Patient Safety Collaborative - Learning Event 4

Patient Safety Collaborative - Learning Event 4

Implementing Patient Safety Dr Suzette Woodward Senior Advisor Department of Health and Social Care 3 things we need to do now 1. Create a balanced approach to safety

Safety I with safety II 2. Urgently tackle the blame culture Negativity, incivility and bullying 3. Care for the people who care Bringing joy to our work

What is safety? Safety I Failure Success Safety I

Incident reporting Root cause analysis Never

events Change the language Change the mindset Patient Safety Working Safely

Human Error Performance variability Zero harm Improvement Violations

Natural variation Strengthen Adjustments In order to do safety we need to understand the complex adaptive system that is healthcare

Unexpected and emergent People adjust and adapt Create order out of disorder Inevitable and necessary performance variability study and celebrate this Healthcare

Simple Complicated Complex Healthcare

Ultra safe High Reliability Ultra adaptive

Help people succeed under varying conditions Understand the everyday in order to replicate and optimise what we do Understand work as done in order to prevent things

from going wrong Erik Hollnagel We need to narrow the gaps Work as imagined Work as prescribed What we think people do

when they escalate concerns What we would like people to do when they escalate concerns Work as disclosed What people tell us they do

Work as done What people actually do We need to look beyond that which goes wrong? 10 / 90

Safety I Never events Significant and Serious incidents

Learning from deaths Incidents Complaints Claims Safety II and Learning from Excellence

Normal day to day performance Exceptional performance When something has gone wrong .. it is probably true to say it has gone right many times before and that it will go right many times in the future

we need to study the times it has gone right in order to know how it normally goes right and how it might go right and wrong in the future Safety II Failure &

Success Safety I and Safety II Two contrasting views on safety The reduction of harm through the study of failure (coined as safety I) The study of how people and systems are able to succeed under variations so that the number of intended and acceptable outcomes is as high as possible (coined as safety II)

Hollnagel argues that the same behaviours and decisions that produce good care can also produce poor care. The same decisions that lead to success can also lead to failure Hollnagel 2013 People make

countless adjustments during their work Most of these lead to success

Some lead to failure This is just work Take the blame out of failure

Adapted from Adrian Plunkett 2 Urgently tackle the blame culture How many of us would survive the microscopic scrutiny of our actions? There is almost no human action or

decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight Intentional v unintentional 70 years 30

1.1 n o i l l

i m The big challenges facing healthcare is about we behave towards one another Rudeness Incivility

Bullying Blame Shame Rudeness = lack of manners, discourteousness, impolite, insensitive or disrespectful behaviour Incivility = rudeness or unsociable behaviour / speech that occurs with uncertain intentionality

Bullying = seeking to harm, intimidate, coerce, torment, or intimidate someone who is perceived as vulnerable Minor incivility can lead to.. an immediate loss of cognitive capacity reduction in the quality and time of peoples work potentially knock on impact on service

users an impacts on onlookers @civilitysaves All can affect our ability to raise concerns and talk to one another such as a debrief

Impact on effort Even just thinking about encountering rude behaviour affects peoples performance Victims are distracted from the task at hand, reducing task-focused cognitive resources, and affecting ones performance People often admit that after experiencing rudeness they may withhold effort and decrease commitment

Impact on learning People who have experienced rudeness: Spend time trying to find justifications and replay the act in their mind which impacts on attention Struggle with ongoing attention and are distracted Experience disruption in cognitive processes Do not learn and recall as well Are impaired in their abilities to comprehend and use prior knowledge

Incivility Kindness Kindness Gratitude

Joy Wellbeing Kindness It isnt just about being nice It isnt a soft skill to dismiss when the going gets tough It is the way in which you can create a positive and joyful

workplace Clear is kind unclear is unkind An act of kindness can be.. helping someone find a new role if their skills dont fit for the one they are currently in helping someone improve their abilities or performance Helping people address their weaknesses rather than leave them to

flounder and struggle Gratitude People are 43% more productive when they feel valued Lowers blood pressure and boosts immune systems Increases happiness and fights depression A person who feels appreciated will always do more than expected Feeling appreciated keeps people going when it is tough

Friendships Close working friendships increase employee satisfaction by 50% People with a close friend at work are 7 times more likely to engage fully in their work Learning from excellence highlights success in an

environment where the prevailing approach to learning is to highlight failure Dr Adrian Plunkett Restorative Just Culture People are not the problem and usually the solution when something goes wrong ask.

Who was hurt? What do they need? Whose obligation is it to meet the need? Sidney Dekker The story of Mersey Care Creating a restorative learning culture

20 min film via: Safety II Learning Just Wellbeing Gratitude

Kindness from Joy culture excellence What matters to people is when they feel appreciated and

supported, when they feel part of a shared endeavour, a shared purpose Plant trees you will never see To understand the fragility of life is the first step in understanding your role and responsibility as a leader Your time is limited

Your greatest responsibility is to honour those who came before you and those who will come after You are the stewards of your organisations, the caretakers of your own lineage Legacy James Kerr your actions today will echo beyond your time

Never forget how powerful it is to simply say thank you Twitter @suzettewoodward

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