Final Report > Chapter 21: Introduction > Guiding principles underlying our approach and recommendations > Systems affect the quality of healthcare

Systems affect the quality of healthcare

16 The skills of healthcare professionals are only one component of the quality of care. As we learned from Bristol, an individual clinician's effectiveness is significantly influenced by other matters, such as the physical arrangements for healthcare, the availability of equipment, the members of the team, whether there are standards and protocols for practice and the extent to which these are followed and monitored.

17 As we set out in the introduction to Section One of our Report, throughout the Inquiry, both in its conduct and in framing our recommendations, we have been convinced of the value of what is known as the `human factors' approach to understanding how people behave and function in complex systems. According to this approach, the performance of an organisation must be understood in terms of the complex interaction of factors which, only when taken together, explain success or failure. Thus, whatever the temptation to focus on the actions of individuals and to seek to blame someone when things go wrong, it is as important to pay attention to the system(s) in which those individuals find themselves.

18 The human factors approach suggests that, in any particular example of failure, there will have been a set of underlying factors which set the scene for the failure, as well as the more obvious direct factors which were the immediate cause. Thus, for example, if we are to learn how to avoid repeating it in the future, a surgeon's error must be understood not as a single, isolated occurrence, but as part of a system in which a host of other factors may well have played a part. These may be more or less visible, ranging from the surgeon's own skills to, for example, the training and competence of the theatre nurses, the quality of the equipment, the morale of the unit, or even of the hospital, and the pressures of time and resources. Using this example, to concentrate on the surgeon's error in isolation is to misdiagnose the problem and thus run the risk of it being repeated on another patient.