The Patient Safety Leader of the Future

Patient safety made headlines at the recent Patient Safety Learning Conference when Professor Ted Baker (Chief Inspector of Hospital for the CQC) declared that there has been “little progress' for NHS patient safety over past 20 years”.

Such an assessment feels overly harsh, but in the context of the Mid Staffordshire incident and the more recent events in Liverpool, it is clear that sometimes hospitals do fail to protect the patients they are caring for.

When Aidan Fowler, NHS National Director of Patient Safety, called for “Directors of Patient Safety” to be appointed in every NHS organisation it was a positive move towards reducing the variation in patient safety across the country. And if the enthusiasm at the recent Patient Safety Learning Conference is anything to go by, then we may soon be able to reach that goal.

One of the interesting discussions at the conference was what do these future directors of patient safety look like? What are the skills and attributes that they will possess? Professor Ted Baker pinpointed three key areas, but what would these look like in practice?

The first identified attribute was that a leader of patient safety should be “humble”. A true leader must be able to reflect on when they are wrong.

Based on some misplaced Machiavellian leaderships beliefs, we've often trained leaders to feel like they have to be infallible. However the art of a true leader is actually someone who can reflect and take accountability for their mistakes.

In healthcare there is no room for cover-ups, the stakes are too high. We need a leader who can put their hands up when things are not safe, and be an advocate for the patients that they are working to protect.

Often when things have gone wrong, it's because organisations have failed to be transparent about the problems that they are facing. The leaders of patient safety must be able to be a torchbearer of safety and be humble enough to admit when the right standards are not being met.

The second element of a good leader for patient safety is “strong values”.

To be a real leader and an advocate for patients they must truly believe in the values of NHS organisations. They must be genuine and believe that the values are there to be upheld. Too often leaders pay mere lip service to values and fail to exhibit the right behaviours.

We see examples of bad behaviour in the workplace but too often they are left unchallenged. A patient safety leader must act with integrity and be prepared to challenge individuals when their behaviours fail to live up to the organisation’s values.

The final attribute of a good patient safety leader is one that works “collaboratively”.

Healthcare works at its best when it utilises the skill sets of all its staff. Only through a multi-disciplinary approach can we hope to keep our patients safe.

The best knowledge is gleaned from a wide range of staff, and patients are kept at their safest when teams work together. Therefore, a patient safety leader of the future would need to be collaborative and able to engage a wide range of expert clinicians.

Only then can we learn to share our mistakes and improve the care we deliver so that every patient gets the standard of treatment they deserve.

Not all people will be able to stay humble, value focused and collaborative whilst delivering patient safety to an organisation. We must be able to have the right conversations with patients to ensure that they are able to make informed decisions to keep themselves safe in our care.

Only through patient engagement can we get the full picture and make care safer in the NHS.

Patient safety is a discipline in its own right and we must not assume all healthcare staff possess the knowledge and skill sets to be leaders in the field.

Patient safety is complex, it is multifaceted, and it cannot be done by one person alone. We must work to train more staff in patient safety so that all healthcare professionals can see its value and the impact that poor patient safety has.

We must all work to be patient safety leaders of the future and work openly and collaboratively to learn from our mistakes.

Oh I Do Like to be Beside the Bedside...

My holidays are here and it's time to dust off the suitcase and drag out the shorts from the bottom drawer. Like many British households it's time to jump in the car, fire up the Sat Nav and race to the nearest seaside resort. What we are presented with is over fifty different options to get to our destination. Dodge the tolls, keep off the "B" roads and swerve past the annual village fête. The same is true for the guidance on falls prevention. There are multiple interventions to apply to patients to reduce falls with harm but difficult to know what direction to take. So what advice should we all be following?

The latest Cochrane review on "Interventions for preventing falls in older people" tells us that there is a vast sea of uncertainty around interventions for falls. The report found that there was uncertainty around the effect of additional physiotherapy, questions around the effect of bed sensor alarms and that multifactorial interventions may reduce rate of falls, but it was difficult to say whether this had an impact on the risk of falling. I'm more certain that it will be a sunny day in Britain in June than researchers are on the evidence for the prevention of falls.

So then what is there left to do? Well, falls represent a huge cost to NHS hospitals and the wider healthcare system, with annual total costs to the NHS alone from falls among older people estimated by the National Institute for Health and Care Excellence (NICE) at £2.3 billion. Falls can cause physical harm to patients resulting in prolonged hospital stays, complaints and sometimes litigation but can also cause psychological distress with patients fearing further falls. Clearly action needs to be taken and in Scotland they have just launched a new consultation paper looking at the "Falls and Fracture Prevention Strategy for Scotland". And whilst it is useful to reflect on national policies and plan strategies for the upcoming years we need to be careful how this translates into the day to to day working on an NHS ward. If the evidence is saying that there is a giant question mark over how best to tackle falls in older people, what are busy patient-facing clinicians supposed to do when they don't have hours to trawl through library books hunting for the holy grail. 

A recent article in the HSJ told a very moving and difficult to read story about the poor care an elderly relative received whilst being treated for a fall at home. This is really disappointing, and unfortunately is not an uncommon story in the NHS. So clearly there is something that needs to be done about the prevention and treatment of falls in our hospitals. These wider strategies need to be translated down to the granularity of the daily working lives of nurses, doctors, physios and the teams on the front lines caring for patients. We need to breakdown these overarching policy documents into something that can be realistically achieved on the ward and intertwined with improvement methodology that wards can manage. 

There are heaps of interventions that wards can implement and then locally study the impact of their interventions. The issue that policy has is that there is not a one size fits all cure for improving falls with harm. There is too much local variance for a national improvement ideas to work across the NHS. The optimal bundle of components is not established, but common components include risk assessments for patients, patient and staff education, bedside signs and wristband alerts, footwear advice, scheduled and supervised toileting, and a medication review. Guidance produced by the National Institute for Health and Care Excellence encourages the participation of older people in falls prevention programmes and falls present a perfect opportunity for wards to involve patients in improvement work. Both patients and staff respond positively to education being delivered on their wards and raising awareness can empower staff and patients to work as a team to address falls prevention on hospital wards.

Preventing falls in patients can only be achieved through strong engaged clinical leadership. Going forward we will need to empower the whole multidisciplinary team to make improvement to their own environments and senior mangers to help build a climate for improvement to thrive. Teams must feel able to take ownership of delivering improvement work but be provided with the support of the organisation. By working with patients, teams can begin to develop customised falls bundles to their patient demographics and make recommendations to improve falls in their areas. 

The Power of Feedback

Time can pass you by if you're not watching. As a nurse, revalidation is a triennial expedition through mountains of files and rivers of paper. Scrambling through the scraps of paper, one can get lost in the depths of despair trying to find that golden piece of feedback. And yet as we go through life we receive feedback almost constantly. From the person behind you tutting for taking too long at the self checkout, to the 'nice outfit' comment from a co-worker. Feedback is everywhere but how you use it is key.

Giving useful feedback to colleagues has never been something that we have been very good at in the NHS. Most feedback has been focused around critical reports, performance management or rag-rated tables with a big red mark through the middle. Such approaches to feedback mean that it makes it almost impossible for people to learn from these. Improvement is all about collaboration and learning to do things better for our patients. Unless we can learn to give open and honest feedback in a way that can engage people and also help them to grow, we will struggle to make sustainable improvements to services.

The key to good feedback is summarised in “Thanks for the Feedback” and is broken into three key components. The first is appreciation and is area that we need to get better at in the NHS. We are always told when something isn’t going right but are too infrequently told when things are good. But there are groups of people out there that are trying to make things better. Programmes such as “Learning from Excellence” and the “The Academy of Fabulous Stuff” are all about sharing the great work that people are doing on a regular basis. There are pockets of real outstanding and innovative services and it is key that this work is promoted and shared. If we are to maximise improvement capability within organisations, we must work to be kind and collaborative and celebrate this when we get it right.

The second is evaluation which is something that is systemic across the NHS. We have Service Regulators, Professional Regulators, Commissioning Groups and Advisory Groups. There are 126 organisations with regulatory influence over the NHS all pushing and pulling services in a variety of different ways. Through this cloud of performance and financial targets it can often be challenging for teams to clearly understand where to focus their energies. Whilst evaluation is important to ensure standards, we must be careful that this doesn't become the basis of all feedback within the NHS. We must continue to evaluate improvements in order to share learning effectively but we must not lose that appreciation for people trying and pushing to bring change in the NHS.

The final key component to effective feedback is the coaching element. If we want individuals and teams to grow we must provide them with the tools and support to improve. Coaching is about helping people to improve their performance and how to approach problems and come up with solutions. This form of feedback is about being supportive and listening, discussing ideas to enable individuals to grow and build improvement. The new offer of Hexitime is a modern community based innovation that looks to build this sharing collaborative approach within the NHS. It is a timebanking concept founded on the idea that you give an hour of your time in order to share tools and skills and in return you can claim an hour back to utilise another members strengths and experience. This is concept that reflects the coaching methodology by providing an opportunity for a community to share expertise in order for individuals to grow and develop.

Feedback is a powerful tool and we must work in healthcare to give more valuable feedback that is appreciative and constructive. Too often we have relied on the red pen and we need to get better at understanding and listening to why things aren’t working. Whilst challenging, we can start to build this, by working collaboratively across services, professional groups and trusts to share feedback on what really works in the NHS and what things needs fixing. We must understand what the data is telling us, learn to listen to our stakeholders and develop services together. Only by appreciating the difficult realities of the NHS can we begin to make meaningful change. So now it’s back to my pile of papers to dig out the smiley-faced sticker from my dentist as some good solid appreciative feedback.

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To learn more about feedback and how to use it, I recommend Douglas Stone & Shelia Heen on how to utilise feedback. It teaches the art of how to give constructive feedback but also how to receive it so that you can grow and develop:

Let Today be the Start of Something New

I have a very long and difficult relationship with the gym. When it good, it's good, but when it's bad it's almost like we never even knew each other. It's a relationship built on mutual understanding but one that has often resulted in us arguing over how often we see each other, hurting each other (mainly me and my back) or ultimately going our separate ways. I know that I should try harder and make myself go more often but the motivation is often lacking and the draw of the sofa is often too overwhelming. Motivation and how to use it is a complex science, motivating yourself is hard, motivating others is even harder. When trying to make improvements in the NHS we need to think carefully about how we motivate our staff to bring about change and improve patient outcomes.

The numbers visiting A&E have risen by over 40% in the past 13 years. NHS services are struggling and can't see how they could make improvements in an already overstretched and challenging environment. Financial pressures, workforce issues and increasing demand on healthcare services makes day to day working in the NHS increasingly challenging. As a nation we are passionate about the NHS, the opening ceremony at the London 2012 Olympics and the tribute to the NHS clearly shows us that. So how can we develop our staff in the NHS to bring about change and improvements in patient care?

A common misconception is that to get people involved in an activity we must reward them for their participation, whether that be a bonus or a promotion. However this isn't the case. A recent BBC article shows that the number parents hit by financial penalties for children not attending school regularly, rose 93%. In a further step, some schools have decided to penalise parents who bring their kids into school late, they implement a fine in an attempt to reduce the number of late attenders. But their plans may not have the desired effect. Rather than reducing the number of late attenders, the number will probably increase. The effect of money will change the mindsets of the parents from an intrinsic mindset of "I want to maintain a good relationship with my child's teacher" to a transaction extrinsic motivation, "I can buy more time".

Whilst we might feel like extra £££ in our bank account would be great, our engagement and passion for an activity diminishes. We give rewards thinking that it will increase a person's motivation and drive but it also has the effect of undermining someone's intrinsic motivation to under take that task. Look at the difference between blood donations around the world. In the UK and New Zealand, people give blood donations altruistically with no financial reward but rather leave with the knowledge that they have done something good. In the USA, Russia and China, giving blood earns you between $20-$50 and demand is currently far out running supply in these countries. The WHO have come out to say that blood donation should be voluntary as the safest blood donors are non-remunerated donors from low-risk populations. So how can we tap into this altruistic motivation within our NHS workforce?

Well the good news is that everyone I have ever met in the NHS is there because they care. Through their belief in the concept of free health service, their love of the NHS, or the dedication to give the best possible treatment for their patients; they all care. We want to deliver the best possible service that we can and we want to motivate ourselves to deliver it. Improvement is a tool that enables all staff to get involved and motivate us to make a change. The essence of improvement is about collaboration and working together to make things better. It builds, constructs and grows services and feeds on the intrinsic values of participants. It is much easier to go to the gym when you have a friend by your side to encourage you to go and motivate you to attend. There are ways and means to get involved in all kinds of improvement activities within the NHS, whether you are a staff member or a patient. The key to improvement is to be curious and to get involved, so check out improvement going on in your local area. Be curious, be proactive and get motivated!

Rage Against the Fax Machines

Technology is everywhere, from instant online grocery shopping to GP apps that use AI to triage you to the nearest hospital. It feels that soon we will be living in a technological utopia in which we will all be creatures of leisure, where work is a thing of the past. And yet, waiting for the arrival of driverless cars feels like waiting for a food delivery after your fridge has been ransacked from too many midnight raids. It doesn’t feel like it’s coming anytime soon. So when the chance came up to see how modern technology is used in manufacturing and how lessons can be learned in the NHS, it felt like it was an unmissable opportunity to have a glimpse into the future.

How many NHS improvers can you fit into a MINI?

MINI have around 1000 robots at their plant in Oxford and have produced over 3 million cars since the factory opened in 2001. The plant has an assembly line stretching 1.7 km and every single MINI is manufactured to order. The plant is on the cutting edge of productivity with an efficiency rate close to 95%, making it one of the most productive manufacturers in the UK. To achieve this they apply LEAN methodology to processes and use Kanbans and root cause analysis to analyse their daily activity and see where improvements can be made. Every station has an improvement board and the team regularly reflect and debrief in these areas to monitor their output. The factory is a LEAN consultants dream with every process monitored, counted and analysed to ensure that nothing is wasted within the system.

Increasingly NHS organisations are relying upon LEAN tools and consultancy models to look at inefficiencies within the service. Often we are told that we need to process map systems and reduce wastage from within healthcare. And whilst these tools are effective for looking at the way we run systems and analyse data, there is a real danger that when used in isolation we miss the complexities of the NHS and the unique values that exist in healthcare. MINI is a slick operation employing 500 staff members at their Oxford plant and achieving impressive results. In contrast the NHS in England alone employs 1.5 million people with 168 trusts spread across the country

The ideas of robots and AI feels like a science fiction movie to the majority of frontline staff who continue to face daily battles with fax machines, Windows 95 and reams of paper. Whilst robotics will play an increasing role in the operating theatre and other areas of the NHS, it is far from the sheer scale of technological achievement they have within manufacturing and other industries. Therefore when we talk of applying LEAN methodology principles, we must be careful to base it in the reality of the NHS. Making processes more efficient isn’t just about reducing waste, creating new policies and streamlining processes. The key to successful change is about building improvement capability within staff and working collaboratively to improve patient outcomes. The NHS does not have the luxury of robots to tweak or new machines to change processes. Instead the greatest asset of the NHS is its amazingly talented staff and its patients. Whenever we look to make any real lasting change in an extremely complex system such as the NHS, we must ensure that it is collaborative with all involved.

The question of whether technology will deliver its promise to healthcare is still up for debate. All of humankind may one day be replaced by robots in the future, but plumbers, electricians and nurses are projected to stay in employment the longest due to the nature of their roles. A Chinese factory in Dongguon City replaced 90% of its human workforce with machines and saw a 250% increase in productivity when they brought technology into their company. The reality of the NHS is very different. The size of the workforce and the variety of different treatments and care that the NHS provides is currently far too complex to solve without taking a collaborative approach. Looking at the NHS today, I think my fear of my job being replaced by a toaster is safe for now.

A big thank you to Alan Dodge and Andrew Pentecost at MINI plant Oxford for the visit and providing facts and figures for this article.