
7. Wedmid A,Llukani E, Lee DI. Future perspectives in robotic surgery. Brit J Urol Int ;108:1028-1036( Avalilable online http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10458.x/pdf)
8. Nath NC.Robotics –the future of surgery. J Ind Med Assoc 2011;109:12-13

Don Berwick Report

Don Berwick NHS patient safety report - will it work?

It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf). There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot

My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

© HEMADRI

Follow me on twitter @HemadriTweets

PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Improving the morale of NHS Staff

Improving the morale of NHS Staff

The vital role of improving the frequency of positive emotions and using positive feedback as a source for improvement. Time for the public/patients to be a part of the action.

Bad news all around

Poor care, cover ups, whistle blowers, gagging orders, complaints, et al; we very often hear about all of them these days through profoundly sad media reports, social media (twitter, facebook, blogs) and reports of various organizations. If you are following the news recently its bad news everywhere with Mid Staffs, Francis, Tameside, Morecambe Bay, Keogh 14 at the extreme end and A&E crisis, GP OOH crisis, rationing of services etc at the moderate end. (It is a worrying state of affairs, isn't it when the GP and A&E crises are called moderate?)

Dealing with what is wrong

When things go wrong there are a number of mechanisms present to address them – the immediate boss, PALS, complaints, medical director, nursing director, chief executive and other directors. There is the healthcare ombudsman if your local systems cannot sort it out. There are national bosses, DoH, NHS employers, NHS confederations and others who are very willing to intervene when things go wrong. Medico legal specialist lawyers who are very willing to take up and chase anything from the trivia to the grievous. There are regulators CQC, GMC (for doctors), NMC (for nurses), Monitor (for foundation trusts, more recently for all trusts). There are plenty of important bodies all willing to tell us how to practice clinical care; the Royal Colleges, NICE, various specialty organizations and others. All of these people and organisations issue the euphemistic 'guidelines' which are basically rules/regulations which if not followed clinical staff will be in trouble.

The NHS tracks its complaints and publishes it – quite rightly so. NHS bad news is reported big time when there is a serious complication or death or when there is a serious let down of an individual’s expectations – quite rightly so. Openness when things do not go right is very comforting for the affected patient and families; it also helps organisations learn and improve.

The Impact of Constant Bad News

'Bad news' i.e. news about poor performance, negligence, criminality, never events, serious untoward events, harm, complications and bad behaviour of healthcare staff even after accepting that it is grossly under reported forms a small part of the overall picture of healthcare and NHS. Vitally important part, but small part.

Majority of healthcare staff are well performing, well behaved, caring and produce good clinical and social results for their patients. An overwhelming majority of patients get good results. This is of course no excuse or balance and cannot be used to justify avoidable problems or even to defend the impact of unavoidable problems.

Having set that out very clearly, let us look at the impact of negative feedback, negative experiences or negative behaviour that healthcare staff get constantly from their newspapers, from their managers and from their patients. 

Studies by psychologists have shown that the effect (value or impact) of negative emotion we feel is twice (2.25 times) as stronger than the effect of a positive emotion. Here we explore how this plays a part in the morale of NHS staff. Let us say the impact of praise (and we feel a positive emotion due to that) is +1 and the impact of non-constructive criticism (we feel negative emotion due to this) is -2. So if we praised a person once and criticised them once, the net effect on an employee's emotion is not 0 or neutral, the employee ends up with a mental state or mood or feeling of negative emotion which in our scale will be rated at -1. Let us assume we praise an employee four times in a day and have a go at them four times in a day the net impact is likely to feel negative emotion rated (+4 -8 =) -4 and if we repeated this for a whole week the employee will have a mental state which on this scale will be valued at -20 or full of negative emotions.

It is indeed no wonder that NHS staff suffer from a low morale. There is plenty of negative news in every media, constant pressure from government and managers. The complaints from patients have reached record levels. It is indeed a surprise that NHS employees have any morale at all.

What can patients (service users) do to improve morale?

We now know that poor morale and unhappy staff results in poor healthcare delivery. As patients we would want to prevent that. We know that majority of the times, majority of the patients get very good results. We know that negative emotion has double the impact on the mind than positive feedback. So as patients I think we want to be congratulating, thanking, praising NHS staff every time we get a good service and/or a good result so that positive emotion can flourish. We should try to do that at a ratio of positive to negative feedback of at least 3:1 (you see a positive:negative feedback ratio of 1:1 leads to low morale staff and 2:1 will lead to neutral morale staff). We know positive and happy staff often translates into good results for patients.

As a patient it is in our specific and direct self interest to increase positive emotion in healthcare staff when things are going right for us as it does most of the time for most of us.

As a manager that is what you want to be doing to your staff, being aware of the impact of positive and negative emotions and using the ratio to boost morale.

Let us take a hypothetical example of a treatment which has a 90% success rate and a 10% failure/complication rate (this will generally be high rate of complications); let us assume that all patients provided feedback with 90% thanking and praising the staff for the successful treatment we have had and 10% of patients complaining about their result. We may have staff in great mood feeling very positive about themselves and are likely to deal with complications/problems in a confident positive manner.

Positive feedback as a source of improvement

The NHS has no system of capturing congratulations and kudos. Complaints are logged, measured and acted upon. Congratulations are not formally logged, hence not measured and almost never acted upon. If a patient writes in with a complaint hospital looks not only for resolution but also to try and prevent it from happening again. If a patient writes in with a compliment it will be a very rare place to study it immediately learn the lesson and roll it out. We learn if at all, on how to avoid bad things, we do not seem to learn on how to improve on good things. My premise is learning to avoid problems puts healthcare providers in a neutral position; learning to improve on what is already working well puts healthcare staff in a strong position. Here is why we need to do it, if you slip from a neutral position you go into a negative situation; if you slip from a strong position you either become less strong or even (though there is a small chance of getting into neutral).

Well we know that it is not exactly very British to be loud, vocal and break into a song and dance to praise when things go right but if we knew what is good for us that is what we would do. It is very wrong not to complain when things have gone wrong, it is very wrong not to whistle blow, it is very wrong not put in extreme effort into getting care right and not remedying problems effectively when they occur. It seems to me now that it is also very wrong not to praise NHS staff when things go right. The silence of the majority could be a major reason for the low morale. It is time patients and managers made the effort to improve the morale of NHS staff, it seems a route to good care.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Notes: The strength of positive and negative emotions we feel and its impact is well described in N Taleb's Fooled by Randomness.