Review: Making Safety Visible Summit


The Summit for Making Safety Visible took place on 7 October 2015. There was great energy in the room as the programme events came to an end. Below is our review of the day, you can also view the Storify, the photo gallery and the presentations

Some of the main themes running through the Summit were:

  • What is possible moving forward?
  • What happens when we implement change?
  • Strategies for the real world

Sarah Garrett, Innovation and Improvement Consultant, was the facilitator throughout the day and opened the event by welcoming the delegates and introducing Tony Chambers, Chief Executive, Countess of Chester NHS Foundation Trust. Tony recapped on the work that had been done during Making Safety Visible, highlighted key themes and said the programme had highlighted the need for the healthcare system to focus on value for patients, carers and staff.

Expanding the vision of safety

Prof Charles Vincent, Health Foundation Professorial Fellow and Professor of Psychology at The University of Oxford, followed Tony and discussed The Health Foundation’s Measurement and Monitoring of Safety framework that Making Safety Visible was based on.

Charles started by saying that Making Safety Visible has “expanded the vision of safety that we envisaged in Measurement and Monitoring of Safety.” He went on to emphasise the need to change from assurance to inquiry as a fluid system such as healthcare needs “constant inquiry” and telling delegates that a system will never be 100% safe but that there needs to be improvement in managing potential risk.

Abigail Harrison, Associate Director of Measurement and Innovation, Haelo, then took to the stage to recap the key themes that had been surfaced during the programme including working across health economies, moving from lagging to leading indicators and building relationships.

Abigail then introduced the Learning Session 3 film which received a round of applause from the audience.

Safety in primary care

Next up to present to the Making Safety Visible teams was Prof Aneez Esmail, who was discussing what we know about safety in primary care. Aneez began with a powerful story of when things go wrong in primary care discussing the Shipman Inquiry which he was Medical Advisor on.

The room was then challenged with Aneez asking “how can we improve safety if communications between hospitals and primary care is so poor?” He finished his passionate presentation by emphasising how important it is not to underestimate how much patients can help to make our systems safer.

Team feedback 

The next section involved the teams giving quick fire feedback on the work they’ve been doing during Making Safety Visible. Below are some of the key topics each presentation covered:

  • Wigan 
    • “The Perfect Week” – 7 days no delays
    • Using before and after patient stories
    • Putting patients first
  • South Manchester
    • Working across health economy
    • CCG and Foundation Trust joint presentation
    • Raising profile of falls
  • Tameside
    • Reinforcing work around governance and duty of candour
    • Came out of special measures
    • CQC using governance and duty of candour work as a best practice example
  • East Lancashire 
    • Moving from “data of the past to data of the future”
    • Focus on falls and deteriorating patients
  • The Christie 
    • Cancer pathway improvement work
    • Joint working with Wigan
    • Scale up and spread pathway improvement to all Greater Manchester

Knowledge exchange

A knowledge exchange session followed the team feedback with a ‘marketplace’ set up in the Vibe room as a showcase of participants work around the Making Safety Visible framework.

There was also opportunities for peer-to-peer discussions with multiple breakout rooms being set up for Chief Executives, Chairs, Directors of Nursing and Medical Directors.

Debunking mortality myths

Gareth Parry, Senior Scientist, The IHI, followed the knowledge exchange with an extremely well received presentation on debunking the myths surrounding mortality data.

Gareth began by referencing how The Francis Report has renewed debate about the use of risk-adjusted mortality rates as an indicator of system quality. He questioned whether the measures are valid and quoted a a study by Hogan et al. in 2012 that claimed the ‘signal-to-noise’ ratio is too low for mortality be a reliable measure of quality.

Gareth told delegates that data for improvement is most effective when; locally owned, rapidly available, plotted over time and points to actionable follow ups. There was some interesting debate in the post-presentation Q&A with 7-day working and weekend data being a particular focus.

Learning from others

Following a networking lunch attendees broke out into one of four sessions to learn what other organisations are doing in certain areas that Making Safety Visible covers. The sessions were:

  • Past, present and future: what is possible? Led by Dr Will Andrews, Pascal Metrics
  • Learning from, and informing Scotland’s testing. Led by Brian Robson, Healthcare Improvement Scotland
  • Safer healthcare: strategies for the real world. Led by Prof Charles Vincent. Health Foundation/The University of Oxford
  • Health economics and patient safety. Led by Brenda Gannon, The University of Manchester

There was real energy in all the breakout sessions with a great debates between delegates and session leads and relationships built to continue discussions post-event.

Safety dispatches 

The teams who hadn’t fed back to the room in the morning were given the opportunity to do so following the breakout sessions. Below are some of the key themes of their presentations.

  • Chester 
    • Improving treatment of Chronic Obstructive Pulmonary Disease (COPD)
    • Patient-focus and patient led redesign of services
    • Use of film to bring the patient voice into the room
  • Central Manchester
    • Baseline assessment led them to reflect on how they can develop leading indicators
    • Want to predict the future
    • Ask “what does this mean for the patient?” at every opportunity
  • Stockport
    • Focus on improving COPD services
    • Used Making Safety Visible framework as a lens
    • Continuous improvement focus
  • Salford
    • Representative from Trust, CCG and Council joint presentation
    • Aim of making Salford safest health and social care economy in the world
    • Linking in with current, ongoing integrated care work

From the ballroom to the backstreet

Abigail returned to premiere the Making Safety Visible ‘best bits’ film, put together with footage from Learning Session 1-3. The film got a great reception from the teams with plenty of laughter around the room.

Abigail then introduced Prof Maxine Power, Director of Innovation and Improvement, Salford Royal NHS Foundation Trust, who focused on what happens when we implement change with her presentation ‘From the ballroom to the backstreet’.

Maxine began by outlining a ‘blueprint for change’ which featured parts including having a flattened leadership hierarchy and relevant and purposeful measures. She asked: “is safety improvement a team sport?”

Using a football formation analogy Maxine explained that many organisations lack improvement architecture and say often the improvement is the job of someone not trained in the field, similar to a defender playing up front. She went on to explain that there is science behind improvement methodology dating back to Galileo and also highlighted the importance of appreciation of a system and system mapping.

Maxine gave a great example of what can happen when change occurs with Semmelweis’ Germ Theory, with Semmelwis being criticised and pilloried at the time before his theory became fully accepted. To finish Maxine commented: “the science and methodology is important but having passion is even more important and I see that here.”

Brilliant programme

To close the day Kevin McGee, Chief Executive, East Lancashire Hospitals Trust, reflected on the programme and three learning sessions that had preceded the Summit. He said: “It’s been a brilliant programme and one that has given us many challenges but has been fun at the same time.”

What do you think?

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