Learning from the 1000 lives campaign

Exploring the role of communications in quality improvement

Campaigning has often been thought of as not particular scientific or credible when it comes to evidence based interventions for change. There is also a paucity of articles or books to help with designing and implementing campaigns which relate to improving quality improvement. The application of communication theories to campaigning has only recently emerged as an effective mechanism by which we can change behaviour, attitudes and values (Rose 2010).   So you can imagine our joy at finding this gem of an article in the Journal of Communication in Healthcare by Andrew Cooper and his colleagues (Cooper et al 2015 web link: http://www.maneyonline.com/doi/abs/10.1179/1753807615Y.0000000006).

As the article states there is substantial literature that examines communication in healthcare settings but very little that addresses campaigns and in particular campaigns in relation to safety or quality improvement. Why are we so interested? Well we are currently running a national campaign in England for patient safety called Sign up to Safety with many of the similarities and challenges shared by our colleagues in Wales.

Both campaigns have placed communications at the heart of what they are trying to achieve. I was heartened that the findings of the review of the 1000 Lives Campaign in NHS Wales resonated so strongly with how we wanted to use communications in Sign up to Safety. We too want to create steady forms of communication via multiple channels, become a sound presence in the lives of those who are taking part and across the NHS in England and generate a positive campaign with clear and simple messages, and a strong sense of purpose.

Our shared aim across the campaigns, to engage the hearts and minds of frontline staff, has led us to develop similar strategies and to using communications as a key method for change, and not simply a way to publish an opinion or what we are doing. We completely agree with the finding that telling stories about real people needs to be at the centre of any healthcare campaign.

Changing the safety of healthcare is a complex process. Campaigns and communications strategies help significantly in turning interventions on paper into implementable actions. As this article states, getting the aim right, understanding your audience, framing the right messages tailored for the specific context and using the right channels is crucial for success.

The team have so clearly described what they were aiming to do and what they achieved that we have been able to use this learning to help shape our own evaluation plans. It is great to see the thought processes are so similar to ours and the discussion section in particular resonates with the same discussions we have had in our planning days.

Everyday millions of people are touched by campaigns and it is important that they succeed. Both the 1000 Lives Campaign and Sign up to Safety aim to make a significant difference to the lives of people affected by the safety of patient care. Yet there is remarkably little evaluation and learning or analysis to help people replicate campaigns that are successful. Andrew Cooper and his colleagues have provided us with some key learning points and recommendations so that other’s efforts are not wasted and campaigns in the future have a much better chance to succeed.

Suzette Woodward, Campaign Director, Sign up to Safety

Catherine Harrison, Communications Manager, Sign up to Safety

References

Cooper, A., Gray, J., Willson, A., Lines, C., McCannon, J., and McHardy, K. Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales Journal of Communication in Healthcare 2015; 8(1), 76-84. DOI: 10.1179/1753807615Y.0000000006

Rose, C., How to win campaigns; communications for change Second Ed. 2010, Earthscan, London

Sign up to Safety can be found at www.signuptosafety.nhs.uk

Twitter @SignUpToSafety | #SU2S | @suzettewoodward

20 things you can learn from campaigning

I recently attended a day with Chris Rose (Reference: Rose, C., How to win campaigns; communications for change Second Ed. 2010, Earthscan, London)

I have posted most of these on twitter but also wanted to share the top 20 things I learnt that day:

  1. Don’t drown people in too much information
  2. Talk about what you want to happen not what you think
  3. People change when they understand whatis needed
  4. Provide visual or physical evidence to show people the problem – if people can see or touch something they will notice more (visuals trump data)
  5. Let people do what they want – i.e. bottom up rather than top down
  6. Provoke a conversation about a real need that solves a genuine problem
  7. Ask why it hasn’t happened yet, why you haven’t been successful so far – the more you understand this the better
  8. If you know what you want people to do then you should tell them and provide simple instructions; for example in a fire the objective is to get people to leave the building, not to understand why fire happens or provide a detailed theory as to why people need to leave the building
  9. Know how the world should be, identify the things that would make that happen and create a sequence of events thats gets us to how the world should be
  10. Communications are your instrument to steer action not just about telling people – a conversation not a megaphone
  11. Say one thing – in multiple ways – but dont communication multiple issues in one go
  12. When communicating consider context, audience, messenger, strategy, channel, action required, messages
  13. Seek individuals who have a story to tell and get them to be the voice of the change – real people, real stories
  14. Create a storyboard for your intervention and describe everything you want to do in pictures
  15. For your three main areas – the problem you want to solve, the solution(s) you want to use and the benefit to the patients and staff – see if you can describe these in just 3 simple pictures – note they don’t have to be literal and can be an abstract representation
  16. Identify who can solve the problem and influence them
  17. For small tests of change, map every single step in detail of the journey from problem to solution – map it in a way as if you were telling a robot how to do it, every single step matters – they need to be sequential taking the person from the step to the next one and so on – test it and then alter the steps – this helps you tweak rather than make bold cuts that may not work
  18. Use iconography, metaphors, visuals to link your ideas and words to the audience
  19. Raising awareness can simply raise fear or concern, it has to be followed by solution and reassurance – e.g. neighbourhood watch is known to cause increased concern and fear of crime (and perceived increase of crime) rather than reassurance
  20. And finally, never presume that people remotely understand a single thing you are talking about – keep it simple

 

Creating a Just Culture

The single greatest impediment to error prevention is that we punish people for making mistakes” Dr Lucian Leape – 12 October 1997

People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.” Don Norman Author, the Design of Everyday Things

I believe that there are things we should all agree on:

  • The best people can make the worst mistake
  • Systems will never be perfect
  • Humans will never be perfect

The current culture we have in healthcare is that; human error coupled with harm to a patient usually results in social condemnation and disciplinary action, that it is proven that disciplining employees in response to honest mistakes does little to improve the overall safety system but that few people are willing to come forward and admit an error when they face the full force of the current punitive system.

So what is a Just Culture? it is one that is open, fair, and a learning culture and combined with the design of safe systems and managing behavioural choices it creates an effective safety culture.

One of the myths of the Just Culture is that it is blame free.  This is not a blame free system in which any conduct can be reported with impunity. There need be no loss of accountability – it is just different – the accountability requires an employee to raise their hand in the interests of safety.  Not reporting your error, preventing the system from learning is the greatest problem of all and some actions do warrant disciplinary or enforcement action.  The key question is; where do you draw the disciplinary line?  in order to know that, we all need to understand the differences between human error, risky behaviour and recklessness.

The big three:

  1. Human error:  inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake
  2. Risky behaviour:  choices that increase risk, where risk is not recognised or is mistakenly believed to be justified – includes violations and negligence
  3. Reckless behaviour:  behavioural choice, intentional acts, conscious disregard to a substantial and unjustifiable risk

Human Error is when an individual should have done something other than what they did and in the course of that action inadvertently caused or could have caused an undesirable outcome for example picking up the wrong keys, forgetting your ID, miscalculating a medication dose, missing a turnoff from the motorway, picking up strawberry yoghurt instead of raspberry.  We make errors every day with generally minimal consequences.  In healthcare we make similar types of errors with the potential for dire consequences and for a number of reasons are expected not to.  We are expected to be somehow ‘above’ human fallibility and not make mistakes.  We need to understand that individuals do not intend the mistake or error or undesirable outcome even though the consequences are potentially life threatening.  I often get asked about the individual who makes repeated errors.  The individual may be in a job, or performing a specific task that is very prone to error.  Drug labels and equipment layouts lacking in standardisation and poor design will lead individuals to make repetitive errors.  A source may lie with the individual who is stressed, distracted, unfocused leading to an increased propensity to error, in fact those that have erred are more likely to do it again because of the stress caused by the first error.  In these cases it may be appropriate to remove the individual from the current task however this must not be seen as a punishment.

Response required – console, support, learn, and be kind

Risky behaviour or violations are when individuals or groups take action which is different from the expected rules [procedures, policies, standard operating procedures, guidelines, standards]– which require or prohibit a set of behaviours.  There are unintentional rule violations and intentional rule violations.  Unintentional – usually that the individual was not aware of the rule or did not understand it.  Intentional – when an individual chooses to knowingly violate a rule while performing a task – does not necessarily mean they were risk taking.  They may be situational or circumstantial or patient centred.  Are all intentional violations bad?  There will always be circumstances where the rule does not fit the situation.  If a healthcare provider felt it was necessary to violate a policy to save a patient, e.g. a cardiac arrest in the car park may mean that some infection control rules are not followed.  We should judge individuals based on whether they knew the risks they were taking increased the potential for harm.  Normalising behaviour is when intentional violations of rules and procedures occur everyday.  This is behaviour developed over time, often without the workforce’s knowledge.  Much can be learned by understanding why certain violations become the norm.

Response required – coach, learn, train where needed

Recklessness is a crime – demonstrating in law greater intent than mere negligent conduct.  For example consider you are driving and you see a car ahead both speeding and weaving in and out of lanes.  The care is violating traffic rules and they are taking a risk which could cause an accident.  It is highly likely that the driver knows the risk they are taking.  The recent air accident in the French Alps is undoubtedly an example of recklessness.

Response required – discipline and sanction

There are ways in which we can support a Just Culture.  Create a resilient system that continually revises its approach to work in an effort to prevent or minimise failure, be constantly aware of the potential for failure and help people make decisions and direct (the limited) resources to minimise the risk of harm, knowing the system is compromised because it includes sometimes faulty equipment, imperfect processes, and fallible human beings.  The factors that help system safety:

  • Use human factors and design for safety
  • Create barriers to prevent failure
  • Enable recovery to capture failures before they become critical
  • Limit the effects of failure

Factors that help people be safer:

  • Information – the right information at the right time to the right people
  • Equipment/Tools – as much as possible standardised equipment and tools to minimise user error – especially for transient and new staff
  • Design/Configuration – design out the chances of error
  • Job/Task – be very clear with instructions for jobs and tasks and dont take on jobs or tasks you dont know how to do
  • Qualifications/Skills – the right qualifications and skills for the relevant tasks
  • Perception of Risk – understanding your own attitudes to risk and
  • Individual Factors – understanding things like stress, mood, distraction and interruptions
  • Environment/Facilities – designing the environment to maximise safety
  • Communication – the right ways to communicate so that you are heard and understood e.g. at handover, with patients, with colleagues, in an emergency

The Just Culture is also about ensuring that you have a learning culture.  When things go wrong and you want to learn from error and incidents, understanding the differences between human error, risky behaviour and reckless behaviour is vital as well as understanding the natural bias we are all subject to in particular outcome and hindsight bias.  Outcome bias is when the same “behaviour produce[s] more ethical condemnation when it happen[s] to produce bad rather than good outcome, even if the outcome is determined by chance.”  For example if a healthcare professional makes an error that causes no harm we consider them to be lucky.  If another person makes the same error resulting in injury to a patient we consider them to be blameworthy and disciplinary action may follow.  The more severe the outcome, the more blameworthy the person becomes.  This is a flawed system based upon the notion that we can totally control our outcomes.  Interestingly outcome bias has influenced our legal system;  A drunk driver suffers far greater consequences for killing someone than merely damaging property, the drivers intent is the same, the outcome very different yet society has shaped the legal system around the severity of the crime.  What is worrying here is that the reckless individual who does not injure someone sometimes receives less punitive sanction than the merely erring individual who caused injury.  Hindsight bias – ‘why did you do it like that’ or ‘I would never have done that’ or ‘the knew-it-all-along effect’.  Happens after an event has occurred and sees the event as having been predictable, despite there having been little or no objective basis for predicting it.  It may cause memory distortion, where the recollection and reconstruction of content can lead to false theoretical outcomes.  So always remember that when we review back at why things went wrong we may never know the full truth, it will be subject to our own bias and views and knowledge, so we may only know one aspect of it.

Three things you can do tomorrow:

1. Review your current disciplinary policy

Ensure it accounts for when incidents are investigated that there is an understanding of human factors and the just culture.  Your key issue is to ensure that learning from the events outweigh the deterrent effect of punishment and your staff feel able to speak out, raise concerns and report incidents.

2.  Conduct a culture survey of your staff

Ask them questions that illicit their views on whether they feel they can speak out, raise concerns or if they feel they will be consoled if they make a mistake.  Feedback the information on a unit by unit basis not for the whole organisation.

3.  Review your incident reporting system

If your incident reports are mainly about:

  • problems with processes and equipment – you have a low reporting culture – these are easy to do without backlash on individuals
  • individuals reporting on other individuals – you have a low reporting culture – it is easy to point the finger at others
  • individuals reporting their own mistakes – you have a good reporting culture – the individual will act against their own self interest and report so that others can learn
  • individuals reporting their own violations – you have an outstanding reporting culture – they understand that you understand that violations are not disciplinary actions and are to be learned from

In summary

  • Human Error is unintentional, accidental, unplanned, there is no intent to be erroneous – therefore there should be no discipline, just consolation
  • At risk behaviour is usually where an employee had no reason to know that he or she was creating a risk – there should be no discipline just coaching
  • If the employee knew and consciously disregarded the consequences of the risk they were taking – this is reckless behaviour and intentional – they must be disciplined and may even be considered to have acted criminally

References

David Marx.  Book – Whack a Mole

Sidney Dekker.  Book – Just Culture – Balancing Safety and Accountability

Eric Hollnagel, David Woods and Nancy Leveson.  Book – Resilience Engineering – Concepts and Precepts