Review: Making Safety Visible Learning Session 3


Learning Session 3 for Making Safety Visible took place on 29-30 July 2015. As ever, we had a great turnout with 123 participants from 25 organisations attending.  Below is our review of the two days. 

The main theme running throughout Learning Session 3 was ‘looking to the future’ with a focus on two of the Vincent Framework domains:

  • Anticipation and Preparedness
  • Integration and Learning

The expert facilitator for the two days was Sarah Garrett, consultant in innovation and improvement, who guided participants throughout the event. A welcome and outline was provided by Jim Potter, Chair, Salford Royal NHS Foundation Trust. One of the key points Jim raised was that the programme has brought a number of benefits, including increased collaboration between organisations and improved relations.

Abigail Harrison, Haelo’s Associate Director, Measurement and Innovation, opened the event by giving an overview of the goals of the programme and sharing the work carried out by teams so far. A film from Learning Session 2 reminded people of how far we’d come, which went down well with participants.


Anticipation and Preparedness

Prof Charles Vincent, co-author of the Measurement and Monitoring of Safety, was on hand to deliver an introduction to Anticipation and Preparedness. Prof Vincent talked about how experts spent the majority of their time planning and thinking ahead, he explained that fighter pilots spent ‘90% of their available time’ constantly planning what might happen and how they could react. He challenged delegates as to how they could move away from constantly reacting to situations to anticipating how and when things would occur.

Prof Vincent went on to describe how he’s seeing people develop the framework locally and how it is being applied at different levels of organisations, demonstrating the framework’s depth and strength.

Following the theory, Carl Macrae and Katharine Goldthorpe gave practical examples of how this could be done in the ‘Out of the rough, from theory to action’ session.

Carl Macrae, Improvement Science Fellow at the Health Foundation, shared some of the different theoretical models and approaches that could be used, including FMEA and the ‘bowtie model‘ for identifying and managing risk. This model is used extensively in the airline and other high-risk industries and could be adopted more in healthcare.

Katharine Goldthorpe, Haelo’s Associate Director of Programmes, gave practical examples of work she introduced at Great Ormond Street Hospital that moved on from assurances around safety to giving key frontline staff the skills and space to make safety improvement happen quickly and correctly. These included introducing weekly frontline huddles which reported directly to board and giving families and patients the opportunity to report safety incidents to support learning.

Carl then looked at ‘proactive problem sensing’ looking at how we learn and detect problems before theyt occur. He shared examples of how some organisations already do this  with emergency preparedness, mock inspections and nursing assessments. Carl challenged participants as to how they could ‘routinely detect problems across their whole systems’ before they happened.

Involving patients 

The afternoon of day one was opened by Josephine Ocloo, a World Health Organisation Champion and mother who has been fighting since her daughter’s death in 1996 to understand why her condition wasn’t properly treated.

Josephine told a compelling story that underpinned the issues raised in the Vincent Framework and went to the heart of team’s work. To do this, Josephine said that “we need to make the phrase ‘no decision about me, without me’ a reality”.

Next it was the team from East Lancashire’s turn to present and they focused on their work ‘Preventing, Recognising, Responding, Improving’:

  • Preventing – using reliable data to feedback
  • Recognising – using reliable education that is reinforced multiple times with appropriate tools
  • Responding – took a standardised approach with the right people, with the right skills at the right time
  • Improving – provided the right infrastructure to support this work

The teams then had the opportunity to spend some time together going back to their health economy safety plans and agreeing what they would do differently in the next action period, pulling together what they had learnt in the day.

Closing the day was a keynote from Emma Head, Director of Health and Safety, High Speed 2. Emma spoke about the work she’d carried out at Network Rail over the last three years to move them to an organisation who not just valued safety but lived and breathed it. She described how the organisation had followed James Reason’s theories to develop and embed a culture of safety.

Network Rail’s ‘everyone home safe every day‘ campaign has been developed to ensure safety is integral, from staff who drive to maintain the railways, to those working in stations. For Network Rail “it [safety] goes hand in hand with good performance” though it still has much more to do to make the railway even safer for the public, passengers, and particularly its workforce. This ‘engrained’ and sustained approach to safety resonated with delegates with many teams looking at how they could do the same with their health economy safety plans.

Day 2 – Integration and Learning

To get delegates energised and ready for the second day, each team was challenged to present their work in 90 seconds in as ‘creative way as possible’. The teams took on the challenge and delivery of the update ranged from weather reports to marriage guidance but the most impressive was the Wigan team’s ‘rap’.

The first speakers of the day were Kate Cheema, Specialist Information Analyst from the Quality Observatory and Abigail Harrison who presented on some of the key challenges with integration and learning facing the teams. They talked about moving from a model of assurance to inquiry, creating a learning and improving system, triangulating different data (apples and oranges) and creating a shared language for safety and improvement across health economies. The duo put forward some challenging questions to the group around embracing their inner Sherlock Holmes and becoming ‘data investigators’, not taking ‘facts’ at face value and really understanding what lies beneath, not relying on the action plan, using social movement theory, social media, film and technology to mobilise across a system and really starting to use the techniques around triangulation of data that we often talk about but still don’t do.

Team updates

The delegates had the last two team updates from University Hospitals of South Manchester NHS Foundation Trust (UHSM) and the Cheshire team.

UHSM shared their work on Falls and how the framework is helping them take a new approach. They’ve challenged themselves to take on a number of new pieces of work including to start reporting in real time and make reporting visible. They’ve taken learning from another organisation and adopted it at UHSM and are now looking at who should leads this work – a specialist or everyone?

In Cheshire, the team focused on its challenges around discharge process and how it manages its hospital beds across the area. Currently the system is fragmented with lots of different teams and organisations not working together coherently. Through the Making Safety Visible programme they have been able to use their data better, look at where the issues lie and start doing something about it.

Knowledge exchange

Covering the sessions before and after lunch was a Knowledge Exchange, which gave delegates the chance to see what other industries were doing to address issues raised in the framework. The sessions were:

  • Learning from data to anticipate challenges – Graham Lovatt, North West Ambulance Service
  • Simple, predictive analysis using statistical process control charts – Kate Cheema, Quality Observatory
  • Visualising ‘Big Data’ in a meaningful way – Ian Everall, Mirroworld
  • Changing mindsets of challenging doctors – John Tiernan, Medical Protection Society
  • Learning from data to prevent unnecessary callouts – Clare Nolan, Greater Manchester Fire and Rescue Service
  • Predictive modelling and uses in healthcare – Clare Cordeaux, Simul8

Finishing the day was the final keynote from Prof Timothy Buchman, Director of the Emory Care Center, and Dr Barbara Zehbauer, Division Director from the Centre for Disease Control and Prevention both in Atlanta, USA.

The husband and wife team presented on ‘The Leading Edge’ drawing on their own examples of how safety works in the aviation industry. They showed how safety was ‘baked in’ to flying and that people shared their errors and mistakes so others could benefit from their learning. There wasn’t a blame culture, it was a culture of shared safety.

They then showed an impressive system in place across intensive care settings in Georgia, USA to remotely monitor busy ICU beds and provide an ‘air traffic control type view’ that enables ICU staff to do their job better, save patients’ lives, reduce length of stay and improve overall outcomes.

That’s all folks!

Summing up Learning Session 3, Sarah Garrett said:

“The last two days have really helped delegates develop their understanding of the final parts of the Vincent Framework. Josephine Ocloo’s personal story made it crystal clear why we need to put safety at the heart of everything we do, while Emma Head gave us a framework for how to achieve and sustain making safety everyone’s responsibility, and Tim Buchman showed us what the future for safety surveillance could look like. I think delegates have gone away inspired and refocused on their local safety plans.

“The engagement from each health economy has been fantastic and they’ve really connected with the approaches and examples shared, not just in this Learning Session but across the whole programme. The summit event in October, when teams will share their own work and learning, is promising to be an unmissable day.”

What do you think?

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