Helping people talk to each other – about learning from excellence

Suzette Woodward

The principle type of learning from ‘learning from excellence’ is the same as the learning we experience from any type of feedback.  The main difference is that it is exclusively positive feedback – an extremely rare phenomenon in today’s NHS.

Adrian Plunkett (2016)

I’m really looking forward to spending this coming Thursday surrounded by positivity and people like Adrian and Emma Plunkett who are leading an event ‘Learning From Excellence’ in Birmingham this week.

Most of the work to date on helping people working safely (patient safety) is about what went wrong. This causes people to focus on how bad it all is and people as a result feel negative, demoralised, frustrated and isolated.  The more we focus on what went wrong the more the problems and difficulties are all we see or talk about.

Learning from excellence is a ‘call to action’ from a team of clinicians and researchers who have a shared cause; to learn from what goes well in healthcare.  While this is a growing concept the pioneers are Adrian Plunkett, Emma Plunkett, Nicki Kelly, Simon Blake and Gabriella Morley and it also has links to the work of resilience engineers such as Erik Hollnagel.

Adrian says that at the heart of ‘learning from excellence’ is a simple, formal positive feedback tool, which allows peers to show appreciation to each other.  That those that receive the excellence reports are made aware of the positive effects of their actions and gives them the opportunity to reflect and think about why their actions were so well received.  As a result people often go on to make changes in their future behaviours based on the new awareness they have of their positive actions.

In relation to ‘celebration’ Adrian goes on to say that while he is all for celebrating achievements, if we celebrate something (or someone) everyday, we devalue that which we are celebrating. Whenever we create winners, we also create losers. For every award-winner, there are countless colleagues going un-rewarded; under the radar.

Therefore a key feature of learning from excellence is that the positive feedback from each report is privately shared with the staff member who has been reported for excellence. As Adrian says there is no overt celebration. No league-tables or performance charting. Learning from Excellence is a way to show appreciation.

Appreciation is more subtle than celebration. It is not a reward. It is not a prize. It is noticing the good. Showing our colleagues that we have noticed their good work is a powerful motivator, because it shows that they are valued in their work.

Learning from excellence in healthcare: a new approach to incident reporting (2015) by Nicola Kelly, Simon Blake, and Adrian Plunkett

Ref: BMJ Vol 101 Issue 9

In the above article the authors set out how learning from excellence can help improve the way we work safely.  It is so good I have lifted the following for this blog (italics taken directly from the article):

Eliminate the negative

In healthcare, we tend to place greater emphasis on identifying and examining failures of systems or individuals rather than recognising and reflecting on positive processes or outcomes…recent psychological research has revealed that people can learn effectively both from reflecting on failure (negative reinforcement) and success (positive reinforcement). Studies involving front-line healthcare professionals have shown that nurturing positivity in individuals and teams is linked with improved resilience and ability to deal with adversity.

Accentuate the positive

In healthcare, there is innate performance variability within almost all systems, which explains why things sometimes go wrong, but more often why things go well. It is often true that in medicine patients are seldom ‘textbook’ cases and our working environment is rarely perfect, but rather it is risky, unpredictable and challenging. Human performance varies in response to the changing environment. While some of this variation is unsuccessful, leading to error or harm, a great deal of variation in performance leads to success through adaptive adjustment.

These adjustments, or ‘workarounds’, are strategies for overcoming problems or limitations to compensate for variable conditions. This is an example of resilience in the healthcare context, which allows an individual or team to function effectively in a demanding and changeable environment. Although a clinical outcome on such an occasion may not be outstanding or perfect, the adaptability or resilience employed by staff in order to ensure a safe and satisfactory outcome could in itself be viewed as excellent practice.

Noticing everyday examples of good practice, and learning from the adjustments required for successful outcomes in variable conditions, ‘Safety-II’, is an emerging approach to safety. Safety-II originates from the concept of resilience engineering, a new way of considering workplace performance and safety, taking into account ‘work as done’ versus ‘work as imagined’. Resilience in this context refers to the ability of a system to adjust its functioning in response to changes in conditions. The goal of the Safety-II approach is to ensure as many successful outcomes as possible by recognising and learning from good practice and functional adaptations to variation in conditions. The Resilience in Healthcare Initiative, led by Professor Erik Hollnagel, aims to apply resilience engineering practice to healthcare worldwide using Safety-II methodology as a key foundation.

A related, emerging approach in healthcare is the ‘positive deviance’ model, which looks at the variations in performance and process that result in good outcomes rather than harm. The hypothesis behind this model is that by seeking and studying groups or individuals who perform exceptionally well, methods for best practice can be identified and disseminated to improve wider performance.

Safety-II and positive deviance methodologies are not currently highly prevalent in healthcare. Reasons for this may include the lack of clear strategies for defining and measuring excellent and safe practice; our innate negativity bias; or our current regulatory climate, which focuses our attention and resources on harm. We believe that improving resilience in healthcare organisations, through application of concepts such as Safety-II and positive deviance, will benefit patients and staff by optimising safety and by helping to improve service quality and efficacy.

Learning from excellence reporting

Learning from Excellence (LfE), aims to provide a means of identifying and capturing learning from episodes of peer-reported excellence or positive deviance .. the spirit of LfE is to treasure and appreciate our everyday successes, rather than taking them for granted. LfE was developed with the hypothesis that reporting and studying success would augment learning, enhance patient outcomes and experience through quality improvement work and positively impact resilience and culture in the workplace.

LfE began with a pilot project in Birmingham Children’s Hospital’s Paediatric Intensive Care department (PICU) as a system for all staff to voluntarily report episodes of excellent practice. Reports are submitted via an intranet-based ‘IR2’ form, suitably juxtaposed to the adverse incident reporting ‘IR1’ form used within our organisation.

They did not provide guidance or restrictions on which types of episode to report, leaving the reporter to apply their own definition of ‘excellence’. Staff in receipt of an IR2 received an automatic email notification and the reporter received an email acknowledgement. LfE is championed by a small multidisciplinary team of front-line clinical staff, who review all reports, creating weekly summaries with learning points, which are shared with the whole department through an e-bulletin.

How learning from excellence can be used to investigate good practice

In order to identify and enhance learning opportunities, reports are given an in-depth consideration at an ‘IRIS’ (Improving Resilience, Inspiring Success) or ‘reverse SIRI’ (Serious Incident Report Investigation) meeting. An IRIS involves a group dialogue between those submitting and receiving the IR2 of interest; facilitated by LfE team members using appreciative inquiry (AI) methodology. These hour-long informal reviews aim to identify how excellence was achieved, including ‘workarounds’ or innovations employed, and to generate ideas for sharing and promoting excellence.AI nurtures a positive mind-set and helps gain new insights into moments of optimal performance. The generative dialogic nature of AI encourages participants to share and reflect upon their ideas for positive change.

Summary

  • Learning from excellence is an approach, which redresses the balance between analysing failure and success
  • Excellence reporting can be used as a tool to capture useful workarounds and adaptations at the ‘sharp-end’—essential components of the Safety-II approach
  • The basic principles could be adapted and applied to engage individuals and teams in the process of identifying and sharing excellence in everyday practice
  • The use of appreciative inquiry to investigate excellence has generated new insights into understanding how processes can work optimally
  • Benefits include; improved patient care and staff development, identifying, sharing and modelling excellent practice, supporting staff involved in accidents and incidents, a positive workplace culture and morale, sharing good practice, identify and support innovation and discover new ideas and insights to inspire and facilitate quality improvement
  • Excellence reporting has been shown to identify and promote excellent practice within a front-line clinical environment, it could also be applied effectively to a wider range of healthcare settings including medical training, professional development and healthcare governance
  • This intervention may also help to develop a workplace culture whereby team members feel more appreciated and motivated and their hard work is recognised with positive feedback

The Learning from Excellence philosophy is really closely aligned to our work at Sign up to Safety.  Learning about what works, day to day experiences, good experiences and in deed excellent experiences are vital data to help people work safely.

It is great that we are all striving to redress the balance

At Sign up to Safety we talk a lot about ‘saying thank you’ – but it isn’t about a grand gesture of ‘thank you’ but much more a small act you can do as often as you like to show your thanks to people around you for whatever you feel they need thanks for.

What has this got to do with conversations?

Talking about what is working well changes the whole conversation completely.

Learning from excellence and other concepts such as appreciative inquiry are underpinned by the principles that learning and improvement should come from a place of understanding how things work well. Positive thinking shifts us from what we could have done differently to what would we like to continue to replicate.

A positive inquiry requires all of the aspects of a good conversation. A way of explaining what is working well through storytelling and personal experience, listening to what is being said and asking both clarifying and probing questions to find out more.  It is dependent upon the right set of behaviours, respect, humility, curiosity and kindness for it to work well in itself.

What we have seen from our own experience and then through others such as Adrian and Emma Plunkett is that positive inquiry and positive conversations are energising and uplifting.

What can you do differently?

  • Consider holding a ‘kitchen table’ (for this any other information about our work please go to the sign up to safety website) or any other methodology for bringing people together to talk to each and ask them to share something they are really proud of, or a task, day, shift or act that they felt went really well or simply to talk about what works rather than what doesn’t
  • When investigating incidents, complaints or claims include in the inquiry questions ‘what went well’
  • Forensically investigate care that went well and identify the points that you would like to replicate time and time again for the future
  • Take time to say thank you

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