Enhancing Patient Safety; using systems and process thinking

1. Enhancing Patient Safety; using systems and process thinking Learning from Listening

3. Session objectives • To understand what a process is. • To practice mapping a simple process. • To understand how processes support systems. • Recognise the points of risk in processes.

4. Systems • Every system is perfectly designed to get the results it gets. • If we want better outcomes, we must change something in the system. • To do this we need to understand our systems.

5. Processes • Processes are the components of a system. • A process is a series of connected steps or actions to achieve an outcome. • They have purposes and functions of their own, but cannot work entirely by themselves.

6. Symbols to use = Action/Activity = Decision = Inputs/ Outcomes

7. Break into small groups and using the symbols map your journey into today’s session.

8. My Map Get out Of Bed Decide What to wear Decide what to eat Get showered Get dressed Agree what we are going to have for tea Decide where to park Feed the dog Leave House Start Car Drive to Work Receive presentation Review notes Photocopy extras Set out room Commence day

9. A system • A system is a collection of parts or processes organised around a purpose. • Each system is embedded in other systems. • Each process is part of at least one system. • Each system is part of a bigger system, which are in even bigger systems, which are in even bigger systems etc. etc. etc. Working in Systems, NHS Institute for Innovation & Improvement 2005

10. Exercise 1

11. Why is it important to understand the systems we work in?

12. Systems Within Systems

13. A short story about ‘expectations’ • Why the NHS is concerned about improvement?

18. Exercise 2 • What went wrong? • What impact did it have? • Can you relate this to a healthcare experience?

19. What does the story tell you about patient safety? • Patients have expectations and failure to achieve these reduces trust • Processes are linked but are sometimes working against each other • Confidence is reduced by failure to be consistent • Patient is not supported and this undermines their personal preparation • The creation of uncertainty increases and perpetuates anxiety

20. Making Improvements within complex Systems • Structures • Processes • Patterns • Frijot Capra 2002

21. The NHS Plan • Patient Choice • Financial flows • Performance targets • Workforce reform • National clinical guidance & standards • Patient Choice Organisational Boundaries Departmental Layout & Structures Roles & Responsibilities Staffing Models STRUCTURES Teams Equipment Boards & Committees Facilities Targets & Goals

22. Patient processes cross many boundaries organisational/departmental boundaries E • 30 - 70% of work doesn’t add value for patient • up to 50% of process steps involve a “hand-off”, leading to error, duplication or delay • no one is accountable for the patient’s “end to end” experience • job roles tend to be narrow and fragmented B C D A Acute episode Rehabilitation Long term /self management

23. Diagnostic tests Treatment planning Presentation History Examination Diagnosis Staging Treatment Discharge Follow up Palliative care Death Looking at the whole journey Points at which: failures in the service occur unnecessary waits and delays

24. Patterns • Thinking, behaviours • Relationships, Trust, Values • Conversations, communications, learning • Decision making, conflict, power. • Often ignored, remain unchanged and unchallenged, despite changes to structures and processes

25. “For me it’s my world – for the staff I am one of thousands”Patient, Learning from Listening – York Hospitals NHS Trust

26. Exercise • From the patients stories, identify a care process that a patient felt could be better. • Is there a potential for improvement that you could influence? • What interactions between the elements would you need to consider and manage if you were going to take this change forward?

27. In Summary • In Healthcare we work in a Complex Adaptive System • Complex – many and varied relationships among parts of the system, making detailed behaviour difficult to predict • Adaptive – people who make up the systems can change and evolve in response to new conditions in the environment • System – coordinated action towards some sense of purpose Plsek 2000

28. To change an organisation, the more people you can involve, and the faster you can help them understand how the system works and how to take responsibility for making it work better, the faster will be the change.” • Marvin Weisbord • Training and Development Journal