PATIENT SAFETY NOW

If we are to rebalance safety, we should spend equal amounts of time and effort on understanding every day safety.

Therefore, back to my – if I was leading safety …..

I think I might start with redesigning the purpose of the safety team. The through line of what we are here to do. It took us two days in the Sign up to Safety Team to work out what our through line was but once we had it, it helped clarify everything that we were doing so that it built on and enhanced the though line.

A safety team through line would be something like, to help the organisation understand what makes work safer, what makes it difficult to work safely and acts on what it learns.

However, a really good through line is shorter and quickly memorable. We have two equal jobs. So a great through line would be:

Understand why things go wrong and understand how things normally go right.

At the outset I would look at the existing workload, what are we expected do, what are we required to do, what do we actually do. I would love it if we could stop doing some things to make room for the change in how we work. I would rather not add to the team’s existing work, I would rather we spent our time differently.

Then, we would start with how we respond to failure. I would implement the plan in my previous blog around creating a safety intelligence system. Figuring out what we need to learn both from failure and about how work normally happens.

Most organisations don’t actually know how the work gets done. Seriously, though, how can they really? Some trusts have over 11 thousand staff and multiple services, units, wards, departments. An NHS trust doesn’t fail to understand work because it doesn’t care, it struggles because understanding work at that scale is incredibly difficult.

We can’t know everything, but perhaps we can know more than we currently do

In being curious about how the work gets done, how people work safely, I would choose a small number of areas or times; a ward, an outpatient service, a theatre, an ED area, a community service, one night shift etc.

The aim is not to pick areas that are having problems or conversely, performing excellently, but to go to see what people do on a ‘normal’ (I know, I hear you saying but not that much in healthcare is the same everyday) day or night.

Organisations are highly complex. Hundreds of teams, multiple hospital sites, multiple specialties, complex operational systems and so on. All these difference areas will have developed their own routines, adaptations and they will all have their own unique pressures and ways of working.

Go and see but don’t feel pressured to see everything

I would encourage others to become more curious about what is going on when nothing bad is happening. Spending time to see how the work actually happens. Not an inspection or audit or official walk round.

Have conversations but don’t create a reporting burden

I mentioned the five minute conversations in a previous blog. Five minutes doesnt feel very long. But I know how difficult it is to ask people to stop even just for five minutes. Don’t make the five minutes another task, make it part of something that is already happening; a handover, a catch up coffee, a walk back to the office if you can.

If you want to understand difficulty:

“What’s the thing that makes doing your job safely harder than it needs to be?”

If you want to understand adaptation:

“Where do you have to work around the system?”

If you want to understand resilience:

“What happened today that could easily have gone wrong but didn’t?”

If you want to understand good practice:

“What’s something someone did today that made the system work?”

If you want to identify improvement:

“If you could fix one thing that would make your job easier, what would it be?”

Sometimes it will take 5 minutes, sometimes 30 seconds, sometimes half an hour. Sometimes no one will want to talk and thats ok.

Only do this if your aim is to help people. Help them with the broken printers, the IT failures, the things that people don’t seem to care about but are really frustrating. All of these impact on safety.

So if you are going to ask, you need to have a way of helping. The whole thing needs to be credible. If someone says the printer or keyboard isn’t working (..and we either have not had time to report it, cant be bothered to report it because no one comes anyway or we have been reporting it for six months and not had a response yet) …..(see the different reporting routes in the previous blog)

Fix it. Do something. Help them. Then tell people what happened, because you want to move from them from a feeling of frustration, or no one cares, to a feeling of ‘can do’.

Some things don’t need an immediate solution. Staff having to compromise or cope when there are not enough staff, people having to figure out the electronic prescribing system, working around official policies and processes because they dont work anymore. These are signals about how the system is really operating. These will help create the intelligence about everyday work if we go and talk to people. The patterns that would show us how work is being made difficult.

Explore it. Learn about why different departments use completely different processes, why one process works in the day but not during the night. These are all things that we just don’t usually get a chance to explore.

Always come back to the through line. We are doing two equal jobs.

Understand why things go wrong and understand how things normally go right.

• Both ask about how it is not working, how things are really hard to do. That is really important in the early days as these are the things that make working safely hard to do.
• And find out what is working well in one area or one ward or on one shift or at night rather than doing the day.

You will only find out this if you go and see, go and talk to the staff.

The goal is not to standardise but to understand why it works.

Feedback.

At Board meetings, at governance meetings, at safety meetings, at quality summits… ask questions like…

• What are we hearing that gets in the way of working safely?
• What are people doing to make things work?
• What have we fixed for people this month?
• What have we stopped doing?
• What practices have we found that appear to make work safer?
• What have we changed to the system?

Then each month…do we understand the safety of the organisation better this month than we did last month?

Feedback what is learnt to the staff.

As Margaret Wheatley says (I paraphrase), if we are going to change the world, we just need to change the conversation, talk to people and care about what is happening to them.