Caring to put safety first

To put safety first we also need to put our staff first. 

Part of the recipe for success in patient safety is to care for those that care. 

I always remember feeling so bad when a patient would ask me for something and a few hours later remind me of the thing they asked for.  I was too busy to remember their individual need. That’s not good care and not safe if the thing they asked for was medication or vital information or telling me about a symptom that should have warned me that they were deteriorating but I simply didn’t recognise it because I got too busy. 

Care workers who look after people in their homes deserve to be cared for, loved for what they do. How can a healthcare worker provide safe and effective care when rushing from one patient to the next, struggling to find time to pee or eat. How do they do that safely when simply whizzing through their patients needs because they are late for the next appointment. 

GPs need to be cared for, loved for what they do. They patiently sit and listen to our concerns while thinking about the previous patients concerns and how they are going to help us to to the point so they can diagnose or assure – are they listening or simply too stressed to hear. How do they do that safely when by the end of the clinic they are so exhausted – yet still know that the next patient could be the potential person with the signs of cancer they might miss. 

Junior doctors need to be cared for, loved for what they do. The nomads of the NHS. How do they do it, go from one place to the next and need to adapt in minutes, know exactly where everything is, know exactly how it all works and when they have it sussed they have to move on. All the while studying, growing in knowledge till they are fit to burst. How do they do that safely when everywhere they go is so different. 

Instilling joy and pride in the NHS is a mantra of Don Berwick. Instilling respect, value and kindness need to be added to these so that we care for each other and help each other get through the day and above all be safe. 

Wicked problems

Over the last few months I have noticed the term ‘wicked problems’ being used more and more in relation to healthcare.  In particular those who work in quality improvement are using it as a term to describe quality or safety problems.

It is a term that doesn’t sit right with me; apart from the ‘evil’ connotation and the unnecessary addition to our language I don’t think it readily applies to quality and safety.

Rittel and Webber wrote in 1973 that wicked problems have ten characteristics (thanks to

  1. there is no definitive formulation of a wicked problem
  2. wicked problems have no stopping rule
  3. solutions to wicked problems are not true or false, but good or bad
  4. there is no immediate and no ultimate test of a solution to a wicked problem
  5. every solution to a wicked problem is a ‘one shot operation’ because there is no opportunity to learn by trial and error as every attempt counts significantly
  6. wicked problems do not have an exhaustively describable set of potential solutions, nor is there a well described set of permissible operations that may be incorporated into the plan
  7. every wicked problem is essentially unique
  8. every wicked problem can be considered to be a symptom of another problem
  9. the existence of a discrepancy representing a wicked problem can be explained in numerous ways, the choice of explanation determines the nature of the problems resolution
  10. the social planner has no right to be wrong

I need to understand more about what this list means, it all seems a bit mind boggling to me – but if I take one or two of the above list it does not fit with what I know about quality and patient safety:

there is no immediate and no ultimate test of a solution to a wicked problem? we know about tons and tons of solutions for patient safety – they just have not been implemented yet

every solution is a one shot operation because there is no opportunity to learn by trial and error? surely that is what we do all the time, test something, adapt it, make it work for the local context and yes it may fail and sometimes we have to stop doing it because it has been found never to work – but this is still trial and error

every wicked problem is essentially unique? the same or similar human error, mistakes, system and human factors, incidents happen repeatedly across the NHS in all care settings – they are sadly not unique but because they are not unique provide an opportunity to make a big difference if addressed

solutions to wicked problems are not right or wrong? odd – are we not trying to find the right solutions to our quality and safety problems

The literature goes on to describe wicked problems as ‘a problem whose solution requires a great number of people to change their mindsets and behaviour’ – examples include global climate change, the aids epidemic, pandemic influenza, international drug trafficking and social injustice.  If we view avoidable harm as ‘a problem whose solution requires a great number of people to change their mindsets and behaviour or an epidemic I can see how this would fit into this description but I would simply call that a large scale complex or cultural problem rather than a ‘wicked problem’.

Am I just being picky about the words?  I suppose I am.  But what worries me is that we can isolate people by trying to use different words, and we can paralyse action if people don’t truly understand what they can do in a clear, easy and simple language.  In the same way as management speak, or acronyms – we can alienate.  In the case of ‘wicked problems’ being assigned to quality and safety issues in healthcare we risk alienating not only frontline clinicians but more importantly patients and their families.

Put Safety First (the system)

At Sign up to Safety we want to re(think) patient safety. We think it’s important that we have an adult conversation about patient safety. I am most heartened by the growing numbers of people and expertise across the NHS such as the people working in the patient safety collaboratives; starting to deeply root our approach to safety improvement and the right safety culture. Moving safety from the periphery to mainstream conversation.

To ‘put safety first’ is no longer about simply setting up incident reporting systems and focusing on the easy to count harms such as falls or pressure ulcers but moving on to design and working on attitudes and behaviours. Measurement should move from counting incidents to observing the way people work, finding out in real life what helps and what hinders safety. Small design changes could make a big difference. Decision making assistance helps human beings think and work. Reducing stress and minimising distractions reduces error. Improving patient safety should be even more important when funds are becoming scarce rather than the opposite.

Human beings need help. Humans love hearing stories about other people. We need concrete examples and actions that we can do now. However, people are stifled by the fear they have not yet been successful. What they need to understand is that others are interested in how people are doing stuff.  The journey and the views are as important as the destination. This helps people experience the challenges and provide them with tips.  Trip advisor provides an insight into a hotel or restaurant through first hand experience.  We need more of that in patient safety improvement. A kind of mystery shopper, ethnography, real world research approach that allows people to share real life progress not the end goal.

Lets start to think differently about what we mean by ‘put safety first’ so that it is not seen as a sound bite but as a demonstrable activity that can be done and done now.

Put Safety First

Bringing our pledges to life

Professor Berwick said the heart of safe care is a culture of learning. The campaign is deploying a number of different mechanisms including; learning events, webdives and webinars, focus groups and local networks to accelerate learning across the system.  In this second year of the campaign we will help organisations revisit and bring to life the five campaign pledges; put safety first, continually learn, be honest, collaborate and be supportive.  Our programme to bring the pledges to life starts in October with:

Put safety first – Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public locally developed goals, plans and progress. Instil a preoccupation with failure so that systems are designed to prevent error and avoidable harm.  We have curated links for participants and will have a number of focused webinars across the month.  During this time we will develop our understanding to share across the NHS on how we can adopt a more systematic approach; we will work with the national leaders of individual ‘harms’ and over the course of the year we will persuade organisations and individuals to focus on the cross cutting contributory system and human factors that impact safety every day. This may mean that they end up stopping things that are simply not working.  We will help people re(think) patient safety.  We will focus on creating a continuous learning culture which addresses our current failure to learn from incidents and investigations but also encourages organisations and individuals to share what they are learning from implementing change.  We will do so through a number of different activities and events in October culminating in our unique event bringing people together from across the system to get beneath the surface of why there is an implementation gap.

This will then be followed by:

December; Continually learn – Reviewing incident reporting and investigation processes to make sure they are truly learning from them and using these lessons to make organisations more resilient to risks.  Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe services are

February; Be honest – Being open and transparent with people about progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong

April; Collaborate – Stepping up and actively collaborating with other organisations and teams; sharing work, ideas and learning to create a truly national approach to safety. Working together with others, to join forces and create partnerships that ensure a sustained approach to sharing and learning across the system

June; Be supportive – Be kind to staff, help them bring joy and pride to their work.  Be thoughtful when things go wrong; help staff cope and create a positive just culture that asks why things go wrong in order to put them right. Give staff the time, resources and support to work safely and to work on improvements.  Thank staff, reward and recognise their efforts and celebrate progress towards safer care

We will share lessons and best practice via videos, frontline videos, webinars which focus on the pledges as well as the cross cutting themes and we will share a variety of blogs, podcasts, and polls so staff can get directly involved in our shared cause.  We would love you to keep sharing your work and stories in our e-newsletter, SignUPdate, so they reach frontline staff who are not actively engaged with the campaign directly.

Challenges and successes

The Sign up to Safety campaign team have been working with participants across the country. The challenges we have noticed include:

  • Challenges with metrics; there is no standardised way of recording or measuring harm and there is an over reliance on incident data
  • Confusion about the role of the patient safety collaboratives
  • A desire by some to be simply told what to do while at the same time a wish to move away from regulation, performance metrics and CQUINs
  • Some organisations are still really early in their journey and are even now only about to start developing their plans
  • Some organisations were dependent on getting the money from the NHS Litigation Authority and had to change their plans when unsuccessful – this caused some anxiety locally
  • A few organisations launched the campaign but workload increased and staff were not released to deliver the programme so have struggled since
  • Organisations have valued the ability to link all work streams together under the ‘heading’ of Sign up to Safety but not all have understood our easy this is and have unnecessarily created additional plans which duplicate or cross over existing plans
  • ‘Sign up’ has been on a steady increase each month since launch with nearly 300 organisations taking part but some only just starting.  Some organisations continue to sign up, for example 78 since January 2015, their campaigns’ first year started in 2015.  Organisations that continue to join (which means that for over 78 organisations their first year starts in 2015) will require the same level of support as those that started earlier
  • Preparation takes time – Signing up (completing the pledges and engaging the organisations senior leader or CEO to agree and sign the joining form) can take time with some organisations needing sign off from their Board.  So the process starts some months before they send in their sign up pack. Then once signed up they take on average between 3 and 6 months to develop their safety improvement plan as we ask them to review their last 3-5 years of data and seek feedback from their staff and patients in choosing what to work on for the next 3-5 years.  Therefore signing up in July 2015 could have meant planning started in January 2015 and their 3 year plan will not start until January 2016.

Positive aspects include:

  • Locally led – Delight that the campaign is trusting participants to develop locally led and locally driven safety improvement plans and relief that once written they could evolve. Also being asked to develop a 3 to five year plan, instead of an annual plan which is the norm, it has given people the permission and opportunity to think more longer term
  • Niche role – The campaign is filling a gap by focusing on cultural and behaviour change, helping implementation of locally led, self-directed safety improvement and in creating the coherent narrative for the front line.
  • Timing – There is a timely opportunity of the current changes at a national level of patient safety policy, strategy and infrastructure for the NHS in England with the campaign being a key method for shifting the emphasis away from focusing on one harm at a time.
  • Alignment – There is a strong desire for alignment, to create a more coherent approach and the campaign helps frontline organisations and staff to understand the different initiatives (patient safety collaboratives, the Q initiative and the buddying programme with Virginia Mason).  
  • Adaptability – The campaign team are kept purposefully small and nimble in order to support changes over time from raising awareness and engagement activity to energising and motivating activity (to keep people going) and to advancing knowledge and learning activity (to share what is working and progress).
  • Continuing to build the community – We have a strong community wand the channels and reach of the campaign is already considerable
  • Extending reach across primary care – CCGs have been mainly at a flat line in terms of sign up and a tiny handful of GPs only just came on board from April 2015 onwards.  Over the next year we have a fantastic opportunity to further engage primary care, care homes, GPs and other areas providing out of hospital care.
  • Implementation gap – It is as important to learn about implementation as it is to learn about improvement – i.e. learn about how as much as what they are doing – the campaign could continue with its unique approach to exploring the implementation gap between theory and practice.
  • Spread –  the campaign has an opportunity to share emerging lessons across the NHS at scale
  • Profile and trust – The campaign has built a trusted brand that is connected in a different way to participants than any of the other national organisations.
  • Skills and expertise – the campaigning, movement and communications skills and experience required for this are quite unique and niche – the current patient safety function does not have individuals with these
  • Evaluating impact – the campaign is exploring different ways to measure the difference we and others are making that does not create an additional reporting burden

A different approach to change

“We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic. If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”. Ara Darzi

The ideas, methods and approach for Sign up to Safety represents fifteen years of work by the campaign team, in particular from a previous campaign patient safety first and lessons we have learnt since about large scale change from across the globe including patient safety campaigns in other countries.  

Year one was all about participation.  Year two in summary is about ongoing participation, spread and reach into areas of low participation together with bringing to life our five pledges.  We will continue to energise and galvanise the NHS in England to deliver locally led, self-directed safety improvement and use new approaches to capture what is going on locally and share what people are doing at scale under the overarching brand of Sign up to Safety.

We will help explore and address the implementation gap under our beneath the surface sub-brand

And help revise patient safety thinking under our re(think) sub-brand of Sign up to Safety to shift the focus from one harm at a time towards a more systematic approach to safety which focuses on addressing system and human factors.

“The NHS needs a profound transformation in its culture”

The campaign is providing a niche role not provided anywhere else in the system and aims to be different by:

  • Engaging, energising and mobilising individuals and organisations across the whole of the NHS in England to create the conditions for a safety culture, a just culture, a learning culture
  • Using a consistent approach to help locally led, self-directed improvement and providing tools and resources to help over 280 organisations ‘own’ the campaign locally; making it meaningful for their staff, patients and community while at the same time being part of something bigger which unites them around a shared cause across the whole of the NHS in England
  • Creating an innovative way of sharing how change is achieved and not just what is achieved

National Patient Safety Strategy

Sign up to Safety is one part of a whole safety system that should be ‘wired together’ to support the conditions for safety.

The unique bit about Sign up to Safety is that it is a campaign – and as such is not about developing new improvement activity.  As a campaign its part in the system is to help learning, sharing and implementation to help make care safer.  It raises awareness about the problems, the solutions and where we should think differently.  As a campaign it uses social movements and campaigning methods which are developing locally led actions and mobilising self-directed safety improvement.  We are also able to work at a national level across the while system to create a coherent approach e.g. working with the national leads for harm based areas such as falls and sepsis to ensure they are helping the frontline cope with the competing interests and ‘wiring up’ the system through strong partnerships, including all the key partners (above) and in particular the patient safety collaboratives and Q initiative; as well as working closely with the NHS LA and supporting their new incentive scheme.

Sign up to Safety therefore adds value and compliments the additional components of the national patient safety strategy which includes the following:

National leadership through the national patient safety team (moving to NHS Improvement under the leadership of Mike Durkin)

Learning from incidents and improved incident investigation via the National Reporting and Learning System and the new Independent patient safety investigation service under the leadership of Mike Durkin

Collaboration through the fifteen patient safety collaboratives sited in each Academic Health Science Network; teams of people who tackle intractable problems and find out how they can be solved and develop the right solutions or safer practices e.g. medication safety, pressure ulcers, and falls.  The programme will run over five years

Building individual capability and a network of quality improvers via the Q initiative – a partnership with The Health Foundation to create 5000 quality improvers over the next five years

Buddying through the five organisations that will be supported by staff from the Virginia Mason Institute (US) who will spend time in the five trusts over the course of the next five years helping the doctors, nurses and leaders figure out how they can improve using the tools developed in Seattle. The programme will run over five years and set five NHS trusts on the road to becoming leading healthcare institutions, at the same time sharing learning and benefitting the NHS as a whole

Patient safety education via Health Education England and the Patient Safety Commission

Patient safety standards and regulation via the professional and organisational regulators and inspections

Financial incentives to reduce harm associated with claims through the NHS Litigation Authority in partnership with Sign up to Safety

All this variety of activity can have the potential to create confusion at the frontline.  Participants frequently look to Sign up to Safety for clarity around the national system for patient safety.  Therefore one other aspect of the campaign is its ability to help make sense of the current system and to explain any changes in the patient safety system for the frontline.