1. Implementing Patient Safety
Dr Suzette Woodward
Senior Advisor
Department of Health and Social Care

2. 3 things we need to do now Create a balanced approach to safety
Safety I with safety II
Urgently tackle the blame culture
Negativity, incivility and bullying
Care for the people who care
Bringing joy to our work

3. What is safety?

4. Safety I
Failure
Success

5. Safety I
Incident reporting
Root cause analysis
Never events

7. Change the language Change the mindset
Patient Safety
Working Safely
Human Error
Performance variability
Zero harm
Natural variation
Improvement
Strengthen
Violations
Adjustments

8. In order to do safety we need to understand the complex adaptive system that is healthcare

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

11. Healthcare
Simple
Complicated
Complex

12. Healthcare
Ultra safe
High Reliability
Ultra adaptive

13. 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

14. We need to narrow the gaps
Work as imagined
Work as prescribed
Work as disclosed
Work as done
What we think people do when they escalate concerns
What we would like people to do when they escalate concerns
What people tell us they do
What people actually do

15. We need to look beyond that which goes wrong?
10 / 90

16. Safety II and Learning from Excellence
Never events Significant and Serious incidents Learning from deaths
Incidents
Complaints
Claims
Normal day to day performance
Exceptional performance

17. 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

18. Safety II
Failure
&
Success

19. 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

20. Some lead to failure Most of these lead to success This is just work
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

21. Urgently tackle the blame culture2
Urgently tackle the blame culture

22. 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

23. Intentional v unintentional

24. 70 years
1.1 million 30

25. The big challenges facing healthcare is about we behave towards one another

26. Rudeness Incivility Bullying Blame Shame

27. 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

28. Minor incivility can lead to..
an immediate loss of cognitive capacity
reduction in the quality and time of people’s work
potentially knock on impact on service users
an impacts on onlookers

29. All can affect our ability to raise concerns and talk to one another such as a debrief

30. 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 one’s performance
People often admit that after experiencing rudeness they may withhold effort and decrease commitment

31. 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

35. Kindness
Incivility

36. Kindness
Gratitude
Joy
Wellbeing

37. Kindness It isn’t just about being nice
It isn’t a soft skill to dismiss when the going gets tough
It is the way in which you can create a positive and joyful workplace

38. Clear is kind – unclear is unkind
An act of kindness can be..
helping someone find a new role if their skills don’t 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

39. 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

40. 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

41. Learning from excellence highlights success in an environment where the prevailing approach to learning is to highlight failure
Dr Adrian Plunkett

42. 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

43. The story of Mersey Care
Creating a restorative learning culture
20 min film via:

44. Learning from excellence
Safety II
Learning from excellence
Just culture
Gratitude
Joy
Kindness
Wellbeing

45. What matters to people is when they feel appreciated and supported, when they feel part of a shared endeavour, a shared purpose

46. 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

47. your actions today will echo beyond your time

48. Never forget how powerful it is to simply say thank you