Re(think) Patient Safety Series – Blog 3

This is the third in a serious title Re(think) Patient Safety.

The series started by looking at learning, moved on to thinking about the right culture for safety and now concludes with a discussion around implementation and implementing the right solutions for safer care.

Many of us have tried to realise ideas and introduce new methods, but after a while we have been forced to admit that things didn’t turn out as we had originally intended and planned.  We all know how complex and challenging implementation is. How it requires ongoing maintenance.  There is a great new series in Quality and Safety in Healthcare entitled ‘the problem with… Kaveh Shojania and Ken Catchpole will be overseeing.  The series will cover problematic improvement strategies, as well as problems that seem never to go away.  They have started to look at checklists, and will go on to review incident reporting, mortality reviews, falls, hand hygiene and others.  In the editorial they discuss the difficulties of implementation.  They describe the challenges we face which can lead to inadequate implementation:

• The unanticipated effort or expertise for implementation – problems requiring substantial effort to solve
• Failure to deliver the expected results
• Solutions that is wrong for the particular problem
• Focusing on a problem out of proportion to its importance
• Failing to appreciate the complexity of a problem.
• Strategies that sound like solutions but still haven’t been worked out, so are really unsolved problems e.g. change the culture, focus on leadership or teamwork

So, yes implementation is complex and challenging and it requires ongoing maintenance. It is a process not an event; it requires both skilled expertise and concerted effort and investment.

Implementation is a specified set of activities designed to put into practice an activity or program or solution.  It includes adoption, dissemination, diffusion (Everett Rogers, author of the classic book Diffusion of Innovations, defined diffusion as ‘the process in which an innovation is communicated through certain channels over time among the members of a social system’), spread and sustainability.

The implementation process starts with someone having an idea about a new way of doing things that can be used to meet a need or solve a problem. The idea may originate in the organisation where the need arose or outside of the organisation where external view has identified a need and a solution.  The idea is presented and a decision is taken to move ward to dissemination.  This should then lead to adoption which includes the key steps of planning, preparation and application of the solution or activities needed to achieve the sought–after change.  Once the new method has been adopted from both a practical and organisational point of view, it is then adjusted to the local context.  Finally, the method is considered institutionalised, embedded or sustained, if it is taken for granted or is the ‘way we do things’ regardless of reorganisations, personnel turnover and political changes.

Implementation research has identified the common factors or components that have significant bearing on the success or failure of implementation.  These include:

• The recognition that there is an explicit need for change and the solution and that the proposed method is the right one in the context
• There are visible benefits
• The solution is in line with the norms, values and working methods of the individuals, teams or organisation implementing it
• The solution is easy to use and it can be tested on a small scale
• It can be adapted to the needs of the recipient and the context
• Finally, it gives rise to knowledge that can be generalised to other contexts

Implementation research has also identified the tools or methods that usually help implementation:

• Oral or written information (guidance, how to guides, standards, alerts etc.) is normally offered when a new method or change is to be introduced, however offering only information, or education or practical training is usually not enough in isolation
• The research has found that an optimum combination of several measures is required, e.g. education and practical training and feedback. This also needs to be supported by continuous high-quality support, time and resources and to involve the users (people subject to the change) at an early stage of the design process
• If a new method does not lead to the anticipated effects, it should be possible to find out whether it was the solution that was not right for the particular problem or the method of dissemination itself that did not work or whether it was down to unsuccessful implementation factors

Many of you are working on individual aspects of patient safety and harm; falls, pressure ulcers, sepsis, acute kidney injury, VTE ….. the list goes on. We have made changes in these areas that mean that patients are safer but even impressive results appear to be difficult to sustain over time.  There are many individuals who are passionate about their particular area.  For the main disease or harm specific topic in patient safety there are nominated individuals – I will describe them as change agents.  A change agent is an individual, either inside or outside the organisation, who ‘lobbies’ people to adopt and implement new methods.  Change agents can be found in different arenas and occupy different positions and common for all of them, however, is that they have a strong belief in the change they are ‘selling’.  They:

• Help people become aware of a problem or a need
• Establish a trusting relationship with the audience
• Help people see that the problem cannot be dealt with using existing methods
• Motivate the audience to choose the new solution to deal with the problem or need
• Provide practical support to implement the solution
• Support the integration of the new method into daily activities in the long term

However, this can have the risk of creating competition in a way that people dont know which ‘interest’ or area of harm deserves more or less effort, time and resource.  These competing interests create competing prioritisation and confusion.   In fact most incidents are caused by the same common set of causal or contributory factors; for example; the deficiencies in teamwork and team culture, communication or problems like patient identification and observations, the way we share information with each other and patients, and the way we design the system and pathway.  The same cross cutting factors or causal factors that happen time and time again can explain the majority of the reasons why harm happens:

• No matter what the problem under investigation is – such as wrong-site surgery, hand-hygiene compliance, or patient falls
• No matter where the problem is – such as hospital, practices, care homes or patient homes
• No matter who is affected

What should we do differently? What should we re(think) in patient safety?

So we could focus on implementation through the lens of these cross cutting themes rather than on the disease or harm specific issues.  We could focus implementation on those causal factors that come up time and time again.

When you design your improvement plan I urge that you back it up with an equally important implementation plan that supports change over time (recognising that it can take up to 10 years) and do a few things well rather than try to juggle multiple programmes.  I also urge you to think about whether you should stop doing something. If it isnt working you may need to be brave and say so.

Mary Dixon-Woods also argues that we should also consider what can be standardised right across the system, across the NHS and in fact across the globe.  So would argue that sustained change be more likely if:

• We support your concerted efforts to reduce harm related to specific topics and address the five causal factors with targeted interventions
• Together with addressing systemic issues at a national and even international level

This unique combination could lead to major improvements across all aspects of safety in healthcare.

At Sign up to Safety, our proposition is that over the last fifteen years in the patient safety field there has been a lot of guidance (alerts, solutions, interventions, standards) for those that work in healthcare to help them ‘make care safer’. However there are three key problem areas:

• The lack of knowledge as to how this guidance can best be implemented in different areas and settings
• The length of time it takes from knowing about the guidance to putting the changes into practice
• The lack of sustained change from these effort
• The concerted effort on solutions which may not be the right ones for the particular problem they are proporting to address

Implementation researchers suggest that the time taken from research and guidance to the practical use of new safer methods can take from ten to seventeen years; speeding up this process feels like an important task.  The Sign up to Safety campaign team will be exploring the subject of implementation with our community, topic experts and expert practitioners in delivery of healthcare. Our hope is that by focusing on this area we will increase the NHS’s understanding and knowledge in this area and will help acquire new knowledge about how we can facilitate and enahce learning and sharing across the system.

Sign up to Safety is helping the NHS galvanise the field of patient safety – to move forward over the next fifteen years with a unified view of the future of patient safety to create a world where patients and those who care for them are free from avoidable harm.  Stopping or doing things in a very different way always sounds like such a big deal.  It sounds like something that should be approached in awe and done once or twice in a lifetime.

I would argue otherwise stopping or re(thinking) patient safety could be a very wise thing to do .