PATIENT SAFETY NOW

Let’s just imagine, I am back at one of the trusts I worked at, heading up safety or I am still working at the national patient safety agency… with what I know now, what would I do differently? If I had day to day responsibility for safety again, what would I spend my time doing on a Monday morning?

I am challenging myself because it is all very well in spouting forth about all these concepts that I genuinely think are needed in safety but I am much more interested in what would that look like in reality. I need to force myself to turn the philosophy into actual practice.

What I would really love to do is completely rebalance where the safety function spends its time. For nearly forty years we have organised safety departments around failure. We employ experts whose job is to investigate incidents, monitor risks, write reports, manage governance committees and comply with regulation. Almost everything happens after something has already gone wrong.

I would ask.. How much of my team’s time is spent understanding how safety is created? I suspect the answer would be less than 5%, and I suspect that is how it is for the vast majority of people who work in safety today. I wonder what that would look like if we shifted that modestly, even to something like 40%.

You all know I love developing things in sevens! so here are my 7 things…

1: Obviously I would continue to respond to failure

That doesn’t disappear. All the safety intelligence still needs to be captured and managed.

2: I would start to understand the conditions under which everyday work succeeds.

Not by inspections or checking compliance, just simply understanding the work. The people doing the work I find are often very eager to talk about what their day is like. The trouble is, they find it easier to talk about when it goes wrong, when things are difficult than when it goes ok. It is very important to value and listen to their concerns but we also need questions like:

• What work have you quietly done that isn’t in any policy?
• How you actually get through today’s list/clinic/shift?
• What makes this run smoothly?
• What helps you have a good day?

I am trying to find out what the day (or night) was like for the people trying to deliver care.

How would I do that?

Five minutes, just conversation – if something interesting emerges then capture it. Most shifts nothing remarkable happens (thankfully) but if you encourage people to do this regularly then something might just be a gem of an idea, or an insight we were not aware of.

I could shadow people or encourage peer to peer shadowing. People behave differently but we know the research shows that is for about 20 minutes. Ethnographers know that you cannot maintain ‘a performance’ for 8-12 hours. Eventually the real work emerges. Importantly, shadowing isn’t about catching people out it’s just about getting to know what they do.

3: I would find the adaptions.

Healthcare runs everyday because thousands of people adapt. Clinicians and managers and leaders alike. In order to understand how brilliantly people have learned to cope with the pressures and situations they face I would love to work out how I collect:

• clever workarounds
• temporary fixes
• different coordination or collaboration between teams
• anticipations and recoveries
• the things staff have improved on their own

4: I would remove unnecessary work.

How much work adds no value? Every month we would ask a department or unit or ward or clinic – what should we stop doing?

• Duplicate work or forms – all that stuff we do everyday and might not notice, or more likely we have become just too accustomed to. We keep on doing the same thing even though it may not be needed anymore.
• Pointless meetings – oh my goodness, I cannot count the number of meetings that didn’t need to happen, or I didn’t need to be at, or were really badly chaired or facilitated so that we didn’t actually achieve anything – or the work was done before the meeting in a pre meeting, and talked about after the meeting in a post meeting – bonkers!

• Reports no one reads – There are reports that are written because it is expected, it has been done for decades, it is just what we have always done – how many of them are actually read, and more importantly how many of them are actually useful?
• Data collected because someone once asked for it – I remember talking to someone about a set of data they were collecting and asked them why and who it was for. They didn’t know the answers to those questions and just said it is what we were asked to do in (decades ago) and no one has told us to stop. I checked. No one was interested.
• Policies no one follows – policies need a complete overhaul in my opinion. They need to be far far shorter, succinct and easy to apply. They do not need to be trying to cover every single detail of what is needed – you can never do that. They just need to help people do what they do. And if they dont do that, then dont write it. Ask -does this need to be a policy? why? will anyone every read it? It needs a radical declutter.

5: I would work with the people we dont traditionally work with when we think about safety

I would bring a team of people from across the organisation to improve the conditions for work. I would work with the people who are responsible for equipment, purchasing, finance, IT, staffing, HR, physical environments, noise, temperature, operational issues. Because all of them are just as responsible for the safety of care than any other person who works in healthcare. Not as part of a governance meeting, not a meeting at all. Just a get together to talk about safety and how they can help in the work they do. I know they will have some brilliant ideas they have been itching to tell someone.

6: I would continuously provide the clear evidence of the importance of the right safety culture.

A culture that is kind, compassionate, respectful, civil. One that enhances psychological safety and responds fairly when things dont go to plan. One that understands the multicultural aspects related to safety and understands what that means for all the staff who work in the organisation.

I would demonstrate the importance of relationships and how we need to encourage people to talk to each other rather than simply filling out another incident form. Safety isn’t achieved simply by a debrief or huddle, or filling out another form, or collecting more data, it is achieved in the everyday actions of staff, the everyday conversations within and between teams. As an aside, most huddles I have been in have not really been a conversation, they have been a way of organising, saying who is doing what and a way to check that everyone knows that.

7: I would feed all of the above back to everyone and particularly the leadership of the organisation.

I would present the picture of how the organisation is safer as a result of how people work. It would work with clever people to measure the conditions that create safer care. Like capacity, how people are coping, what doesn’t get done when they are understaffed, how often plans change, how often hangovers are rushed, how often staff have to workaround operational systems or tasks, whether people feel safe to challenge, or to stop what someone else is doing. Answering questions like:

• What is making today’s work easier?
• What is making today’s work harder?
• Where are people having to compensate?
• What unnecessary burden are we placing on them?
• What are the features of teams that consistently succeed despite pressure?
• What should we stop doing because it contributes nothing to safe care?

These are all measurable.

In summary

None of this is about introducing new initiatives, it is about changing where attention is directed. For decades patient safety has directed attention towards failure, what we need to do is direct attention towards the conditions that make safe care possible.

What does a patient safety department look like when its primary purpose is to improve the conditions for safe work rather than simply respond to unsafe outcomes?

If I were to pick just one thing to start with….

I would start by removing unnecessary safety processes (and for that matter any process that is unnecessary). Instead of being seen as the people who ask for reports, forms, audits and meetings, the safety team become the opposite. We could combine this with small practical experiments:

• Try five-minute end-of-shift conversations in one team for a month
• Shadow one service for a day each week and record only observations about how work is accomplished
• Ask one department to identify five things they could stop doing, then measure what happens – you can use the tool developed by the safety researchers at Yorkshire and the Humber de-implementation toolkit
• Present a Board with a paper that contains as much information about how safety was created as about where it failed

And see how the conversation changes.