Carl Horsley wrote on twitter just the other day…

It’s not about Safety II or even safety, really. It’s bigger than that. It’s about how we work. And it touches on leadership, teams, quality, safety, staff and patient experience.

Everything

Over the last five years a small group of us have had the privilege of working on the Sign up to Safety campaign.

Previous campaigns had focused on disseminating interventions related to individual area of harm. In fact we were initially charged with reducing harm by 50% and saving 6000 lives. Interestingly these figures have been bought to life again in the latest national patient safety strategy.

We were adamant that a focus on reducing harm was not the way to go. Our collective experiences in patient safety had taught us that things needed to be done differently.

Our curiosity led us to study psychology, behavioural insights, complexity theory, safety theory, just culture, human factors, safety II and more. We have shared this learning over the last five years on our website, in presentations and in this blog.

Our first realisation was that relationships and how people talk to and listen to each other was at the heart of creating a safety system and culture.

This led us to encourage conversations within and across teams. We called them ‘kitchen tables’ to bring to mind the times people sit round a table and share their day.

We encouraged conversations with respect, humility, curiosity, kindness, and civility.

However over the last two years it has felt like there was something missing, something just over the horizon but we couldn’t yet see it.

This view has just recently become clearer and clearer as we and others have grown in the understanding about really what safety is.

That it is clearly about learning about success as much as failure but so much more.

Our second realisation was that there is an undeniable link between staff health and wellbeing and safety.

For us staff health and wellbeing is not just that they are physically or psychologically cared for or that their basic physical needs are met such as food, hydration and sleep. Staff health and wellbeing is dependent upon the way they are led, the way they are trusted and supported especially when things don’t go as planned.

Staff health and wellbeing is also dependent upon the way people behave towards each other, the way they are kind to each other. It also means building a positive workplace; increasing morale and enjoyment at work.

What is thrilling is that there is not only an evidence base behind all of this thinking but that there is a growing group of people who are coming to the same conclusion.

Patient Safety will be enhanced if we care for the people that care – help staff with their everyday.

Help people work well, be the best they can be, learn, perform, and work together across the different professions and boundaries.

In fact it’s not just about patient safety, as Carl says … it’s bigger than that. Which comes to our third realisation .. thank you Carl.

It is about how we work.

It’s everything.

As each placement progressed and as each year passed by I became more and more skilled as a nurse.

I learnt by watching and working with some fantastic role models. I learnt to work with multiple different teams and then to lead them.

I learnt by doing things over and over again, getting better and better at them slowly and incrementally.

I learnt how to do some technical stuff I never imagined I would ever be able to do.

I also learnt how to talk to and listen to patients (even when they couldn’t talk) and their families and my co-workers.

This was my everyday.. my ‘work as done’…

Care for my patients, whether it was one very sick child or the whole ward. Care for them in every way. Their physical and psychological needs. Care as I had been trained to do but also as I grew in experience.

Observe them – really observe them. Through sight, touch, and smell. By listening, watching and counting. By measuring things that could be measured but also noticing things that couldn’t. Sometimes the monitors bleep would change imperceptibly but my brain would register that something was wrong before the numbers changed.

Adjust. Adjust my care to fit the patient need, adjust my choices and actions depending upon what I observed. Adjust my day depending upon the workload and the staff around me.

Inform. Inform patients and families what was happening and when, inform colleagues of status and changes.

Treat. Make sure I (or others) administered the right treatment at the right time in accordance with the individual plans.

Most of the time the basics were the same. Occasionally a new technique or new drug or new practice would be introduced and our skills would be ‘updated’.

We worked hard but we were also cared for. Told to take breaks, urged to eat and drink properly to keep ourselves well. And there always seemed to be someone to go to to ask for help or ask a question or to hear a concern.

This is what I mean when I talk about the fundamentals for patient safety or ‘working safely’.

I don’t recall doing quality improvement projects or filling out incident forms or being constantly scrutinised by investigators or regulators. I don’t recall being constantly aware of failure in fact the opposite. I recall us being constantly focused on success. Not just success in improved outcomes but success in beautifully caring for someone dying.

Does that mean I was any less safe? We will never quite know because the data we collected then and the data we collect now doesn’t really tell us whether we are safer today than 30 years ago .

I worry that we want to progress without doing the time. That years of experience are seen as secondary to promotion. That the experts quickly move on and the role modelling they are so important for is lost.

I worry that we have forgotten to enjoy the everyday and that we think we are making a difference by our obsession with small scale projects.

I worry that we feel we have to focus on the bad and not the good. If we were to believe the safety research we would think that staff are failing constantly when they are in fact doing the opposite.

We need a different conversation. A movement around a shared purpose centred on supporting everyone in healthcare to:

Care with compassion and kindness

Gain and value experience

Observe easily and effectively

Adjust safely

Inform and communicate well

Treat people using the best evidence based practices

Look after those that care by meeting their basic personal health and wellbeing needs and maintain a positive workplace

Ensure there is always someone to turn to

Too often I get a question from the audience which goes a little like this …

“It’s all very well all this being kind to one another but what can we do about the people who are useless or lazy or unsafe..”

Now I would argue that it is being kind if we help those people deemed ‘incompetent’ or lazy to find something or somewhere that suits their skill set more.

It is also being kind to figure out what may be behind their perceived incompetence.

Crucially it is vital this exploration does not leave us with the view that safety is purely down to ensuring the workers are competent.

What we actually need to study is how ‘work is done’ and what factors influence success and failure. We need to understand the role that the system and the environment plays (i.e. resources, education, infrastructure, staffing, culture, attending to health and wellbeing, supportive behaviours, relationships and so on) in helping people be the very best they can be.

One of the ways we could explore this further is to understand what psychologists refer to as the four stages of competence, or the conscious competence learning model, and how these stages impact on safety.

How we progress from incompetence to competence in our skills in healthcare is a component of safety.

So let’s explore these stages of competence.

First. Unconscious incompetence

The staff member does not understand or know how to do something and does not recognise that they don’t know.

We are all like this when we start out in life or start a new job. We are that novice who may take risky decisions without knowing how risky we are being.

So we don’t know that we don’t know? And not knowing means we could act unsafely without knowing we are acting unsafely.

Second. Conscious incompetence

The staff member does not understand or know how to do something but they recognise this.

The novice that knows they need expertise and experience to become more expert. This means that we can seek the knowledge to help us act safely. Feels a less risky stage to be.

Third. Conscious competence

The staff member understands or knows how to do something but makes a concerted effort to concentrate on the task in order to get it right.

The novice who is becoming an expert but still makes an effort to really think about it when doing the skill. On the road to being an expert but aware they need to continuously learn.

This feels like the conscious mindset to act safely. To have safety at the forefront of the brain when carrying out a procedure or task.

Is this where we should all try to be?

Fourth. Unconscious competence

The staff member has years of experience or has practiced over a significant time to master a skill. The skill has become second nature and can be performed easily. In fact the skill can be performed while doing other tasks at the same time.

The novice has become the expert and so much so that they can become the educators.

While this seems on the face of it optimal it could also be a risky state to be in. What if this leads to complacency or cutting corners inappropriately.

In healthcare there are around 1.3 million employees. All of whom will exhibit all of these stages at one time or another. In fact most of us exhibit all four stages all of the time. We may be both novice in some areas and expert in others. All of which impacts on the ‘work as done’.

It is too simplistic to say that what we should aim for is everyone being in the third stage (if we consider that to be the safest) when we will be constantly moving between the stages. What we need to do is help people who are in all four stages to work as safely as they can.

There feels a link between system competence and individual competence that may shine a light on ‘work as done’.

So how can truly understand how ‘work is done’ in order to help people work safely.

Collecting and studying incidents will tell us how work is done through the lens of failure.

Investigations and inquiries will provide insight into where there are flaws in our systems and processes.

Quality improvement tends to focus on a problem that needs fixing.

But what of the everyday? The everyday that most of us ignore because it simply just went ok. This we know is the majority of the time yet we fail to study this. What are the factors that help our work simply go ok?

How can we study this?

The research methodology that lends itself to this would be to follow people around and watch what they do (ethnographic methods) or to survey or interview people on the ground. However another way may be for those people to simply share their stories of their everyday. Storytelling is really powerful especially written in the first person.

So if you are interested in sharing your everyday stories I am really interested to listen.

Use the hashtag #workasdone and share on twitter your story or if you have too much to say send me a tweet and you may end up being a guest blogger.

I have the privilege of going round the country talking with people from all backgrounds and all levels in the NHS.

The focus of these conversations is safety. There are three themes that keep coming up.

1. The relentless pressure to increase the number of incident reports together with the consequential investigations is not working. There is no time to do anything else but meet the targets rather than truly learn about what can be done differently. This also means that studying what works is seen as a ‘nice to do if there was time’ rather than actually a way in which we might just get to grips with helping people work safely.

2. There is an urgent need to address and tackle the negative culture. People are experiencing high levels of rudeness, incivility, blaming, shaming, sanctioning and bullying. This is a symptom of the conditions in which people are working; the chronic fatigue, poor diet, overwhelming workload, polarised relationships across professions, poor staffing levels, low morale and the constant struggle to do a good job. It is also a symptom of the punitive governance culture we seem to have fallen into.

3. Morale is really low. People want to be respected, valued, cared for.

This leads to what we should do about it.

Be respectful of each other no matter what our background.

Be kind – it is an unbelievable strength.

Take time to get to know the people around you – you may have no idea what is going on in someone’s life.

Be the leader people want to follow. Support your team. Never be above making the tea, clearing up, being there to help. Listen more than you tell. Say thank you.

These are all lovely things to do but…

this is also the time to say ‘this has to stop’ – to hear students say they are subjected to a toxic culture in the NHS is heart breaking.

This has to stop.

National Kitchen Table Week will be from 18 March until the 24 March 2019. The week will also be a wonderful way to celebrate the ending of our work.  The team have run the Sign up to Safety campaign, funded by the Department of Health and Social Care (DHSC), for the last five years.  Our work was to create a shared purpose; all of us focused on helping people think and act differently about patient safety.

Our roles will be ending in March 2019 but this doesn’t mean that the work should not carry on. As you know two of our principles of the campaign were local ownership of the campaign and for you all to work on things that matter to you.  So Sign up to Safety still belongs to you to carry on the great work you have been doing so far.  To help you do this, to thank you all for joining and for working so hard to help people work safely we are going to share everything we have learnt, from how we have worked to what we have done and why and perhaps what we think people could do after we have gone.

Around 98% of the NHS in England joined the campaign and we have learnt tons. However, we don’t want to write the usual report that has a list of sweeping recommendations about how we should all make safety our top priority or how leaders need to pay attention to safety.  In our humble view that would not help particularly and let’s face it, it has been said many times before.  Instead we want to ‘do as we tell others to do’ and have a conversation.  We will produce some podcasts of us talking about our learning and back these up with links to evidence, stories and blogs.  We will focus on what has worked but also share our challenges and where we went wrong a few times.

The way we think about patient safety in healthcare needs to change. Achieving patient safety is not about short term projects to reduce individual harms it is much much more than that.  There are emerging theories (safety II), the world of behavioural insights, positivity and positive deviance, learning from excellence and addressing behaviours such as incivility.  There is also a deeper understanding developing of the learning and restorative just culture that healthcare needs.  This is a wonderful time to be working in safety.

To add to these, in our view, caring about people working in health care is the key to helping people work safely.  In fact we believe it should be the central driver to improving the safety of patient care.  How can staff work safely if they have not eaten anything for 12 hours, how can they make safe decisions when they have not had a good night’s sleep for weeks, how can they be helped to safely carry out complex tasks when they are frightened to ask for help.

We started thinking about this when we concentrated on helping people talk to each other, and provided the opportunities for people to listen to one another in a kind and respectful way via our ‘kitchen tables’. We will continue over the coming months to provide the evidence that underpins all of these ideas, some practical ideas for you address them but we also hope to stimulate a wider conversation about what we should do differently.

Caring about people working in health care is the key to helping people work safely

We would like to thank all of you for being a part of the campaign and in particular we are grateful to the Quality, CQC and Investigations Policy Team at the DHSC who have supported us throughout the last five years and importantly commissioned us for those extra two years which have made all the difference to our learning.

I would like to thank Amanda Oates [ @amandajoyoates ]  Joe Rafferty [ @JR_MerseyCare ] and Beatrice Fraenkel [@BFraenkel ] together with large swathes of staff at Mersey Care NHS FT whose names I may never know for providing those of us who have been working in patient safety with hope.

I have just watched the film about their work in growing a just and learning culture across their organisation.  This work has been in partnership with Sidney Dekker [ @sidneydekkercom ].  The film can be found here.

Complex systems like healthcare and hospitals are filled with hundreds of moving parts, scores of players and varied expertise. The moving parts and people are ever-changing with constant adaptations in action.  Even though there is an attempt to create mechanisms of ‘command and control’ it is impossible for the senior leadership of a hospital to be able to control everyone’s behaviours and actions.  However, despite this the prevailing view is that people should be controlled in some way with targets, policies, standards and guidelines and that when people inevitably deviate from these or fail to achieve them that they (the individuals involved) should be punished or sanctioned in some way.

The leadership at Mersey Care think differently.  They are doing their best to think and act differently about how to respond when things go wrong.

The film shares snippets of the individual stories of staff who have been hurt by the traditional way in which people are dealt with when an incident happens or a complaint is made.  This is not isolated at Mersey Care, it is in fact the default position across a lot of the NHS.  Sadly I have numerous stories from staff from all professions and all care settings who have been treated badly.  They have been suspended, investigated, banned from practising, moved, shifted, sacked.  They have felt ashamed and in some cases have taken their own lives as a result.   There is a moral imperative to support staff not blame them when things go wrong.

People make countless adjustments during their work. Most of these lead to success.  Some lead to failure.  There is no error.  There is just work, which we can try to understand.  Takes the blame out of failure (Adrian Plunkett via twitter @adrianplunkett )

We could fire everybody who makes a mistake, punish everyone who makes an error and put in an entirely new workforce but it would be far more useful to learn about why the mistakes and errors happen, together with learning about what actually goes ok or even well.  This balanced view means we stop defining an individual by the single mistake they make and instead understand the context of the thousands of times they got the same thing right.  People are not the problem.

Mersey Care are doing just that, working out how they can learn from when things go wrong, hearing from the people involved and what happened and not simply get rid of the people.  The film describes how they are doing this beautifully so I don’t need to repeat that, but the film would not have happened, the work would not have happened and the chance of hope would not be there if it wasn’t for the inspired leadership at Mersey Care and the fact that people want to follow.

They themselves say they have not yet got to where they want to be.  As I always say safety is not a 3-5 month project its a lifetime of work.  I for one cant wait to follow their progress.

In the third of my trilogy on ‘joy’ I will explore the things that everyone can do.  As it says in the title, role modelling isn’t just for leaders.  Firstly, everyone has the ability to be a leader no matter where your role sits within the hierarchy or structure.  Secondly we can all role model the behaviours we want to see in others including joy. Similar to our @signuptosafety twitter campaign #kind2018, there are some really simple things you can do today to bring joy to others.

Say thank you

Saying thank you is a powerful act of civility

(Kumar and Epley 2018)

We never thank people enough.  I don’t mean just the generic ‘thank you’ at the end of the shift or clinic or session.  It has to be authentic and genuine – you have got to mean it.  Research* shows that we underestimate the positive impact on others and ourselves when we say thank you.

What can you do today? Send someone a thank you message; write a text, a tweet, an email or a letter telling someone how they had helped you.  Do this in a meaningful way by being personal and detailed, explaining what they did and how it had affected you, how it had made you feel.

Be kind

What’s not to like or to lose by being kind to people?

What you can do today? Follow the people who inspire me everyday with their efforts to mainstream kindness, fairness, learning from excellence, joy in work, appreciation, and civility…:

• Gemma Crossingham – Consultant Anaesthetist in Plymouth.  Tweet: @gemolio
• Adrian Plunkett – Consultant Paediatric Intensivist at Birmingham Children’s Hospital.   Tweet: @adrianplunkett
• Emma Plunkett –  Consultant anaesthetist at University Hospitals Birmingham and Birmingham Women’s Hospital. Tweet: @emmaplunkett
• Neil Spenceley – Head of Paediatric Intensive Care in Glasgow and the Scottish Paediatric Patient Safety Lead. Tweet: @Neilspenceley
• Chris Turner – Consultant in Emergency Medicine. Tweet: @orangedis and more via http://www.civilitysaveslives
• Steven Shorrock – Psychologist – Human Factors and Ergonomics Blog at http://www.humanisticsystems.com and Tweet: @StevenShorrock
• Richard Taunt – Tweet: @RichardTaunt and @kscopehealth
• and of course – the team @signuptosafety

Keep a gratitude journal

Its hard being positive all of the time, in fact I would suggest impossible.  But there is a human trait which is to doubt ourselves or to feel like nothing seems to go right.  To help, some people have found it works to keep a gratitude journal. It has helped them feel more positive about their life or their work.  Those that keep one have said it is really easy and over time the things that they feel grateful for become smaller and smaller, as in they recognise more and more the things they feel grateful for.  Some people have given blank notebooks to staff when they start a new job or a new rotation or for attendees of courses to use to keep a gratitude journal.

What can you do today? Simply jot down the things you are grateful for at the end of the day or the end of the week. Write about what you feel is great, what you are proud of, who you might want to thank, what kind act you mind want to do, as well as things you might want to do differently.

Share stories

Lisa Rosenbaum** wrote an article ‘Twitter tailwinds – little capsules of gratitude’ about the Twitter campaign #ShareAStoryInOneTweet – this as she says ‘briefly transformed twitter’ into the most wonderful collection of stories from healthcare practitioners. It describes how an emergency doctor in Oregon US – Esther Choo – shared a story and used the hashtag. This role modelling of storytelling was picked up and briefly twitter ‘lit up with stories’.

What can you do today? Share your own stories with others.  Share what brings you joy and what you are proud of or grateful for.

Don’t use incident reporting systems as threats

Sadly so many people tell me that incident reporting systems have lost their purpose.  Rather than being used to learn they are being used to threat.  This keeps the negative culture alive.  It is a significant symptom of the culture of your organisation if it is used to blame people, target individuals, prod people to prioritise your issue above others.  It is a significant symptom of the culture of your organisation if it is used to replace a simple conversation between one human being and another.

What can you do today?  Completely rethink the way incident reporting is implemented in your organisation so that it is purely about learning.  If you need to tell someone that you are not happy with their attitude or behaviour then think of a different way and if possible sit down and talk it through with them.  And Be kind to people when things go wrong….  Ask the 3 questions Sidney Dekker suggests; who is hurt, what do they need and whose obligation is it to meet those needs.

Learn from what works

Shift the emphasis from just looking at things that go wrong and move towards learning from things that go right.  Try it out. When you are in a room full of people talking about what works you can almost touch the joy.  Appreciative inquiry is a great method for shifting the tone of a conversation from relentlessly focusing on the negative.  Carrie Biddle shared a blog*** on how she used appreciative inquiry in culture survey debriefings to keep a positive focus on what people wanted to do for a better future.

What can you do today? Ask positive questions.  Ask – even when things have gone wrong, – what worked.  Ask – even when you are investigating a complaint or incident or claim, – what worked.

When you are opening a meeting or receiving a report from others or carrying out a debrief or huddle, ask what worked first.  Asking what works first sets the tone for the rest of the conversation.

References

*Amit Kumar and Nicholas Epley (2018) Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation, Psychological Science

**Lisa Rosenbaum (2018) Twitter Tailwinds – Little Capsules of Gratitude N Engl J Med 379: 209-211 DOI: 10.1056/NEJMp1806737

*** Blog: Carrie Biddle (2018) Improving team culture to deliver safe sustainable services for patients – The South West Academic Health Science Network – http://www.swahsn.com/blog