Review: Making Safety Visible LS1

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The team from Wigan learning together

Making Safety Visible Learning Session 1 took place on 11-12 February at The Village Hotel, Bury. Over 170 delegates from more than 20 organisations attended the learning session across the two days. Access all the presentations from the conference, view the Storify curating the social media activity from Making Safety Visible and see if you are featured in the Making Safety Visible photo gallery.

Sir David Dalton opened the two day event by addressing the audience of over 160 and said he was delighted to see so many organisations in the room.

Prof Maxine Power, Director of Innovation and Improvement, Salford Royal NHS Foundation Trust, followed Sir David by saying that there has “never been a better time to think about safety” and then warming up the audience using a mini-quiz and live polling.

Prof Power then handed over to Prof Charles Vincent, Health Foundation Professor of Psychology, University of Oxford, who alongside Dr Jane Carthey and Susan Burnett authored “The Measurement and Monitoring of Safety” which the Making Safety Visible programme is using as a framework.

The Measurement and Monitoring of Safety

Prof Vincent discussed the architecture of safety, commenting that “simplicity is crucial” and that if you “think you’ve ‘done’ safety you’re finished, safety is a cycle”. The presentation also encouraged a shift in thinking around safety with Prof Vincent saying that we keep asking ourselves: “Are we safe? I think a better question would be ‘what can we learn about safety today?'”

Dr Jane Carthey picked up where Prof Vincent left off by telling the delegates that they “need to rationalise the data they collect and focus on the measures that matter”.

Dr Carthey was joined on stage by her co-author Susan Burnett to discuss the baseline assessments that each of the Making Safety Visible organisations had undertaken in the build up to Learning Session 1. The delegates then broke into their teams for active debate around what they’ve learnt from their baseline assessments and how they currently measure and monitor safety.

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Prof Charles Vincent takes to the stage during Learning Session 1

Lifting the lid on past harm

Prof Vincent kicked things off after the lunch break by asking the audience what they define as a harm, adding the consideration that “harm can look different from the point of view of a patient”. He then introduced Dr Mike Cheshire, Non-Exec Board Member, Stockport NHS Foundation Trust, who had the audience captivated with his moving stories about different stages in his medical career.

Dr Cheshire gave gripping accounts of two patients he had been involved with during his career who had suffered harm and also an example of a lady who had received excellent, life changing care. He finished his presentation with a call to action, saying that “if there’s a real problem, talk to people and make change happen”.

Feedback from the delegates around what harm is included “the ‘soft’ elements of harm are very difficult to measure” and “harm is in the eye of the beholder”.

Data, data, data

Self-proclaimed ‘data geek’ Kate Cheema, Specialist Information Analyst, Quality Observatory, gave a fantastic presentation around using data for improvement and how crucial it is to measure over time. Kate told the delegates that once they had their measures “presentation is key” and that “data is never the end of the story, it is just the beginning”.

Prof Power gave teams the task of setting themselves improvement goals and beginning work on a plan to outline how they were going to achieve these goals. The teams then had a representative present the work they’d begun back to the audience before day 1 was brought to a close by Jim Potter, Chair of Salford Royal NHS Foundation Trust.

Whole system view

Prof Power began day two of Making Safety Visible Learning Session 1 by telling the teams to take a “whole system view” and to ensure that “solving a problem in one area doesn’t create problems in another”. She also asked the audience whether the rules of engagement she had drawn up for the programme were correct.

After further time to work on their improvement plans, Peter Weller, Director of Quality and Governance, Tameside Hospital Foundation Trust, gave an excellent presentation on his Trust’s culture change. The stories Peter told around the changes at Tameside seemed to resonate with other delegates and sparked a lot of debate within teams.

Peter was followed by Pauline Jones and Julie Southworth who discussed the collaboratives that Wrightington, Wigan and Leigh NHS Foundation Trust and Wigan Borough CCG have been taking part in around safety.

A well received ‘world cafe’ session then took place, with each delegate choosing two of the six available topic-themed tables to participate in for the active discussion cycles. There was some lively debate around these themes, which ranged from “Learning from heroic intervention” to “Are we measuring what matters?”.

Reliability

Susan Burnett got the final session of Making Safety Visible Learning Session 1 underway by asking the teams to write down their definitions of reliability. The definitions were then shared, with a wide range of variation observed. Dr Carl Macrae built on this reliability thinking with his presentation on what healthcare can learn from high reliability industries.

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Delegates enjoying their work

Abigail Harrison, Haelo’s Associate Director of Measurement and Innovation, then outlined to the delegates what they’ve signed up to and how the Making Safety Visible programme will run.

Andrew Foster, Chief Executive of Wrightington, Wigan and Leigh NHS Foundation Trust, reinforced Abigail’s comments on how working together is so important. Andrew discussed how collaborative programmes have produced some of the best work he’s been involved with and discussed how important networks such as NHS QUEST are.

Dr Macrae used industries including the military and aviation as examples of best practice around reliability and said that “a lot of high reliability issues hide in plain sight” and that “we need to make them visible”.

He made the point that high reliability organisations are “deeply standardised but can also be very adaptive and flexible”, and added that “healthcare needs to decide which processes should be standardised and which require discretion”.

Collaboration is for life

Before handing over to Steve Mycio, Chair of Central Manchester NHS Foundation Trust, Prof Power urged the delegates to view the Patient Safety Briefing and think how they could use it in their organisation. Prof Power added that “something simple can make a big difference”.

Steve Mycio closed the learning session by saying that “you can judge an event on how many people are left at the end, and I say a full house” before adding that “collaboration is for life, not just conferences”.

Making Safety Visible Learning Session 2 takes place on 6-7 May 2015.

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