We worked with the Sign up to Safety campaign team to narrow the gap between what we know works to improve the safety of care and what actually happens in practice. Through a process of reflective practice we helped clinicians to notice more, say more and move away from a ‘flight to the personal’.
Dr Suzette Woodward, National Campaign Director, Sign up to Safety
“Our aim is to really get beneath the surface of why care is not as safe as it could or should be. Seconded from The King’s Fund, David Naylor's expertise is vital for this work, and the links through to the wider resources and expertise of The King’s Fund provide a fantastic world-renowned and credible partner for the campaign.”
Sign up to Safety is a national patient safety campaign, launched in June 2014 by the Secretary of State for Health. Its mission is to reduce avoidable harm by 50 per cent and to save 6,000 lives.
The campaign seeks to enable people who work closely with patients and service users in NHS organisations to lead their own self-directed safety improvement work. More than 380 organisations across the NHS in England have signed up to the campaign.
One of the big issues the campaign team faces is to find a way to narrow what is known in patient safety as the ‘implementation gap’. This describes the gap between what we know works to improve the safety of care and what actually happens in practice. People working within the NHS are subject to a constant stream of information, guidance and instruction about how to keep patients safe, and yet on a day-to-day basis local systems and human behaviour can combine to cause harm in ways that no one wants.
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.
Find out more
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