Making Safety Visible LS1

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On Wednesday 5 July 2017, the first learning session of the Making Safety Visible (MSV) programme 2.0 took place.

This is the second time Haelo are hosting the MSV collaborative programme, bringing together leaders from health and social care in the Greater Manchester North East Sector to improve safety. Operating across a hugely complex health system, Oldham, Bury, Rochdale and North Manchester locality teams, met for the first learning session following the launch event in May.

The learning session began with energetic opening words from Dr. Ian Wilkinson, Chief Clinical Officer and Accountable Officer, Oldham CCG. Following, Abigail Harrison, Associate Director of Digital and Innovation at Haelo, set the scene for the day, revisiting the Measurement and Monitoring Framework (Vincent et al, 2013) and outlining the focus for the learning session: to build foundations for improvement, explore the framework and develop a shared ambition.

First up on the agenda, we heard from Rochdale couple Liz and Mike Brookes, alongside Nicky Timmis, Engagement and Participation Officer for Greater Manchester, Alzheimer’s Society and Julie Gonda, Assistant Director Commissioning & Procurement, Adult Care Services at Bury Council.

Liz, a former psychiatric nurse, is the wife and carer of Mike, 74, who lives with vascular dementia. In a patient-centred session, we explored their experiences interacting with the health and social care system with our guests having to deliver some difficult truths. Liz explained how their view of safety was very different to those in the room, highlighting the lack of communication between services being one of the challenges they have faced together and requesting that you “talk to the people that know the patient best” which in Mike’s case is Liz.

Liz brightly expressed “he’s not lost his mind… he’s not even lost that many marbles!” and how it’s important to remember the person.

After the diagnosis in 2012, it was a huge blow to Mike’s self esteem and confidence. It was important that he had someone who, when the dialogue closed with the health service, was there he could speak to. ‘Side by Side’, a service provided by the Alzheimer’s Society afforded Mike that support and friendship, where various clubs and events weren’t appropriate. Mike said, “I was really craving male company and someone to just have a chat with each week. It’s given me a new friend and a focus in my life”. You can read more about the invaluable support of Guy in an Alzheimer’s Society story.

We then heard from Elizabeth Bradbury, Director at the Advancing Quality Alliance (AQuA) on the learning from complex system integration, giving the example of the Salford Integrated Care Programme for older adults (ICP). This was the forerunner to the ‘Salford Together’ vanguard.

When asked what the feelings were in the room ahead of working across the whole system, leading change, the room answered: ‘positive’, ‘curious’, ‘daunted’ and ‘on the brink of something great’. Together they shared why they felt that way as they begin to learn new things in the collaborative, revealing the complexity of the system and ultimately finding the best result for the patient.

Elizabeth presented two of the various definitions and models on system leadership that are out there, and highlighted the three Cs: Courage, Curiosity and Clarity.

Elizabeth draws on the courage of teams to go together where there isn’t a road map, “it feels better jumping off a cliff when you’re holding hands with someone else.” Teams were asked to answer:

How will your collaborative leadership team demonstrate clarity?
How will you display curiosity?
And how you will you support your colleagues in courageous action?

This was also time to think about what they’ll need as a team and where AQuA can support them to get to the answers of those questions. Caroline Drysdale, Director of Community Health Services, AQuA fellow and member of the Oldham team, accompanied Elizabeth to share her personal account of working in a collaborative and through the 3 Cs, stating that the future of the NHS is the hands of those in the room.

In a Safety Dispatches session, representatives within teams were asked to prepare presentations to present back to their locality team on their safety story, answering:

What does safety meant to you organisation?
How do you currently measure and monitor safety?
What are your focus areas for improvement?

It was then time for breakout sessions where attendees split up to learn from four keynote speakers.

First up, Tina Lynge from the Danish Society for Patient Safety – fresh from the Patient Safety Congress – presented on a harm reduction case study. This multi-faceted harm reduction collaborative, resulted in reduced harm for 10,304 patients and increased improvement capacity in 4,418 healthcare professional. For more information about Tina’s work, please view her poster.

We were also delighted to welcome Jonathan Hazan, Director at Datix, on utilising incident reporting data to implement whole system safety. As the previous Chief Executive of Datix, Jonathan is keen to move from data and incident reporting having a negative connotation (he is on a mission to make the threat ‘I’ll Datix you obsolete’) to it being a learning opportunity. Now a Director at Datix, Jonathan is working with James Titcombe on ‘Patient Safety Learning’, a new venture which seeks to promote a patient safety learning culture. This hopes to launch in September 2017, so keep an eye on Jonathan’s twitter.

Followed by Jo Evans who spoke about the Safer Handover work stream of Safer Salford, improving handover in Salford. You can read more about the programme on their website and about the Rapid Improvement Event that the guest speaker, Junior Doctor Hannah Baird, attended.

Nick John, Lead Analyst at Haelo, held an expert data session on understanding variation and using data for improvement using a diagram from 1860 drawn by Charles Minard of Napoleon’s Army’s attempt to take Moscow in 1812. This has been called the ‘best statistical graphic ever drawn’ by Edward Tufte.

Teams met back up for the final session of the day, group work. Teams were given dedicated time to work together, discuss their focus area, their aim, driver diagram and measures specific to their locality team. On giving feedback to the room, emerging themes at this stage were discharge, care homes, older people and falls.

It was fantastic to see the progress made and we can’t wait to meet with teams during the current action period to support them on their journey. The next learning session will be in September 2017 with a focus on measurement and monitoring of safety maturity matrix and safety today – reliability, sensitivity to operations and whole system learning.

You can find more about the programme and launch on our website.

 

Resources

Framework: The measurement and motoring of safety framework, access online.
The King’s Fund: System leadership
OPM: Evaluation of the Leading Integrated System Level Change Programme

LS1 presentation slides, Prezi. Includes Nick John’s data session.
Jo Evans Safer Handover Prezi: The power of thinking collectively about safety
Tina Lynge presentation: Improving safety across whole system
Jonathan Hazan’s presentation slides: Learning from errors – a system wide approach.

 

AQuA References

To find out more or to contact AQuA visit their website, email of via twitter.

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