Don’t look Medusa in the eye

After attending an NHS conference yesterday, I was cut-up on the way home. Not emotionally: that will come the next time my credit card bill arrives. But I was cut-up by another car, the driver of which thought that it was perfectly fine to merge from his lane into mine without indication, or apology. As a result, I was forced to brake hard and release a torrent of expletives that my mother must never hear.

I can’t remember the model of the car, but it was a hatchback. It was a colour that could generously be described as ‘lime green’ and it was being driven by someone with an unfortunate skin complexion and an even more unfortunate air of invincibility that belongs to all young male drivers. It had tinted windows, a sawn-off exhaust that made it sound emphysemic, thin tyres on brushed chrome alloys, an aerodynamic spoiler and a sound system that wouldn’t be out of place at Glastonbury.

I caught up with him at the next set of lights, and pulled up alongside him. My gut instinct was to repeat the expletives, perhaps adding a few more in for good measure. Or perhaps I should have taken the moral high ground and offered some sage advice on the perils of the road. I could have asked him how his mother would feel if she got a call saying he had been in an accident (relief possibly?).

In the end, I settled for a much more cutting ‘Does your mum know what you’ve done to her car?’

He clearly wasn’t expecting that, and as his bum-fluff lined chin dropped and his brain searched for a witty riposte (comes with age, sunshine), the lights changed. I smiled to myself, and turned left.

I like to think he sat there for a minute, ruminating on his life, before eventually being honked by the car behind him, which would lead him to offer an apologetic hand in his rear mirror before crawling off, forever changing gears smoothly and feeding the wheel, and always wondering what happened to the man that turned his life around that day. The reality is that he probably shrugged his shoulders, turned up ‘da tunes’ and went about harassing other motorists.

The point is this: whatever he did to his car, whatever colour he painted it, whatever Blaupunkt system he installed, however hard he revved the engine at lights and other motorists, it would still be the same car. Essentially, a hairdryer on wheels.

It got me thinking (and getting around to the point of this blog) about a key theme that came out of the Patient Safety Congress: that of culture. “We need to change the culture!”, “We must have a more open culture!”

I agree, entirely. The challenge is not in what but how. Saying “We need to change the culture” on its own is the equivalent of our mutual friend putting a set of shiny alloys or a fat exhaust pipe on his mum’s car. In the end, it will still be his mum’s car, fundamentally limited, however pimped up it is on the outside. If you really want to pimp a car (or the performance of a large public body), you’ve got to get the hood up and get into the engine, where the magic is. As John Travolta once put it “We’ll get some overhead lifters and four barrel quads…fuel injection cutoffs and chrome plated rods oh yeah…”

If you want to change the culture, I don’t think you do it by saying you are ‘changing the culture.’ Cultures don’t want to be changed. They are nebulous, ever shifting, and bloody stubborn. My own view is that the key to successful culture change is not to focus on culture change: to not look Medusa in the eye directly.

That’s because the culture of an organisation is the output from everything that you put in and if you want to change it, you have to do it without the culture noticing, or it will come at you and turn you to stone.

How? By doing the practical stuff. By developing an understanding of how to maximise the performance of staff (answer is not by demanding more for less); By designing ‘in’ safe working environments and tools that make it easy to do the right thing, and designing processes that make it hard to do the wrong thing; by striving to become a high reliability, listening and learning organisation (all human factors) by ensuring that decision making is devolved to those people who are best placed to make them. These are things that can be done, systematically, over time, and shared with others who are striving for the same goals.

Eight

It’s an exciting time if you are a football fan, with the World Cup in Brazil just around the corner. As I write this, breweries, tinned hot dog producers and flat-screen TV manufacturers up and down the land will be hoping that both England and the weather turn up on time. In workplaces, people will be planning annual leave and forecasting sick leave in roughly equal measure. Tabloid newspapers will be printing cut-out prayer mats and giving away free flags to whip the nation into a ‘1966’ frenzy before we inevitably go out on penalties in the quarter-finals. Probably.

It’s a chance to see some of the world’s best players. And Wayne Rooney. Argentina’s Lionel Messi will be causing defenders to wake up in cold sweats, whilst Cristiano Ronaldo will be doing the same for many female supporters. Spain will inevitably win the thing, having passed the ball around for a month, probably texting their mates and signing autographs at the same time, before eventually deciding they’ve had enough for the day and decide to put a few goals past their demoralised opponents. England, well, it’s England isn’t it? The Forrest Gump of International Football – “you never know what you’re gonna get.”

Still, the fans of all nations can look forward to the spectacle.

Apart from a few. Marcleudo de Melo Ferreira is one. He was working on the stadium in Manaus where England are due to play Italy when he fell 35 metres from the roof which was being installed. He was 22 years old and the third person to die during the construction of the World Cup stadiums. Since his death, after which there was a period of mourning before work resumed, five more workers have died, bringing the total to eight who have been killed during the construction phase.

It’s no secret that Brazil’s tournament has been beset by problems: delays, a collapsed roof, budgeting issues and an immovable deadline. On its own, eight doesn’t sound like a big number. After all, it’s less than double figures and if you can’t make an omelette without breaking a few eggs, can you expect to build twelve stadia without killing a few workers? Is that an acceptable price to pay? The problem with the number ‘8’ is that it’s just a number. It doesn’t tell the story of the workers who gave their lives for the World Cup to happen and the impact that their deaths would have had on their families, children, wives and co-workers. The ripples of their deaths will go on in their communities long after the carnival has finished and England have trudged home sheepishly.

It’s hard to get details surrounding the circumstances of the eight deaths, other than what has been stated in the press so understanding the root causes is pure speculation. Poor management systems? Weak leadership? Faulty or poorly maintained equipment? Lack of training? Weak safety culture? Time pressures? Possibly all played a part. The 2012 Olympic build in London showed that you can build significant infrastructure safely by embedding a strong safety culture (no workers were killed during construction) but to compare the two is a little unfair: the UK has a world-class regulatory system and has made major strides in the last century in protecting workers from injury and ill-health and even in the UK the construction industry remains one of the most dangerous with 29 deaths between April and December 2013.

Everyone knows safety is important but it’s crucial that each fatality is learnt from, that the foot remains on the pedal in driving safety improvements. Because whilst each dead worker is represented by a statistic in official figures, they represented so much more to their own families and colleagues. We should constantly seek new ways of communicating risk and ‘nudging’ people to truly understand not just the risks of their work, but the impact that their failure to follow safe practice can have on others. I’ll leave you with this picture as an example.

Has anyone seen an eyeball?

We had a bit of a crisis here last week. One of our employees, in the microbiology team, got sick. No one knew it was coming because he’s such a quiet chap by normal standards, a bit of a loner really. I’ve walked past him several times without even realising he’s there. It was awful. There was no warning, he just projectile vomited, like a scene from The Exorcist. It was all over the floor and up the walls. What’s worse, the poor guy vomited with such force that he lost an eyeball.  We’re still looking for it.  It’s not the first time he’s been sick at work either but he’s a good sport and hasn’t complained so we aren’t inclined to record it in our sickness data because we see him as a bit of an outlier and not representative of the healthy workforce we have here at HSL.

Meet Larry.

Larry has had an interesting career. He worked for many years as a successful resuscitation dummy in first aid training. He was a hard worker too. He’s been jumped on, had his mouth probed with dirty fingers, his chest cavity has been crushed by overenthusiastic and overweight first-aiders, and he’s nearly been suffocated several times by people who blew into his mouth AND his nose at the same. No doubt he has helped save many lives. Larry thought he was settling down for a nice retirement, albeit an inactive one, given that he has no legs.

And then he met Cat Makison-Booth. He should have known better. 

Cat, seen here filming for a BBC documentary on her work, is one of our microbiologists at HSL and is leading our innovative work around Norovirus.

Cat needed to be able to replicate the way that human beings vomit when infected with Norovirus and was looking around for a suitable dummy to help. Unfortunately for Larry, he didn’t move out of the way quick enough (difficult, with no legs).

A bit like Robocop, Larry found himself strapped to a gurney while surgery took place. His chest was removed and replaced with an artificial stomach, all secured with a wooden frame that held him firmly in place. When he woke from surgery, something was sloshing around his insides and the next thing he knows, he’s projectile vomiting and has been doing it ever since. The poor guy:  he spent his working career on his back pretending to be unconcious, and now he spends his semi-retirement wishing that he was. It’s a tough life.

He should be proud though, the work he is helping with is important. Norovirus is nasty. Picked up by eating the wrong thing (I didn’t know that oysters are a potential source of Norovirus as well as pearls) or by touching a contaminated surface. Symptoms typically last at least 48 hours and include projectile vomiting and diarrhoea (we’ve asked Larry if he’d like to have a bottom half attached but he just looked at us with suspicion).  

Norovirus is incredibly infectious. There are around one million virus particles in just 1 ml of vomit. When you think that the average person can vomit up to 1.35 litres and that it takes just 10-20 particles to cause an infection, you begin to understand why it causes such problems across industries. Healthcare is the most publicised. In addition to the patient safety issues an outbreak of Norovirus can cripple bed capacity in a hospital through ward closures. Other industries also suffer though. In fact, anywhere there is a confined space such as oil rigs, schools, conferences, submarines and cruise ships, there is the potential for infection to spread. The financial burden to the economy is huge and around £100m per annum in healthcare alone. It’s so infectious, that some governments deem it a potential bio-weapon.

It’s hardy stuff too. It can survive up to twelve days in the environment and many disinfectant products, such as alcohol-based hand gels are not effective in killing it.  You also shed the virus for 48 hours after your symptoms have stopped, which is why it spreads so quickly because people come back to work when they are feeling better and infect colleagues. Oh, and unlike, say, chicken pox, you can get re-infected with norovirus and there is no vaccine. So, all in all, something to avoid.

All of which is why the work that Cat is doing is so important, because it fills a gap in the science which is: When someone infected with Norovirus vomits, how much of the physical environment is contaminated?  The answer, as it turns out, is a lot. Here’s a link to video of Cat explaining how Larry works, and then him doing his thing.

Don’t feel sorry for him, he’s got a holiday coming up. The spread of virus is up to 7.8 square metres. What’s more, the naked eye can’t see the smaller particles of vomit. You can only see them in the video because Cat uses a fluorescent marker when filling poor Larry’s stomach. This light or the marker isn’t available to people decontaminating the environment, so you tend to find that the main spillage is cleaned – the bits you can see – but that there are significant levels of virus left in the environment.

So, Cat’s work goes on, developing the science underpinning decontamination of the Norovirus environment and has applications for most industries in the UK.  And as for Larry, well, it’s not so bad for him. He made it onto the Letterman show, which was exciting for him. Also we do feel terrible that he lost an eyeball as part of his routine work.  So we’ve booked him a nice two week holiday.

On a cruise ship.