The speakers have no conflicts of interest

1. Building a learning organisation for Patient Safety: Implementing the recommendations of the Berwick Report Professor Jason Leitch Clinical Director, Scottish Government, Scotland Ian Callaghan Patient Representative, Berwick Review, England Sir David Dalton Chief Executive, Salford Royal NHS Foundation Trust, England Elaine Inglesby-Burke Director of Nursing , Salford Royal NHS Foundation Trust, England

2. The speakers have no conflicts of interest

3. Tweeting during the session • For general comments on the session, use hashtags#M3 and #quality2014 • For feedback on the five exercises during the session, use hashtag#M3Feedback

4. “If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics that really matter, and that is what must never be forgotten ...” Robert Francis QC

6. Appalling suffering of many patients’ between 2005 and 2009’ primarily caused by: • failure of the Trust Board to listen to patients’ concerns; • correct deficiencies and tackle an ‘insidious negative culture’ that tolerated poor standards; • clinical disengagement from managerial and leadership responsibilities.

7. 290 Recommendations 5 categories

10. Problems Patient safety problems exist throughout the NHS Fear is toxic to both safety and improvement With too many in charge, no one is NHS staff are not to blame Incorrect priorities do damage

11. Solutions

12. “Use quantitative targets with caution. Such goals do have an important role en route to progress, but should never displace the primary goal of better care.”

13. Driver Diagrams

14. Primary Drivers Secondary Drivers Aim Key factors that will influence the aim Secondary factors which will influence delivery of the primary drivers How much? By when?

15. Improving Jason’s Silhouette Aim Primary Drivers Secondary Drivers Number of calories per meal Daily calorie count Limit daily intake Calories in Substitute with low calorie foods Jason will have achieved a BMI of 25 by the end of April 2014 Avoid alcohol Average drinks/week Calories out Weight, BMI Work out 5 days Days between workouts Don’t take the bus Exercise calorie count

16. Improving Jason’s Silhouette Change Ideas Aim Primary Drivers Secondary Drivers Track Calories The changes that can be tested out to achieve the secondary drivers Plan meals Substitute alcohol for water

17. Primary Drivers Secondary Drivers Aim Key factors that will influence the aim Secondary factors which will influence delivery of the primary drivers How much? By when?

18. Implementing the Berwick Review Aim Primary Drivers Secondary Drivers Hearing staff and patient voice (EI & IC) Leadership behaviours (EI & DD) By the end of 2014 all recommendations of the Berwick Review relevant to my context will be fully implemented. Build capacity and capability (JL & IC) Measurement and transparency (DD & EI) Organisational learning (DD & JL)

19. Hearing the Staff and Patient Voice

20. “Involvement means having the patient voice heard at every level of the service and our voice should be heard even when we whisper”

21. Four tiers of involvement Patient involvement is essential at every stage of the care cycle: • at the frontline– the patient/clinician interface • at the organisationallevel – from ‘ward to Board’ • at the community level – e.g. Patient Participation Groups • at the national level – e.g. Healthwatch

22. Having a voice The patient voice must also be heard • during the planning and commissioning of healthcare • during the training and ongoing development of healthcare personnel • in the regulation of healthcare services – peer review teams

23. Patients and their Carers Should: • Be helped to establish effective relationships with their clinicians • Be involved as much as possible in their care planning • Always have access to a summary of their health needs and preferences • Always have access to someone to report safety concerns • Expect providers to collect in real time and be responded to as quickly as possible • Expect complaints to be gathered and responded to in a timely way • Be represented throughout the governance structures

24. Why is it so Important? Evidence tells us that: • Organisations that are more patient-centred have better clinical outcomes • Improved doctor-patient communication leads to greater compliance in taking medication and can enable greater self-management for people with long-term chronic conditions • Individuals’ anxiety and fear can delay healing • Experience is personal and although some experiences are common to many, everyone experiences things differently • And…It’s just the right thing to do

25. The Mark Holland Story It is a common theme in serious incidents that the patient and/or family knew something was wrong – told staff – and weren’t listened to

26. Listening to patients Current practice • Patient surveys, patient stories, focus groups, individual clinician practice What could it look like in the future? • ‘What matters most to you’ clinics • Shadow coaching • Consultant level patient experience data • Patients as coaches to staff – service review, rounds • Social media - designing services by crowdsourcing • Barriers • Stereotypes of patients • Fears about time • Paradigm shift in traditional hierarchy • Recognition of need to change by clinicians

27. What makes a great experience? Head Rational Patients want to feel better: Research shows this is as much about: How they feel about the service they received (emotional experience) as The clinical outcome they were seeking Patients may not always remember what you said but they will remember how you made them feel (Anonymous) Heart Emotional

28. The Patient Voice should be heard at every level of the service • Challenge patient survey results – is being comparatively better than average good enough for our patients? • Find out what matters most to your patients – not just through survey’s but personally for each and every individual

29. Listening to PatientsThe best of what we do: • What matters most to patients at SRFT… • Family • Pain relief • Going home • Manchester United Matches • Getting to have a coffee in the morning before being talked to by doctors

30. What is it like when we get it right?Shared Decision Making Benefits patients, clinical teams and the organisation • ↑patient knowledge, understanding and adherence • Improved patient experience • Better use of limited resources/ ↑ self care • Better outcomes than patients who are passive receivers of care

31. Aims of project 100% of patients attending the Advanced Kidney Care Service will be counselled on renal replacement therapy using SDM techniques Culture To influence and promote a culture of SDM amongst staff and patients in renal services Communication skills To educate renal staff to understand SDM and have the necessary communication skills to use SDM effectively SDM tools Develop practical tools and systems that would support the use of SDM in renal services

32. How we did it Stakeholder events Engagement with pt groups Clinical Champions Patient champions Senior Management support Clinic Environment Weekly team meetings Peer Support Motivational Interviewing Research evaluation Patient led website Patient Decision Aids My Kidney Care Handbook Timeline Option grids Consultation Cards Agenda Setting

33. Evaluation 3 months after starting dialysis • 100% felt confident they had made the right choice • 89% felt as involved as much as wanted to be • 88% found the information helpful • ‘Is there anything you wish you had been told?’ – transport waiting times

34. Listening to Patients • National patient survey • Local surveys • Friends and family test • PALs/complaints • Teach listening skills to staff • Teach customer service skills for staff • Social media • Encourage real time feedback • Interview staff who have been patients • Online health care rating sites • Patient call-in answering machine • Suggestion cards upon discharge Salford Royal: • HELP Line: Helping to Empower Loved Ones and Patients • Testing “shadow coaching” in outpatients Challenge: List the ways you already listen to patients and add at least two more

35. Leadership Behaviours

36. Summary of Berwick Positive Leadership Behaviours • Leadership behaviours that reduce risk and make healthcare safer: • Abandon blame as a tool • Insist upon transparency • Hear the patient voice • Listen to staff • Apply modern improvement methods • Use data accurately • Lead by example • Open dialogue about risk • Some problems are complex and require many innovative solutions involving all who have a stake in the problem

37. Currency of Leadership:Learning From an Aircraft Carrier USS Nimitz • They have clearly spelled out expected behaviours, examples: • INTEGRITY - never avoid accountability • FORMALITY - work as a team, communicate well by giving precise orders, providing verbatim repeat-backs, listening to repeat-backs and adhering to established NIMITZ standards • PROCEDURAL COMPLIANCE - procedures have evolved over many years from the lessons learned following mistakes made by others.  We don’t want our Sailors to re-learn old lessons the hard way, so we insist on using the right procedures for each evolution.  We train our Sailors to understand the ‘why’s’ behind its use. • LEVEL OF KNOWLEDGE  - We believe that if we’re not learning and teaching more each day about our job and our ship, then we’re not doing our job right. • QUESTIONING ATTITUDE  A questioning attitude is both a critical thinking skill and an exercise in vigilance • There’s No Hierarchy On Deck • No one dresses by rank on the flight deck • The most senior officers walk the deck each morning with the staff to check for safety • Empowering People Means Rewarding Good Catches • People who raise safety concerns are singled out by the leadership and praised in front of their team • Transparency • Pilots rate each others landings and this is posted publicly on the ship Population: 5,000 Average age: 22 Can launch or land a plane every 25 seconds Source: Virginia Mason and Cincinnati Children’s Hospital

38. Principles into Practice Clearly spelled out expected behaviours • Have frontline staff translate your values into behaviours specific to their ward or department • Example: Never walk by a patient or family member that seems like they might be lost • Example: Use repeat backs for communicating crucial information • Formalize list of never events and publicize list to staff as an ever growing catalog of the kinds of errors and harm that the Trust will not accept • Formalize list of always events • Have clear patient safety aims, measures and goals at directorate and individual level There’s No Hierarchy On Deck • Cincinnati Children’s Hospital starts each morning with an organizational Daily Safety Brief.  On this call, led by the Executive, about a dozen departments and clinical areas discuss safety risks and plan for the next 24 hours • The message: Safety is the top priority above all else at this Trust and we expect you to be open about your concerns

39. Principles into Practice Empowering People Means Rewarding Good Catches • Regularly publicise cases where staff raised patient safety concerns with direct positive feedback from senior leaders • Each directorate makes 1-2 cases of error visible, on a quarterly basis, to reinforce the desired behaviours around learning from errors and fair-blame. (Examples of senior staff errors as well) Transparency • Post safety data publicly on wards, intranets, etc. Safety and patient experience data shouldn’t be anonymised • Make all staff fully aware of the Being Open Policy and informally test staff knowledge of it • Add content on dealing with errors to junior doctor seminars and new nurse orientation • Apology training • Multidisciplinary review of the next 5 cases of moderate to severe harm for evidence that the Being Open Policy was adhered to. Interview staff involved for their perceptions of the process followed

40. Hand Back the Reigns to the Frontline

41. Deference to Expertise

42. Abandoning Blame

43. Blame – Find out how it feels on the Frontline • MDT review of the previous 5 cases of moderate to severe harm and interview staff involved for their perceptions of how it was handled • Does it feel different for different disciplines (nurse, doctor, etc.) • At a local level, make 1-2 cases of error visible on a regular basis, to reinforce the desired behaviours around learning from errors and fair-blame. (Examples of senior staff errors helpful)

44. Listening to staff/Open about Risk When using frontline signals, when do you take action? • Theoretical day in the life of a hospital: • Hospital full to capacity • Several elective lists have been cxl • Higher than usual acuity (sick people that need to be seen) • 2 senior members of staff report to management that they feel the workload might be making things unsafe • 1 junior doctor sends note saying that they won’t return until there are safer working conditions • Unclear whether these reactions are perceptions that staff have due to the overall stress of the situation or are reality Is the stress level of staff an accurate indicator of unsafe conditions? Is taking a stressed junior doctor off the floor more or less unsafe than working with 1 less junior seeing patients? What could it look like in the future?

45. Listening to staff • Barriers • Overwhelmed with dealing with past harm (10,000 incident reports/year) = 10,000 action plans • If we listen to staff we have to be prepared to do something about their concerns (What merits stopping a surgical list? Stopping ward admissions? Adding temporary staff?) • Trust data is slow to catch up and is sometimes used as evidence of safety (we have a low mortality rate so we must be okay) • Are ‘real’ issues and ‘perceived’ issues the same thing? (when we first started WalkRounds every ward cited staffing as a problem) • Hierarchical norms • Fear to speak up – does this mean I’m doing a bad job? Common practice • incident reporting, clinical governance, WalkRounds, appraisal What could it look like in the future? • Sensitivity to signals from the frontline • Problems are investigated as true until proven otherwise • Normalised critical language • Failure modes analysis • World class communication systems • Psychological safety

46. Staffing Staffing levels should be: • Consistent with the scientific evidence • Adjusted to patient acuity and local context • Made public and easily accessible to patients and carers NICE will produce definitive guidance on safe and efficient staffing levels in a range of NHS settings

47. Lead by Example WalkRounds are great but they’re not enough Highly Visible – breaking down barriers Currency of leadership is what leaders pay attention to Situational Awareness – to know how people and systems operate on the shop floor If you dig a few levels down in your organisation – what % of time do leaders spend on safety vs. operational pressures? Leaders need supporting at all levels – particularly middle tier Accountability yes – Hierarchy No Listen – especially to the voices of patients and their loved ones Must be authentic – humility in place of arrogance

48. Summary • Leadership is currency: staff will pay attention to what leaders pay attention to • Find new ways to listen to staff • Abandon blame as a tool • Lead by example • Work on safe staffing • Deference to expertise • Build leaders at all levels • Hand the reigns back to the frontline

49. What can I do right away? • Executive rounds/ Work-withs • Track and guide the % of time your leaders spend with the frontline • Leading by example on 7-day working • Start the day with a team huddle – what are we worried about today? • Strive for world class communication systems with staff (leadership forum, newsletter)

50. Building Capacity & Capability