Helping people talk to each other – in GP practices

From the Guardian article – GPs losing sleep over patient safety fears, says head of profession – Denis Campbell 8 October 2017

“Shattered” GPs are lying awake at night worrying they may have harmed their patients by making mistakes caused by tiredness and overwork, the leader of the profession has revealed. Family doctors are losing sleep because they are so anxious that they have put patients’ safety at risk by missing a symptom or not keeping their medication up to date, said Prof Helen Stokes-Lampard. The doctor, who is the chair of the Royal College of General Practitioners (RCGP), told the Guardian: “GPs, like many caring professionals, never completely leave their jobs behind when they go home; it’s a 24/7 responsibility.

Like everyone in healthcare GPs are time pressured, however they are particular time pressured in that their consultations are time limited. They have to listen, assess, ask the right questions, make a diagnosis, respond and act all in 10 minutes. Not only do they have clinic hours they have prescription reviews, telephone calls, home visits, hospital letters and ensuring records are up to date; all of which require people to work safely.

The clinics are invariably full or over running so a key question is…

When do GPs get time to talk to each other?

When do they get time to talk to the rest of the staff in the practice?

When do they get time to talk about working safely?

There are a number of reasons why it is hard to talk to each other in GP practices. These are a few that have been shared with us:

  • Time – clearly an obvious one but needs reiterating
  • Hierarchy – a lot of practices are very hierarchical with the most long serving doctor as the senior partner who has ultimate say and then it works its way down from docs to nurses to admin – the further down the less of a voice they have
  • Silo working – GP practices can be structured so that the different ‘groups’ work in isolation of each other; GPs work on their own, nurses on their own, admin and receptionists on their own
  • There is no ‘structure’ or time period that creates the opportunity to talk to each other
  • The interventions often associated with conversations feel clumsy; such as the use of huddles, briefings and handover tools such as SBARR
  • With the ratio targets of GP practices per population there are increasing numbers of mergers which also has the issue of split sites – these can create challenges and barriers for getting to know people

One GP we spoke to said that often GPs will arrive, go into their room, see their patients and then leave – one GP said ‘he had no idea who else worked there as he had never met them’.  A number of GP practices are trying out different ways to tackle these factors.  Local newsletters, lunchtime huddles, coffee time get together.

Prof Helen Stokes-Lampard …

“GPs are professionals’” she said. “We do everything we can to be meticulous; that’s in our nature and is part of our training. But when you’re shattered, it is possible to overlook a changed prescription request, or not update a patient’s record as comprehensively as would be ideal – things that can impact on patients’ health further down the line.

 “But there are also more sinister things we worry about. Did I miss a symptom of something that could be more serious? If I’d had more time with that patient, would my eventual diagnosis have been different? These things play on your mind, and it isn’t healthy.”

With GPs still awake at 3am or 4am wondering if, as a result of being under constant pressure, they have made errors we need to find ways in which they can talk to each other and their practice colleagues about working safely.

How do you talk to your colleagues and how you would like to see things change.  If you have just a moment spare – go and say good morning to all your colleagues, find out about their day because talking to each other can help in so many ways:

  • Bring people together to talk and in particular to focus on working safely around a cup of coffee and cake (or whatever you like to drink and eat!)
  • Discuss the links between working safely, quality of care and productivity, efficiency, effectiveness and reduced cost
  • Discuss your CQC inspections (before during and after)
  • Build on your significant event audits and talk about what is working well – building on the concepts from the ‘learning from excellence’ research – we love this positive approach which could help a little with the morale in GP practices, helping people feel valued and acknowledged for the great work they are doing
  • Help with connecting up the different sites
  • Bring together from across the patch from the CCG and other practices – not just your own

Another approach would be what we are calling ‘walking meetings’ – these are ways in which people can get out and about and can be for as little as 10 minutes.

What are the benefits?

  •  Walking with your colleagues helps people develop relationships and connect in a different way
  • Walking side by side has been shown to be less intimidating so people really feel they can open up about the things that keep them awake at night
  • The increased blood flow to the body and in particular the brain keeps you alert and can also help with creativity
  • People also feel great when they get back – not only have they had a great conversation they have stretched their legs and got a little bit of extra exercise in their day

We need to help everyone with the loneliness that some experiences when working in the NHS.  Help people unload their concerns rather than leave them with the dialogue that takes place in their head which keeps them up at night.

If you want to know more about talking to each other to help people work safely?

Thanks to colleagues from the West of England AHSN for their invaluable insights http://www.weahsn.net/

Conversations to help people work safely

“Humble Inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person”

Edgar H Schein (2013)

Over the last five years there has been a growing conversation about the language of patient safety.  If we keep referring to safety or patient safety as a ‘issue’ to be tackled by central teams or vertical programmes rather than talking about ‘working safely’ – patient safety remains a ‘thing’, a side issue or an add on to day to day work. It also remains the responsibility of a few people rather than all.

Working Safely is a phrase suggested by Erik Hollnagel which we feel defines patient safety in a much better way.  When we talk about improving patient safety versus improving the way people work safely there is an instant change in mind-set.  It changes it from being a project to our everyday actions.

Hollnagel and others describe the latest thinking ‘from Safety-I to Safety-II’.

Safety-I is where safety is defined as a condition where the number of adverse outcomes (accidents, incidents, near misses) is as low as possible.  Where there is a simple linear approach to describing and investigating accidents or incidents.

Models and methods which require that systems are linear with resultant outcomes cannot and should not be used for non-linear systems where outcomes are emergent rather than resultant’

Erik Hollnagel

Hollnagel asserts that the solution is to change the way we look at safety from always looking at what has gone wrong and (potentially punishing the individuals who were involved) to really studying what is going well. This means analysing everyday activities to understand what works with a view to replicating them in addition to analysing single isolated events of things that went wrong.

‘Safety-II is the ability to succeed under expected and unexpected conditions alike, so that the number of intended and acceptable outcomes (in other words everyday activities) is as high as possible’

In ‘Safety II’ humans are seen as an asset rather than a liability and their ability to adjust what they do to match the conditions is a strength rather than a threat. This is a shift from the current focus which views non-compliance with certain procedures as ‘violations’ and as immediately negative and in some cases punishable acts or indicators of poor performance.

What has this got to do with conversations for helping people work safely?

Working in healthcare is rarely about certainty and predictability. Healthcare is complex with decisions that need to be made every moment of every single day and for a variety of reasons some of them will be bad and some good.  Often the decisions we make are full of dilemmas where two or more choices can be made and one must be chosen.  This can be in so many ways; which procedure to offer, which drug to prescribe, which patient to send home, which patient to keep in and so on. We need to help the people working in healthcare to make these choices.

To help people make choices and work safely means talking to each other.

Often leaders feel that they need to be ‘in control’ and highly directive, that the task of leadership is to ensure that people do as they are told and reliably perform their function. Instead what people really want is to be helped to do their jobs well and as safely as possible through guidance and coaching.  They want to be trusted to do the right thing.

To trust people to work safely means talking to each other and listening to what is actually going on and not what you think is going on.

In patient safety we often talk about culture and people can have a tendency to say things like ‘if we just change the culture’… but culture is as invisible as the wind so how do we change it? Within the walls of organisations or practices, there are structures, processes, plans and procedural documents but …none of these are as important as the individuals who work there and the way in which they behave and interact together.

To help people interact with each other means talking to each other and creating those connections and relationships.

Culture change cannot be achieved by a top down mandate. If you want a culture of positivity, respect and kindness you can’t order people to be positive, respectful and kind. What you can do is use more positive approaches to learning about working safely (positive deviance, appreciative inquiry, learning from excellence) and you can be respectful and kind.

To help people be respectful and kind means talking to people with respect and kindness.

 You can be a great role model. Role modelling the behaviours you want to see and visibly demonstrating the culture you want is a great way to influence the culture of others. Rewarding and recognising those that also exhibit the behaviours you want to see shines a spotlight for others to see and also want to replicate. Calling out behaviours you don’t want to see (bullying for example) shows people you are genuine.

Rewarding when they exhibit the behaviours you want to see, where people are able to speak out or when they act on something they have heard, starts to build the culture from the ground up.

The culture we want to see is where people are cared for and supported when things go wrong and that others are asked questions first before being judged. The culture we want to see is where we listen to the multiple diverse voices that need to be recognised, heard and engaged.

Sidney Dekker says: If you want to change behaviour, don’t target behaviour. Target the conditions under which it takes place. Those conditions are not likely the worker’s responsibility. Or only in part. Think for a moment about whose responsibility the creation of those conditions is in your organization. And then take your aim there.

The safety culture of a team or organisation or even an entire system is influenced by how people interact, the language, words, writings, and stories they use. However in healthcare a lot of our forms of communication have become one way information sharing or as others might say ‘simply telling’.  People are drowning in emails, policies and procedures telling them what to do and what not to do. Conferences are mainly about people sitting being talked at with minimal time for questions and answers.  Meetings are the most common way people come together yet most people find meetings boring and unproductive.

In some cases meetings can be more than unproductive they can be counterproductive. For example, up and down the country there are all day meetings where individuals (mainly nurses) stop what they are doing and nervously trickle into a room clutching mounds of paper and sweaty hands to argue their case for whether the incident they were involved in was avoidable or unavoidable. Judge and jury sit and debate with people desperate to be put in the unavoidable camp.  This at best is distracting and at worst perpetuates the blame and fear culture.

People feel that they can’t deliver the bad news or problems without retribution. This approach is too simplistic and stifles people who need to share the problems in order to identify the potential learning and solutions.

It doesn’t have to be like this

Judgement silences things, turns learning into a secret. Empathy enables that secret to be shared.  It is everyone’s responsibility to create the conditions for others to come together and talk to each other.

 Is there an evidence base?

We have based our thinking on academic theory, research and our own experience. The knowledge we have gained and seeing how others are developing this view of the world has helped build our confidence to explore further.

We recognise that the concepts and ideas we share are not new to many. There are more than forty examples of conversational methods we have come across; appreciative inquiry, organisational learning conversations, polarity management, and world café to name a few.  There are all sorts of people who have and are studying how we could tackle this issue. The deliberative democracy movement, the high reliability experts such as Karl Weick, those concerned with creating psychological safety when we make it easy for people to talk to one another, to share, to admit their mistakes and to be supported such as Amy Edmondson. Wiggins and Hunter talk eloquently about how change happens through changing conversations and relationships.

One of the things we have come to realise is that it is not so much the method used to help people talk to each other but the right conditions and mind-set that is needed regardless of what specific approach you choose. In fact we would rather people didn’t turn them into a ‘thing’ or a ‘catchy name’ that gets foisted on frontline staff as the latest trend for helping them talk to each other. What we don’t want to do is perpetuate the view that everything can be solved by a tool kit or neat intervention.

What is the benefit?

Helping people talk to each other – or conversations to help people work safely involves engaging people in things that really matter to them, providing opportunities for people to have effective conversations to connect, build relationships and explore new ideas and opportunities. To explore, to share, to gain more information than we already had.

We believe that helping people talk to each other could significantly impact on the safety culture in the NHS.  Whichever way you choose, taking the time to talk to each other can help:

  • Bring people together, connecting up the different teams, departments and sites to talk and in particular to focus on working safely
  • Talk about what is working well – building on the concepts from the ‘learning from excellence’ research
  • Be more positive and help a little with the morale, help people feel valued and acknowledged for the great work they are doing
  • Talk about the things that are keeping you away at night
  • Discuss the links between working safely, quality of care and productivity, efficiency, effectiveness and reduced cost
  • Discuss your CQC inspections (before during and after)
  • Bring together from other organisations not just your own

Over the next phase we will continue to share our ideas and insights from people across the NHS and providing practical help and knowledge to continue to demonstrate the importance, build the evidence base and share stories of conversations that have truly helped people work safely.

References:

Schein E (2013) Humble Inquiry: the gentle art of asking instead of telling

Brown J, Isaacs D (2005) The World Café; Shaping our futures through conversations that matter San Francisco: Berrett-Koehler Publishers Inc.

Marx D (2017) Dave’s Subs: A novel Story about workplace accountabilityDekker S (2017) http://www.safetydifferently.com/the-original-hearts-and-minds-campaign-and-the-dereliction-of-behavior-based-safety/

Woodward S (20016) Rethinking Patient Safety via amazon https://www.amazon.co.uk/Rethinking-Patient-Safety-Suzette-Woodward/dp/1498778542

And more here on this blog www.suzettewoodward.org

Wiggins L and Hunter H (2016) Relational Change Bloomsbury Publishing

Wheatley M (2009) Turning to one another; simple conversations to restore hope for the future San Francisco: Berrett-Koehler Publishers inc

Naylor D, Woodward S, Garrett S, Boxer P (2016) What do we need to do to keep people safer? Journal of Social Work Practice – [online] Available via http://www.tandfonline.com/eprint/bVgSRFVSIpjh8cwp2Gka/full

Erik Hollnagel and Rene Amalberti, (2001) The Emperor’s New Clothes or whatever happened to human error? In: 4th International Workshop on Human Error, Safety and System Development, June 11-12, Linkoping, Sweden (keynote)

Erik Hollnagel, (2010) Safer Complex Industrial Environments. CRC Press, Boca Raton, FL

EUROCONTROL (2013) From Safety-I to Safety-II: A White Paper.

Erik Hollnagel, (2012) A Tale of Two Safeties – via

www.resilienthealthcare.netErik Hollnagel, (2013) Is safety a subject for science? Safety Science; Elsevier Ltd http://dx.doi.org/10.1016/j.ssci.2013.07.025

Sign up to Safety – a campaign with a difference

 “The task is, not so much to see what no one has yet seen; but to think what nobody has yet thought, about that which everybody sees”

Erwin Schrodinger (1952)

Sign up to Safety is a national campaign focused on helping people work safely. We are part of a number of patient safety initiatives across the NHS in England. We started with a very broad mission of helping the NHS reduce avoidable harm and save lives as a result. Over the last three years we have evolved into something quite different.

Who are we? We are a small group of people who have differing experiences and expertise in subjects like nursing, patient safety, campaigning, social movements, digital media and communication.

We started with 12 organisations (members) and have grown to pretty much the whole of the NHS in England – at the time of the blog we have nearly 480 member organisations.  Our emerging approach is based on the latest thinking on patient safety together with our learning from the last three years working within the NHS helping people think about what they can do to work safely in a somewhat complex and often chaotic environment.

We started fairly traditionally, by asking people to analyse their patient safety data and talk to their staff and patients, to create a vision for what they wanted for their organisation and then to create and implement a 3-5 year safety improvement plan.

What we saw and what we heard changed our thinking and approach. We saw how leaders were grappling with the dilemma of directing how things should go versus enabling staff to organise themselves. This requires a careful balance.  Too little organising and there is chaos, too much and people feel you are back to telling people what to do.

Over the last three years we have listened and heard how staff wanted to be valued, respected and trusted to do the right thing. We have met people who are increasingly confused and conflicted by being told what to do and they are fatigued by the current approach to change.

We have seen new interventions, ‘catchy’ names for local initiatives which are different from the ‘catchy’ name of the same thing down the road and old methods dressed up as new methods. We have seen them being imposed on busy staff who shuffle from one intervention to the other without knowing quite why they are being asked to do it.

So we chose not to add to the current ‘top down’ list of interventions and trusted organisations to develop their own plans and to work on things that matter to them. We wanted to give people the freedom to best exercise their own expertise and knowledge. Our philosophy is that the campaign belongs to everyone who has joined so instead of ‘one’ campaign we are 480 campaigns.

However this was not our main concern. Interventions will always come and go. Essentially a lot of them are all the same just dressed up differently.  No, our main concern was what people were telling us about how they felt.  How they struggled to develop relationships, they struggled to speak up and they struggled to be heard.

Healthcare is always about relationships and those relationships are completely dependent upon people being able to talk to each other. So we wanted to restore the balance, provide real support and help people with the vital skills in communication and cooperation they lacked. We also wanted to do it with kindness.

We help by providing ideas, insights, and positive encouragement via our website and newsletter. We conduct extensive research on all aspects of patient safety and share other people’s ideas, opinions, and knowledge.  We then go round the country talking and listening to lots of different people who work in healthcare, helping them through coaching and connections to think about what they could do differently. We have found that people react really positively to our thinking; we hope the same will be true for you.

What can we all do differently?

  • Help people create the right environment so that people can feel safe to talk to one another
  • Provide people with the opportunity of talking to one another and practice the skills needed for a good conversation
  • Help people think about their purpose, goals with a long term mind-set
  • Role model positivity, kindness curiosity and humility
  • Mobilise people to act and help them flourish and shine
  • Promote a form of ‘distributed leadership’ and a way of working which avoids the fragility and narrowness of relying on a central team or a single person who holds all authority
  • Encourage people to trust their teams, to start to decentralise structures and decision making, to recognise that different people contribute different strengths
  • Help people recognise what their staff are doing and thank them for what they do
  • Use stories to create an emotional link to the shared purpose and values
  • Adeptly use tone and language to make information more understandable, making emotional connections, telling stories of hope

We leave the other ‘tools of change’ to those responsible for quality improvement, performance management, inspection, contracts, targets and incentive schemes. The last thing we need to do is duplicate what these organisations and people are already doing but instead we chose to add value and find the gaps that are not being addressed.

What is our shared purpose or common cause?

Helping people work safely is clearly the topic but we have narrowed this down to safety culture and then narrowed it down even further to how people talk to each other.

We believe that in order to grow a safety culture people need to be able to talk to each other freely and without judgement. To some extent this is a profoundly simple solution; engaging in conversations where people are willing and able to share their stories and people are willing and able to listen carefully to one another.

That is our call for action; talk to each other.

 

Helping people talk to each other

Over the coming months this blog will build further on the issues explored in my book ‘Rethinking Patient Safety’.

The aim is to help readers and anyone interested in helping people work safely to think about the simple things they can  do differently now.

The thread throughout that connects the blog, the forthcoming outputs and downloadable resources of Sign up to Safety and the twice monthly newsletter is our refined ‘throughline’ (*)

helping people talk to each other

The book still provides the detailed knowledge, latest thinking and descriptive stories related to how we might learn from and build on our work to date in relation to patient safety.  It also provides, for the change makers amongst you, lessons in social movements and campaigning together with how the Sign up to Safety campaign has evolved and matured over the last three years.

The forthcoming blogs will provide additional concepts, insights and ideas which will be linked to the next phase of the campaign.  They will provide practical ways in which people can behave and act as well as provide useful references and links to sources and resources which can help.  We are really looking forward to sharing our knowledge and that of others to truly help you work as safely as you can.

(*) there is a blog devoted to what a throughline is which was written on 8 September 2016 … a summary of which is….

A throughline for our campaign  is something we have adapted from guidance shared by Chris Anderson in his excellent book ‘TED talks, the official TED guide to public speaking’ .  It is a simple sentence of around 15 words which describes what you are trying to achieve.  In the case of TED talks – it should describe your presentation in around 15 words.  We adapted it to describe the strategic direction of the campaign so that we could use those 15 words (or less) to connect everything we do together and a way of creating a strong thread throughout all the elements of our work.