Sign up to Safety asked The King’s Fund to work with the campaign to find an approach to tackle this problem. Since the start of the campaign, a member of the Fund’s leadership and organisational development team has been seconded to the campaign team for several days each week to provide strategic and practical support. We are helping to develop a theory about why the implementation gap exists, and exploring ways to overcome this challenge.
Our work so far has drawn on The King’s Fund’s expertise in facilitating work-based learning, critical analysis, and in developing leadership skills in front-line NHS staff. From experience we know that simply telling people what to do isn’t working. Instead we are trying to develop ways to engage with people’s desire to keep patients safe, and find approaches and practices that will help them do this within their busy working environments.
Together with the campaign team we co-designed a process for collecting people’s ‘falling short’ stories, resulting in a workshop involving 33 clinicians, who were encouraged to talk openly about the times when their desire to keep people safe fell short.
The workshop participants reminded us that they work within a highly regulated culture where there is a tendency towards blame. This means clinicians often feel cautious talking about things that have gone wrong. By creating a safe space to explore these examples, we were able to move beyond the standard narrative about safety within the NHS, and start to make sense of the many factors that influence patient safety on a daily basis. We have continued to explore this work through a number of additional events and shared knowledge and theory is emerging.
Our work will help the NHS to move away from the traditional simplistic understanding of what goes on when people ‘fall short’. Historically this has led to clinicians assuming sometimes intolerable levels of responsibility for what goes on and has left unspoken a conversation about the effects of local systems on them as people and their practice.
The Sign up to Safety campaign has set out to help the NHS reduce the number of avoidable deaths by 6,000 by 2017. Avoidable deaths result in a lot of trauma, not only for families, but for the clinicians too. An unexpected consequence of our work so far is that the clinicians involved are also finding ways to work through the trauma they’ve experienced when things have gone wrong, and are sharing how this trauma can be compounded by the investigations that follow adverse events.
Importantly, the clinicians we’ve worked with tell us that in facilitating a process of reflective practice, we are helping them to notice more, say more and move away from a ‘flight to the personal’, where the first response is to blame the individual.
This is an approach that has the potential to balance a critique of self and others, with a discussion about how local systems can create the conditions for certain errors to occur. The next steps will be to turn this learning into some practical steps to facilitate safer care in the NHS.