Patient safety in partnership

The AHSN Network has made a significant contribution during the first year of the NHS Patient Safety Strategy. An update on its patient safety plan – one year on outlines the impact England’s AHSNs, including the West of England, had improving safety in hospitals, maternity and neonatal units, care homes and the community.

It also describes how AHSNs and the Patient Safety Collaboratives they host have responded to the COVID-19 pandemic, supporting programmes on tracheostomy safety and the use of pulse oximeters to safely monitor patients at home.

The report, ‘Patient safety in partnership: Our plan for a safer future 2019-2025’, was first published in September 2019. It sets out how AHSNs and PSCs will contribute to the NHS Patient Safety Strategy, through the PSCs’ work supporting the delivery of the National Patient Safety Improvement Programme and the AHSNs’ focus on accelerating innovation.

Natasha Swinscoe, lead AHSN Network chief officer for patient safety, said:

“AHSNs and PSCs have a unique ability to connect people, and work at both system level and with individual organisations to capitalise on opportunities. Our response to COVID-19 for example was swift, agile and effective.

We know there is a huge amount of enthusiasm and dedication for patient safety work, and through the Patient Safety Plan we look forward to exploring more ways we can collaborate with our many partners.”

Examples featured in the report include tools to spot and manage patients at risk of serious illness in hospitals and care homes, discharge safety bundles, and award-winning projects to support premature babies and their families.

You can download the AHSN Network patient safety plan here.

Find out more about the West of England’s patient safety work here.

AHSN Network has benefited more than 479,000 patients and generated £322.3 million inward investment for UK economy

The innovation delivery arm of the NHS, the AHSN Network, has released its Impact Report 2018-2020. The report highlights outstanding impacts achieved by AHSNs, including the West of England, and evidences how they are driving adoption and spread in healthcare innovation, transforming patient outcomes, enabling efficiencies, saving the NHS money, generating economic growth and attracting millions of pounds of investment for the country’s economy.

The report also details how AHSNs have mobilised quickly to COVID-19 to support the NHS and health and social care response.

National programmes

Commissioned by NHS England, England’s 15 AHSNs delivered seven programmes during 2018-20, developed regionally and selected for national adoption and spread, which are benefiting more than 479,000 patients: Atrial Fibrillation, Emergency Laparotomy, ESCAPE-pain, PINCER, Prevention of Cerebral Palsy in PreTerm Labour (PReCePT), Serenity Integrated Mentoring (SIM) and Transfer of Care Around Medicines (TCAM).

Key national programme findings from the report show that 13,387 fewer patients are at risk from harm from medication errors as a result of PINCER. The Network’s atrial fibrillation work has helped prevent 11,734 strokes and saved 2,933 lives. Whilst 8,472 people with chronic joint pain have participated in ESCAPE-pain courses.

AHSNs also play a key role in supporting the NHS to adopt new, better and more effective technologies through playing a leading role in supporting the NHS Accelerated Access Collaborative (AAC), by operation as the local agencies to drive adoption of Innovation and Technology Payment (ITP) and Rapid Uptake Products (RUPs).

Economic growth

From 2019-2020, the AHSN Network has generated almost £322.3 million inward investment for our nation, and created and / or protected over 1,000 jobs during this time.

The AHSN Network helps mobilise the value that the NHS can add as an economic asset to the UK economy. AHSNs broker access to a range of expert support and services across the health and care sectors that support NHS innovators and companies to realise the commercial and economic potential of their ideas.

The latest round of company surveys conducted by the AHSN Network show remarkable progress in the health innovation sector. Find out more about how the AHSN Network has attracted millions of pounds of investment for the country’s economy.

Patient safety

England’s 15 Patient Safety Collaboratives (PSCs) have significantly contributed to the NHS Patient Safety Strategy through their work on managing deterioration, maternity and neonatal safety, and adoption and spread programmes.

PSCs play an essential role in identifying and spreading safety improvement programmes (SIPs) to create sustainable and continuous improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes.

Successes include spreading the National Early Warning Score (NEWS2) to 99% of all acute hospital trusts, a 92% uptake of a discharge care bundle for patients with chronic obstructive pulmonary disease (COPD), and more than 120,000 views of a series of training films developed for care home staff.

Review our regional Patient Safety programme here.

COVID-19

To support the COVID-19 response AHSNs pivoted their expertise and resources, highlighting their unique ability to be able to work with regional health systems to spread innovation, whilst collaborating across England to drive rapid transformative change across large geographies.

Key examples of AHSNs responding to the pandemic include; providing expertise to NHS regions, by embedding staff in regional COVID-19 response cells, which was equivalent to 157 full time staff. And working with NHSX and NHS Digital, AHSNs help to drive digitisation of primary care, achieving a near-total uptake of video and online consultations in two months across GP practices in England. We also published a rapid-learning report on our patient safety work, ‘Safer care during COVID-19’.

By autumn 2020, AHSNs were continuing to support the COVID-19 response whilst providing expert input to regional NHS planning around the restoration and recovery of services. Nationally, AHSNs have also been leading the NHS ‘Reset’ campaign with NHS Confederation and the Health Foundation and have been playing a key supporting role in the NHS Beneficial Changes Network, focusing on ‘locking in’ learning from the pandemic.

Find out more about how we are working with health and social care colleagues across our region to keep people safe during and after COVID-19.

Piers Ricketts, Chair of the AHSN Network and Chief Executive of Eastern AHSN said:

“We are achieving results that make a real difference for patients and service users, as well as healthcare professionals, innovators and NHS organisations. These strong foundations make us ideally placed to help all those involved in improving and innovating health and care to tackle together the challenges that lie ahead.

The AHSNs’ response to COVID-19 has highlighted how our core strengths and ways of working have proved a valued asset to our partners. AHSNs are agile and well connected organisations, and we were able to mobilise and respond to this new crisis almost overnight, providing additional support and brokering relationships across health and care, research and academia, industry and the voluntary sectors.”

New national programmes

From April 2020, AHSNs are working on three new national programmes;

  • Focus ADHD; a number of AHSNs are working with mental health trusts and community paediatric services to improve the assessment process for Attention Deficit Hyperactivity Disorder (ADHD) using computer-based tests (measuring attention, impulsivity and activity).
  • Early Intervention Eating Disorders; a number of AHSNs are supporting mental health teams across England to speed up diagnosis and treatment of eating disorders in young people aged 16 to 25.
  • Lipid management and FH; AHSNs are scoping a national programme of work around cardiovascular disease (CVD) prevention, which is anticipated to start in autumn 2020.

Review our regional work on FOCUS ADHD and Early Intervention Eating Disorders.

AHSNs continue to support national NHS initiatives such as the National Innovation Accelerator (NIA), Small Business Research Initiatives (SBRI) and Clinical Entrepreneurs programme and developing work on new and emerging NHS priorities such as workforce innovation.

Read the full AHSN Network Impact Report 2018-2020.  

Flu resources launched: People with a learning disability are at greater risk of developing serious illness

The national flu campaign to encourage uptake of the free flu vaccination, particularly amongst at risk groups, has launched.

Individuals with a learning disability are identified as an ‘at risk’ group and are therefore entitled to a free flu vaccine. As are their carers, whether that is a family member or paid support staff who care for the individual day-to-day.

As such, the West of England AHSN and our Learning Disabilities Collaborative will be continuing to share advice and raise awareness of the importance of individuals with a learning disability, their families and carers, getting the flu vaccination throughout winter.

On behalf of the NHS, Misfits Theatre Company have created a great video which tackles the misinformation surrounding the flu vaccination head on and urges people with learning disabilities and their carers (family member or support worker) to not delay in getting their free flu vaccine.

You can watch the video here.

People who have a learning disability can be more susceptible to the effects of flu and are therefore at increased risk of developing complications such as bronchitis or pneumonia. As the NHS emerges from the covid pandemic, anyone with a learning disability is encouraged to get their free vaccination and annual health check to help stay well this winter.

Carers of anyone with a learning disability are also entitled to the free vaccination. All carers (family member or support worker) are urged to ensure they are registered at their local GP practice as a carer of someone with a learning disability. Individuals should also be on their GP Learning Disability Register to access the very best care.

Now is the time that GP practices and community pharmacies are carrying out vaccinations for those at risk. The vaccine offers the best level of protection from the flu virus, and it’s important to have the vaccine every year, especially as the flu virus strain changes every year. Anyone who is defined as being in an ‘at risk’ group should contact their surgery and arrange an appointment to have the vaccine.

Having the vaccine sooner provides the individual with protection over a longer period of time; it also helps reduce the chances of spreading the virus to family and friends.

Watch this NHS England and Improvement video where Camilla, who has a learning disability, talks about getting her flu jab. 

Hannah Little, our Patient Safety Improvement Lead and Senior Project Manager said:

“Flu is a very unpleasant illness. The symptoms can be miserable for many of us, but it can lead to more serious complications for those who fall within certain clinical ‘at risk’ groups. Some people with a learning disability can be more susceptible to flu and can go on to develop more serious complications like pneumonia. Respiratory conditions remain the most significant causes of premature mortality for people with a learning disability where deaths have been reviewed as part of the LeDeR programme.

I’d urge people to make sure they have the vaccination as soon as possible. They should also ask to have their Annual Health Check, which our Learning Disabilities Collaborative discussed at our September 2020 webinar. Carers of anyone with a learning disability should also get the free vaccine from their GP surgery or community pharmacy, the sooner the better to get the best possible protection.”

 

The full pack of winter flu resources for people with learning disabilities and their carers (which includes high resolution resources for social media, communications toolkit and grab pack for professionals) is available on the NHS England and Improvement website.

The flu vaccine is also free for patients in the following at risk groups:
• Those aged 65 years or over (including those becoming age 65 years by 31 March 2021)
• Those aged from 6 months to less than 65 years of age with a serious medical condition such as:
• Chronic (long term) respiratory disease, such as severe asthma, chronic obstructive pulmonary disease (COPD) or bronchitis.
• Chronic heart disease – (such as heart failure).
• Chronic kidney disease (at stages three, four or five).
• Chronic liver disease.
• Chronic neurological disease such as Parkinson’s disease or motor neurone disease
• Diabetes
• Splenic dysfunction
• Reduced immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment)
• Morbidly obese (defined as BMI of 40 and above)
• All pregnant women (including those women who become pregnant during the flu season)
• All children aged 2 and 3 years

• All children in school years R through to year 5
• People living in long-stay residential care homes, or other long-stay care facilities where rapid spread is likely to follow the introduction of infection and cause high morbidity and mortality.
• People who are in receipt of a carer’s allowance, or those who are the main carer of an older or disabled person whose welfare may be at risk if the carer falls ill
• Consideration should also be given to the vaccination of household contacts of immunocompromised individuals, specifically individuals who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable

Supporting Care Homes: Transfer of Care Around Medicines

Since 2018, as one of the AHSN Network’s national adoption and spread programmes, Transfer of Care Around Medicines (TCAM) has been an important medicines safety project for the West of England AHSN.

Upon discharge from hospital, 30-70% of patients experience unintentional changes to their medications or an error is made because of a miscommunication. 37%1 of older patients experience medication related harm within eight weeks of discharge. This was estimated to cost the NHS £396m per year. These errors can also result in patients being readmitted to hospital.

TCAM identifies patients in hospital who need additional support with their medicines, often people using multi-compartmental compliance aids. These patients are referred for pharmacy input in the community.

We know through our recent project work commissioned via the national network of Patient Safety Collaboratives that medication errors in care homes is a significant issue, and that residents medications upon discharge from hospitals are a consistent concern nationally.

The COVID-19 pandemic brought a renewed focus from NHS England and a national call to action for the NHS to support the “provision of pharmacy and medication support to care homes”.  Building on the communication system utilised to deliver the TCAM project, our response pivoted to supporting reviews of new care home residents or those recently discharged from hospital by sending messages directly to community based pharmacy teams that support care homes with their medicines management.

Working collaboratively with member organisations and commissioners, the West of England AHSN is testing the hypothesis that utilising the TCAM communication system to refer to pharmacy teams that support care homes will mirror the impact identified in the nationally commissioned programme and reduce medication errors and potentially reduce readmission rates1,2,3,4.

Our medicines optimisation programme benefits from active and experienced colleagues from member organisations who form the Medicines Safety Steering Group. Through this group, experience and understanding was utilised to build on the original TCAM programme for the benefit of care home residents. In responding to our commissioner’s renewed focus, the collaborative and cross-system nature of AHSNs was demonstrated by the implementation of this project at pace in one regional trust.

Chris Learoyd, Project Manager said:

“Listening to our member organisations, care homes and understanding their needs and regional system(s) was crucial. The COVID-19 pandemic has changed many things, but the AHSN’s approach to project delivery has remained. The reactive, adaptive and collaborative practices required in responding to the COVID-19 pandemic have indeed drew-upon the AHSN’s approach: supporting healthcare innovation, quality improvement across the system; generating additional capacity, avoiding unnecessary costs whilst enhancing safety across the health and social care sector”.

References:

  1. Sabir FR, Tomlinson J, Strickland-Hodge B, Smith H. Evaluating the Connect with Pharmacy webbased intervention to reduce hospital readmission for older people. International Journal of Clinical Pharmacy. https://doi.org/10.1007/s11096-019-00887-3
  2. Nazar H, Brice S, Akhter N, Kasim A, Gunning A, Slight SP, Watson NW. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation. BMJ Open. https://doi:10.1136/bmjopen-2016-012532
  3. Mantzourani E, Nazar H, Phibben C, Pang J, John G, Evans A, Thomas H, Way C, Hodson K. Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2019-033551
  4. Wilcock M, Sibley A, Blackwell R, Kluettgenas B, Robsen S, Bastian L. Involving community pharmacists in transfer of care from hospital: Indications of reduced 30-day hospital readmission rates for patients in Cornwall. International Journal of Pharmacy Practice.  http://doi:10.1111/ijpp.12603

HSJ Patient Safety Award Nominations

Two of the West of England AHSN’s member organisations have been nominated across five categories in the 2020 HSJ Patient Safety Awards.

Avon and Wiltshire Mental Health Partnership Trust (AWMHP) received three nominations:

    • Learning Disabilities Initiative of the Year (Improving Patient Safety on the Daisy Unit),
    • Mental Health Initiative of the Year (Reducing Restrictive Practice on a Medium Secure Unit) and
    • Quality Improvement Initiative of the Year (A Collaborative QI approach to improving the quality of care on the Daisy Unit).

Royal United Hospitals (RUH) Bath received two nominations:

      • Deteriorating Patients & Rapid Response Systems Award (Improving Patient Outcomes from Sepsis and Acute Kidney Injury) and
      • Patient Safety Team of the Year (The Sepsis and Kidney Injury Prevention (SKIP) team improving outcomes for patients).

In a news release, Dr Lesley Jordan, RUH Consultant Anaesthetist and Patient Safety Lead at the RUH, said: “We’re very proud to be shortlisted and recognised for our continued work in improving outcomes for patients with sepsis and acute kidney injury.

“Sepsis is a life-threatening reaction to an infection, when a person’s immune system overreacts and starts to damage the body’s tissues and organs. Acute kidney injury is when a person’s kidneys suddenly stop working properly, usually as complication of an acute illness, and this can range from minor loss of kidney function to complete kidney failure.

“These can have serious consequences and early detection of both conditions is really important to improve outcomes for patients. We have focused on identifying the conditions as early as possible, introducing process and tools to enable our frontline staff to implement treatment promptly and improve the care we deliver. We have also established a new senior nursing support team, the Sepsis and Kidney Injury Prevention (SKIP) team, to continue to drive this work and support frontline staff.”

Nominees will be presenting their work virtually to a panel of judges to decide the category winner, which will be announced at a virtual awards ceremony in November. You can read the full list of award categories and nominations here.

The West of England AHSN wishes both AWMHP and RUH every success with their nominations.

New online video training for care home staff

Wessex and the West of England Academic Health Science Networks (AHSNs), and West Hampshire CCG, funded by Health Education England, have collaborated to produce a series of free videos and e-learning materials to support staff working in care homes to care for residents who are at risk of deterioration.

As recognised in a recent paper supported by North East and North Cumbria AHSN, identifying acute illness, including sepsis, amongst older adults in care homes can be difficult, and opportunities to initiate appropriate care may be missed, if illness is not recognised promptly.

Videos

The short videos describe how to take measurements from residents correctly (such as blood pressure and oxygen saturation), spots the signs of deterioration, and prevent the spread of infection.

You can access them via Health Education England’s e-Learning for Healthcare (e-LfH) Hub, an educational web-based platform that provides quality assured online training content for the UK’s health and care workforce here.

You can also view the full suite of videos on our designated YouTube channel.

Natasha Swinscoe, national lead for patient safety for the AHSN Network says:

“Patient safety is a guiding principle for all AHSNs. Our care homes report highlighted numerous successes that AHSNs have had working with care homes across the country. Collectively, these have the potential to save many lives and tens of millions of pounds. I am excited to see the launch of these videos, which will support care home staff to be trained in a consistent way to recognise and respond to the soft signs of deterioration”.

This is one of a range of tools which AHSNs are supporting to provide training materials to up skill people who work in care homes, which will be published on our website over the coming weeks. This follows the AHSN network report, which highlighted over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the AHSNs which host them, published in September 2019.

Guidance for care home staff to register for an account

To register for e-Learning for Healthcare visit this link.

Select the ‘Register’ button. Select the option ‘I am a care home or hospice worker’ then enter your care home / hospice name or postcode and select it from the options available in the drop-down list. Finally enter your care home / hospice registration code and select ‘Register’. You may need to see your employer to get this code.

If your employer does not have a code, then they need to contact the e-LfH Support Team. The Support Team can either give the employer the registration code or arrange a bulk upload of all staff.

Detailed instructions on how to gain access are available here.

Quick start guide to e-LfH hub is also available here.

Collaborating for a safety culture in primary care

At the end of May, colleagues from 13 primary care practices from across the West of England, including GPs, practice managers, practice nurses and quality and safety leads, came together for the first meeting of our new Primary Care Collaborative.

The event was opened by our  Patient Safety Programme Director Ann Remmers who spoke about the context for collaboration. Dr Hein Le Roux, GP & Primary Care Lead for Patient Safety for the West of England AHSN, then explained how collaboration was a combination of people and technical skills. He told a cautionary tale of the Choluteca bridge and painted a picture of what better could look like in primary care. He explained how taking a systems approach could tackle some of the challenges through collaboration, and gave an example of a patient in his care where their care could have been better, and shared the learning from that incident.

Stephen Ray, Quality Improvement Programme Manager, expored why things go wrong in a systems context and some of the methods to take a systematic approach to quality improvement to build reliable systems. He explained the clinical microsystems approach, the model for improvement, and case studies from his experience working on improvement with GP practices.

All the presentations from our speakers are available here.

Attendees told us they really valued the time to meet other practices, learn from others and discuss subjects that they don’t normally get time to. There was great feedback about the speakers and group sessions, and the bacon sandwiches first thing were a big hit! They made a list of actions to take away from the day including looking at their existing processes and communications, developing a map of responsibilities, using PDSA and changing their language from “significant event” to “learning event”.

At our next meeting in September, the Collaborative agreed to focus more on sharing learning from particular examples from practices, with in-depth support on a topic chosen by attendees. Suggestions included:

  • Engaging and motivating staff to make changes
  • Putting changes into practice
  • How to engage all staff to make real change
  • Motivating staff and changing culture
  • Bringing on board difficult characters – what impact can individuals have on instigating change?

About the Primary Care Collaborative

The Collaborative has been set up to promote a safety culture in the primary care setting through the use of incident reporting, whilst giving the practices involved tools and training in quality improvement methodology. It will also help practices to undertake their own improvement journeys and network with other practices in the region to share learning and facilitate collaboration.

Benefits for the practices involved in the new Primary Care Collaborative include helping their practice in its next Care Quality Commission inspection and will contribute to the revalidation and appraisal processes for all staff. Staff are receiving quality improvement methodology training and resources throughout. Being a part of the collaborative will also increase awareness amongst practice teams of the patient safety agenda, while promoting an open and honest culture.

Patient safety is high on the public agenda, and practice’s involvement in the scheme will improve assurance that their practice has an open and transparent approach towards patient safety, in addition to improving the overall patient experience. Patient representatives for each practice have also been invited to take part as members of the practice core team.

Future events

  • Swindon| Hilton Swindon, Wednesday, 7 September 2016 from 08:00 to 12:30
  • Gloucestershire | Stonehouse Court Hotel, Wednesday, 30 November 2016 from 08:00 to 12:30
  • Bath | Royal United Hospital, Wednesday, 1 March 2017 from 08:00 to 12:30

Contact

For more information on the Primary Care Collaborative, please contact Kevin Hunter at kevin.hunter@weahsn.net.

Building strong foundations to support the most vulnerable in society

The West of England AHSN held a meeting recently, marking the first steps towards building a valuable partnership with the regional voluntary and community sectors.

The aim was to build relationships with organisations that could help us effectively engage with the most vulnerable groups in society, those who are isolated, housebound, the frail and elderly. Organisations that attended were Age UK, LinkAge, the Red Cross and West of England Care and Repair.

Two of our workstreams found the meeting particularly useful in terms of informing and supporting future areas of work.

Our Enterprise team is keen to make sure they are reaching people who might want to get involved in the next phase of our Design Together, Live Better project. This is providing the opportunity for people living with long-term health conditions, carers, family, friends and anyone else interested in healthcare, to suggest or give feedback on product ideas that might improve quality of life and independence. Last year, the first phase of the project developed three product prototypes, based on the experiences of people that attended a series of workshops and crowd-sourcing activities across the region. This next phase is looking to widen and increase our reach, and so voluntary and community organisations, through their membership and users, are extremely well placed to help us do that.

For some time, our Patient Safety Collaborative has been aware that its focus has been on acute care. With an increasing emphasis on healthcare in the community, it is important for us to influence those who have a role to play in safety in the home. Organisations like the Red Cross and Care & Repair often go into people’s homes and provide support to vulnerable people who might be just under the radar of health professionals. The role of staff in these organisations could be vital in improving patient safety and preventing avoidable Emergency Department admissions.

By the end of the meeting, there was great excitement about the potential for working together. A start was been made at the recent ‘Wisdom of the Crowd’ event to launch phase two of Design Together, Live Better, attended by several voluntary and community sector organisations. The Patient Safety team is also planning to offer SBAR (Situation, Background, Assessment, Recommendation ) training to several of the organisations.

Emergency Department Safety Checklist Masterclass

“Checklists are like toothbrushes; everyone wants one, but they don’t want to use anyone else’s!”

On Monday 25 April 2016, the West of England Academic Health Science Network (AHSN) hosted a free masterclass on the Emergency Department (ED) Safety Checklist, piloted at University Hospitals Bristol NHS Foundation Trust (UHB). Delegates were invited from EDs and AHSNs around the country that had expressed an interest in the project.

The masterclass was attended by 22 delegates from 12 different organisations.

Dr Emma Redfern, ED Consultant from UHB, explained why they had developed the ED Safety Checklist: to respond to the challenges of crowding in ED; to be able to quickly assess the sickest patients (by using the National Early Warning Score (NEWS) as an indicator); and to be able to triage according to patient’s needs.

Alex Hastie and Caroline Clark, ED Nurses from UHB, explained how the ED Safety Checklist had been developed. They described the quality improvement methods and the plan-do-study-act (PDSA) cycles employed to test the checklist, and described the benefits they had realised ‘on the shop-floor’:

  • an aide memoire for basic clinical care,
  • NEWScores used to differentiate the sickest patients,
  • a tool for measuring performance in real time
  • a tool to support staff when they are at full capacity
  • a tool to resource plan during periods of crowing
  • a ‘how to’ guide for bank and agency staff unfamiliar with the setting
  • a reduction in free-text writing in notes which has consequently improved patient contact time.

The West of England AHSN presented the implementation toolkit developed to assist adopting Trusts with how they might introduce the principle of the ED Safety Checklist. We also explored the principle of measurement to prove an intervention has an impact, key performance indicators and the ‘Life’ web-based platform to support quality improvement projects.

Dr Phil Cowburn, Acute Care Medical Director at South Western Ambulance Service NHS Foundation Trust (SWASFT) and Consultant in Emergency Medicine at UHB described the challenges of interfacing the ED Safety Checklist with the ambulance trust, particularly where the responsibility of risk sits for patients waiting to off load into ED in the queue.

Feedback from delegates on the day was very positive and the masterclass was well received. Funding, staff capacity and general ‘intervention fatigue’ were seen as challenges. However, the benefits of the ED Safety Checklist, the improvements to patient safety, improved patient triage, improved patient flow through ED, and improved staff resourcing and management were recognised and agreed across the board.

The slide show from the ED Safety Checklist masterclass can be downloaded here.

A full event write up on the ED Safety Checklist masterclass can be found here.

The ED Safety Checklist Toolkit can be downloaded here.

If you’d like any further information on this programme, please contact ellie.wetz@weahsn.net.

How inspiring leadership makes honesty possible

In his latest blog post, GP Hein Le Roux reflects on the differences between strategy and culture when it comes to patient safety.

In patient safety, an academic definition for strategy is a plan that takes you to your long-term safety goal, whilst the culture is more about people; the practice’s personality or ‘the way we do things around here’.  So for me, strategy is about talking the talk, whereas culture is about walking the walk. Clearly strategy and culture are both important, but often there is a gap between the two. Leadership attitudes and behaviours, particularly on honesty, form a crucial bridge in the quest to connect a safety strategy to the generative patient safety culture that we are all trying to build.

Changing mindsets

If our leadership is able to create a supportive environment, then it is so much easier to talk about an error or near miss in an open and just way. Whilst system and process factors are very important, my firm belief for what underpins the culture we are trying to create revolves around the mind-set of people. Medicine traditionally has been very hierarchical, often with power and thus decision-making based on tenure rather than merit. In my experience, this can inhibit openness and learning.

One recognised antidote is a move to a flatter organisational structure where leadership is distributed to the frontline; this is where the real clinical responsibility lies and is to be welcomed. Often this is where the safety and quality challenges occur, but it is also where much of the determination to change things for the better lies.

I feel attitudes are changing and in my view leaders need to continue to foster a culture of honesty particularly by exhibiting more versatile leadership, based less on command and control and more on coaching and visionary leadership styles. These behaviours can empower and liberate the front line to make things much better for patients.

“Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic”

We regularly talk as a practice about our individual significant events which provide powerful learning. Encouragingly, we are also talking more about the systems and processes which underpin our work, with an appreciation of the impact of a decision or behaviour on other parts of the practice. A recent example was where one of my nursing colleagues came to me saying that she had given an incorrect vaccine to a patient and what should she do? She could have kept quiet and no one would probably have been the wiser, but she actively chose to be open and honest. We discussed the incident and she phoned Public Health England, finding out that there was a low risk of harm. She then phoned up the patient to let them know what had happened and to say sorry. They valued her candour. Furthermore, she reported it on the National Reporting and Learning System.

As is often the case, our internal practice significant event analysis revealed more of a system and process error and some ‘human factor’ issues – in this case, a busy clinic. We have all learned from this and the nursing team are developing a vaccine check list to reduce the chances of such errors occurring again. On a personal level I found my colleague’s attitude to be both brave and inspiring. In particular I noticed her feelings of anxiety, which made her honesty in coming forward even more of an act of ‘bottle’. Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic.

Difficult conversations

So why can it be difficult to come forward with an error or near miss? What psychological factors can bring out our defensive feelings? The themes contained in a book that I read recently called ‘Difficult Conversations’ by Stone, Patton and Sheen seems very relevant to this particular blog. Whilst it is dangerous to generalise, an observation I would make about myself and some GP colleagues is that we can cling to a purely positive identity of ourselves, which leaves no place in our self-concept for negative feedback.

If I think of myself as a super-competent person who never makes mistakes, then feedback suggesting that I have made a mistake presents a problem. The only way to keep my identity intact is to deny the feedback – to figure out why it’s not really true, why it doesn’t really matter, or why what I did wasn’t actually a mistake. If we are going to engage in honesty and candour then we are going to come up against information about ourselves that we find unpleasant.

We all make mistakes

The bigger the gap between what we hope is true and what we fear is true, the easier it is for us to lose our balance. One way to get around the overly simplistic all-or-nothing thinking is to be aware that we are all probably more complex than just ‘I am perfect’ or ‘I am worthless’. Just because something is missed or goes awry does not mean that I am a bad person. We all make mistakes and if we can’t admit that to ourselves it becomes harder to learn, improve and move on because we spend all our time and energy defending ourselves.

One reason people are reluctant to admit to a mistake is that they fear being seen as weak or incompetent. Paradoxically, from my experience, it is generally competent people who take the possibility of mistakes in their stride and are seen as confident, secure and ‘big enough’ not to have to be perfect.

Bridging the gap

In summary there is a saying that ‘culture eats strategy for breakfast’. In other words, it is easy to talk the talk on honesty at a superficial level, but walking the walk is psychologically much more complex. Leadership attitudes and behaviours are crucial in order to bridge this gap. What I would say about our practice is that whilst we readily acknowledge that we are not perfect, we actively try to be open and reflective, so we can learn and improve the service we offer. Honesty has obvious benefits for our patients and also to our colleagues both within the practice and across the wider health and social care community.

As everyone already knows it is tough in general practice these days, but the esprit de corps that this honest culture generates is immeasurable.