The “feedback gap” – an important quality improvement concept


The original concept of LfE was to create a system for positive feedback for excellence in healthcare.  The excellence was not defined a priori: i.e. we assumed that people know excellence when they see it, and they can define it subjectively.  That did indeed turn out to be the case, and thousands of reports have been submitted since we started the initiative back in 2014.  Over the years, it has started to become clear that there are certain themes in the reports, most of which focus on non-technical skills, many of which are not described in the published non-technical skills frameworks.  Examples include, generosity, compassion, perseverance, positivity and my personal favourite: kindness.  There is also a significant theme of reports around technical excellence (e.g. diagnostic and clinical acumen).

After LfE had been in place for a year or so, we wanted to know if there was a measurable impact on the behaviour of professionals.  i.e. we wanted to know if people “learn” from positive feedback, by changing how they go about their business.  That was the idea behind the PRAISe project, in which we showed that “everyday” behaviours could be enhanced through simple positive reinforcement.  i.e. if you show people what they are doing well, they will do more of it.

We named this approach LfEQI, and last year we delivered bespoke training for a number of teams around the NHS and Ireland to help them develop their own LfEQI projects.  We’ve written a guide on how to do this, and the PRAISe project describes the impact we were able to measure.  Several of the posters at LfE3 also illustrated study designs using this approach. We are now adopting this approach in several QI projects in my place of work.  Slowly it is embedding as a valid and legitimate approach to QI.

So, I thought it would be helpful to share a vital insight into this approach:  LfEQI relies on changing behaviour through the provision of positive feedback for successful work.  This work is usually simple, everyday work – i.e. “people just doing the right thing”.

And here’s the key to this approach:  this work is not usually associated with positive feedback.  So much everyday work is simply accepted as “doing one’s job”, and there is no recognition of success.  This is the “feedback gap”.  Applying positive feedback to a chosen area of everyday success will increase the rate of success.  It’s very simple and it really does work.  There is no need to make a song and dance about it, there is no need for celebration.  A simple acknowledgement that the work was successful is all that is required, and over time, it will improve.


This morning I fell down the stairs.


Here is the latest blog post from Alison Jones, our LfE fellow:


This morning I fell down the stairs.

I woke up and my first thought is always ‘a nice cup of tea’ so I got up and headed for the kitchen.

As my heel slipped over and beyond the edge of the second step I realised this was not going to end well and in that often-reported, slow-motion sort of way, I crashed bottom first, toe and groin twisting second, forearms third, bump, bump ,bump into the stairwell.

I knew, as I righted myself that there was no significant personal injury but my goodness I was shocked.

My 2 boys were still asleep and blissfully unaware. They would need breakfast and guidance for their home school day. A work day for me too, thankfully: zoom teaching, data crunching and emails so no need to ‘let anyone down’.

I’m really sore now. I think I’ve responded to everything I really needed to today as well as I can. Plus, my boys have been kind to me, they’ve eaten, done school work and we managed a short dog walk (knowing that I needed keep moving and stretch my aching muscles).

So now it’s 10pm and I’ll admit, I’ve had a relaxing glass of wine.

This experience has given me a new analogy, a fresh insight.

We ‘got up’ wanting our usual days in March 2020 only to fall into the stairwell of CoViD19.

Copied and pasted from above: ‘I knew, as I righted myself that there was no significant personal injury but my goodness I was shocked.’

I am incredibly blessed that no-one in my closest circle of family and friends has passed away this year. However, as healthcare professionals, we are dealing with a pandemic. For many there have been considerable personal consequences plus everything else that life can throw at us like loss/hurt/conflict/illness other than CoViD and serious social and political concerns  …

I thought, as an active member of the LfE movement, research and well-being teams, I understood or at least empathised with much of what was being experienced. Still, it took a profound shock and the consequent physical limitations to help me understand more deeply the real impact of all the anxiety and threat we are managing at this time.

Copied and pasted from above: ‘I’m really sore now. I think I’ve responded to everything I really needed to today as well as I can. Plus, my boys have been kind to me, they’ve eaten, done school work and we managed a short dog walk’.

In the last 48 hours I have felt anxious, tearful and rather fuzzy-headed and I have been forced to pay attention to these symptoms. Of course this is an entirely human, even predictable response to a tumble down the stairs. But it has made me wonder – how many of us are currently functioning at this level which feels ‘less’ somehow and compromises home and/or work as necessary as each day in CoViD recovery unfolds?

So this is my opportunity to ask ‘How are you?’ ‘How are you really?’ and to say ‘Take good care of yourselves and each other’. Here are few Appreciative Inquiry-style questions for you to play with when you have a minute:

How can I use the current slower pace of life to notice feelings and emotions in myself and others?

What resources do I have to help me cope (or even to thrive)?

How am I expressing gratitude, moving my body, getting outside, helping others today?

Which stories do I want to be part of in 2020?

Alison Jones

The view from the corridor


The following blog is from LfE fellow, Alison Jones.  Alison’s professional role has changed significantly during the pandemic, and here are her reflections on her recent experiences:


One of the central tenets of Appreciative Inquiry is the importance of storytelling or the power of narrative. MariaSirois said in her DLCCenterforAI webinar that if we talk authentically about how we have lived events, our story will resonate with someone, somewhere and as a consequence meaning will be added to both experiences. This story was part of my #COVID19 experience:

I have a background in adult ICU nursing but haven’t been registered with the NMC for many years. With the onset of the pandemic my greatest wish was to regain registration and join my colleagues on the ‘front line’ to help ‘fight’ this dreadful virus (the language of war we so easily adopt in these scenarios). It soon became clear that I had been away from the bedside too long to qualify for expedited re-registration; I was deeply disappointed and also experienced a strong sense of guilt at not contributing in the way I felt I should.

And so my role during COVID19 became that of ‘clean runner’ outside the intensive care unit at the children’s hospital where a new zone was created: an area made necessary by COVID19 isolation procedures. In this space, along with numerous hand sanitizers and the sequential PPE donning stations (first a gown, next a mask, then goggles, visor and finally gloves) a new team convened whom I shall call the Corridor Crew!

Once a nurse is in PPE and through the unit doors, s/he cannot come and go from the patient’s bedside out to store rooms and facilities beyond the isolation area. So they need ‘runners’. Runners for supplies – linen and IV fluids, blood products and medicines, ventilators and feed pumps; send swabs and specimens, bring tubes and wires.

In my role as a clean corridor runner I have been struck by the variety of people and emotions and responses passing through and gained a new perspective on this COVID experience: the view from the corridor:


Some in wheelchairs hours after an emergency C-section, some beginning to establish a routine – new normal. Post-partum people trying to heal and bear milk (often difficult enough at home with a healthy baby) now having to navigate the land of critical care, separation from baby, family, other children maybe … and carers in full PPE another type of separateness. I see in them dependency, vulnerability, shock and disbelief – how on earth did I get here? 3 weeks ago I was a chief exec/happy-go-lucky 17 year old/ran my own business/had all my ducks in a row.

But the thing I remember most is what they said to me in that corridor: ‘I have never met so many lovely people in one place’ and, tearfully, ‘you are all so kind, I can’t thank you enough’


Red-eyed dads displaying anguish, fear and frustration. Not in an aggressive way, although I know that happens too, but in a keyed-up, dumbed down sort of desperation. Through no fault of their own they are facing their greatest challenge; not only does their child require intensive care, but the world is in lockdown, global pandemic. Visiting is restricted, medical teams are cloaked in PPE and of all things, touch is prohibited. We witnessed brave but ever so slightly broken young dads walk past whilst we simultaneously adhered to social distancing and resisted the most natural instinct to give physical reassurance. Caring at arms length takes its toll on all of us.

Seeing, thinking, feeling these things emboldened me to enquire – how are things today? (eye contact, be brave, the answer might be tough to hear but it’s his answer and this is how we must express our love in the time of COVID).

The Day Shift

Mindful, rehearsed, #weareinthistogether. As they calmly progress through the donning stations I hear breathing exercises, the odd mantra and, whenever I ask ‘Are you hydrated? Feeling OK? Ready?’, ‘As I’ll ever be! Oh yes! Absolutely!’ come the replies. Thanks to stellar leadership from the ICUnurse management team we are as prepared as we can be for the daily evolution of the COVID19 response.

Throughout the shift they appear at the unit entrance often with gloved hands folded, steady eye contact and clear articulation through the mask: ‘Could I please have the special feed for Sally Morris, the blue thingy that adds a neb to the vent, some Micropore and a small sharps bin. The nurse next to me needs a temp module for the Philips monitor and 2 Weetabix cos her patient has kept free fluids down for 4 hours. I’ll come back for them, thank you so much’. They turn on their heels, speed walking back to their patient so they don’t waste a minute of care-giving time.

Short, frequently interrupted conversations punctuate the clean corridor day. Full of intimate details shared now like they never would be on a normal office day. Brief exchanges spanning the whole of our current existence: the grey roots showing in our hair (reframe: appreciation of hairdressing as a craft), supermarket queues (reframe: how lucky are we to live in a land of plenty), Generation C19 – adolescents with no exams and no motivation, the death of a neighbour (oh god, I’m so sorry) and dad’s had surgery so urgent not even COVID19 could stop it …nurses have lives too.

To The Corridor Crew:

27,000 steps today. We bring our whole selves to the job at hand – manning the corridor can be a fetch and carry task or an observing, serving, providing, learning experience

I know more about you now than I did before [Simon/Esther/John/Jen]

More unites us than divides us [tech/stores/pharmacy/labs/housekeepers/admin]

(Corridor) Music soothes, lightens, connects and heals

Thanks for the opportunity

So often we dismiss the value of our own stories and dwell on what we are not.We must cultivate an appreciation of who we are and the stories we have lived; show up to the situation as we can and bring our whole selves to the task. And the best stories end with an invitation into the next chapter so, when you tell your stories of what happened during COVID19, enrich them with how it made you feel, who or what inspired you and what good has or could come of the experience.

Alison Jones

The “909” club


This post is from my friend and colleague, Dr Barney Scholefield.  When lockdown became a reality, Barney had the brilliant idea of creating a daily on-line virutal meeting, with no agenda, for the staff in our department.  It’s a great example of “innovation in the time of COVID”.  As I often say to my colleagues, “909 is the best meeting of the day”.  AP

The ‘nine-o-nine’ virtual hug club

How do you provide a virtual hug in a locked-down world? On March 23rd the UK government announced the lockdown. Overnight society and workers were distanced. Working from home became the norm for most of us, with stricter self-isolation for the ’12 weekers’. The COVID19 pandemic had reached our doorstep and the paediatric intensive care unit (PICU) family, of which I am just one member of, was feeling the full impact. Fear, for what will be for our vulnerable patients, our wonderful staff, our precious families; willingness to help with the NHS’s battle plans in this pandemic; but uncertainty about pretty much everything else.

Out of this dust storm spawned many ideas. Mine was simply to set up a little group meeting: the 09:09 club. A daily, Monday to Friday, on-line videoconference. I joined the 300 million other users of Zoom to connect with around 60 paediatric intensive care consultants, medical trainees, advanced nurse practitioners and other members of the Birmingham Children’s Hospital PICU family.

So what did we talk about? Well that was the fun part – anything! At the beginning the only rule was connection and to check in with everyone. By 09:09 each morning I would see 15-25 familiar faces appear on my screen. Smiles, mad hair, tired post on-call eyes, tears, and the occasional face-licking dog. Children’s faces would pop up too, sometimes with muted intriguing looks, sometimes unmuted declarations of ‘I need a poo daddy!

But it was soon clear we had important topics to discuss. We needed to help our frontline PICU team and they needed us. The fear and uncertainty felt by all the team needed to be aired. Manifestations of stress, sleeplessness, risk of work exposure to COVID, maintaining safety and the thorny, complex, emotional issue of personal protective equipment (PPE). Absorbing the seemingly ever-changing Public Health England advice on level of PPE, our own hospital Trusts frequent communications and peoples own fears and concerns driven by a 24 hour, never ending social media driven monologue. The discussions sometimes exhausting, but nevertheless essential. Staff personal protection and well-being a fundamental basis of support that the team needed and 09:09 club tried to provide.

We had very sad and difficult news to share too. The death of health and social care workers from COVID19 had a numbing effect on us. Initially from hospitals in the region, but then the news got closer and closer until it was our own loved and admired family members. Offering bereavement support, sign-posting to help, allowing venting of anger and fear, all whilst the group watched each other’s faces, listening to responses and sensitively reaching out a hand, a chat room comment, or a post meeting message. But then the beauty of the 09:09 club kicked in and after a reflective pause, the topic could change to the pros and cons of the cancellation of this summer’s Love Island series due to the social distancing and the effect this would have on our diverse staff members. 09:09 trying to fulfil its role of providing both a hug and a laugh for anyone.

So why call it 09:09? Well I always knew that some would struggle with the IT barriers, zoom login challenges, dodgy home WiFi, microphone unmuting paralysis and of course some people are always late. So although advertised as a 9am meeting it was clear I needed to set a little allowance for some to roll up a bit late with their cup of tea, relaxed in the knowledge no one was judging them. This free reign at the beginning of the meeting was another compensation for the chaos around us, and well, the name just kind of stuck.

But in fact the 09:09 did start at 9am and those apparently insignificant 9 minutes revealed to me perhaps the most important of our vulnerabilities and to those of us who needed the 09:09 club the most. Those members whose daily routine was kick started by the club in the knowledge of socially connecting and keenly logging in as soon as possible. Pleased to see the first smile outside of their home and family circle. To feel needed, wanted, useful, hopeful and supportive and in return be looked after by others. The early joiners, the pre-09:09ers were an extra special bunch, they know who they were, and I was proud to be one of them.

The 09:09 club over the last 6 weeks has spawned many ideas, unravelled controversies, improved home working productivity and supported the frontline PICU activity. COVID19 disease affecting both adults and our paediatric ICU population needed understanding and untangling from the politics and emotion with science and evidence based medicine lessons. Complex issues with guidance on PPE were chewed around, action was delivered. Multiple versions of guidelines and standard operating procedures were drafted and shared, 3D visors were designed and printed, contacts with MPs and major hardware companies were made and equipment flowed into the NHS procurement chain to support our team. We had routes to communicate with the hospital Trust management and pandemic command team in their thinking and had the bravery to challenge and support. The 09:09 club became an ideas think tank to the problems that were affecting both life and death issues.

Then we had a sing-along. 30 faces on the screen, singing with their dogs and children to Olly Murs, you can dance with me tonight. Technically poor (not like the polished, edited youtube versions) but emotionally and memorably richer than can ever be described. Tears, dancing, singing, music. Connection at a level that started to repair the soul and allowed us to say that its ok to not be ok.

Oh, and then the weekly photo competition was born. Another little idea to allow us to share and link our family, pets, homes and our lives with each other. Talent and humour mixed together a Friday slideshow montage that could then be broadcast to the wider PICU team to spread as wide as possible the smiles and the 09:09 hug.

The 09:09 club meeting is owned by the members. Professionals, friends, colleagues, humans in need of a way of sharing a virtual hug and making a difference to the world. In our case the staff, patients and parents whose lives are entwined with the PICU at Birmingham Children’s Hospital. Created in crisis, the 09:09 clubs future is uncertain as we hopefully move out of lockdown. But there are two types of uncertainty; aleatory, the unpredictable dice-rolling uncertainty of what number will appear next. This one you can’t do much about except learn slowly to accept it exists and can’t be controlled. The other is epistemic uncertainty, this type can be learned and eventually controlled. Through knowledge, science, discovery, the uncertainty can be unravelled and start to be understood. The future uncertainty of the 09:09 club existence lies only in whether the alarm clock will be setup to join a zoom call login with colleagues or friends and not in whether a group of PICU professionals/friends, by connecting, can make a small difference to the world we live in.

By 10am each day the 09:09 meeting ends, but always with a wave and a smile, as people head off, hopefully a little bit stronger to face the reality of the day and the life we now live.

By Barney Scholefield.

On ancient wisdom and LfE


I recently presented on LfE at the 2019 Patient Safety Congress.  At the end of the presentation there was an interesting question from the audience:

(Paraphrased): “I was stuck by the similarity between LfE philosophy and ancient eastern philosophy; in particular, the common theme of kindness and compassion.”

I was drawn to this question, because I have recently started to think along the same lines.  I have been reading about meditation and mindfulness, and for the last few months I have been building meditation into my daily routine.

I am no expert, but I think the comparison with eastern philosophy is worth considering in two overlapping areas:

Firstly, the area of safety-II:  LfE is not safety-II per se, but there is a clear overlap, particularly with respect to recognising and understanding Work As Done through appreciative inquiry.  Considering Work As Done requires a mindful approach to daily work.  In order to recognise the day to day adaptations which underpin work, one has to “take a step back, and observe”.  This is akin to observing the mind when meditating, or practicing mindfulness.  When one engages in these activities, it is often surprising what is noticed, and with practice, it is possible to gain insights.  Taking the time to be still, and observe what we tend to take for granted is a necessary part of meditation / mindfulness and safety-II practice.

Secondly, kindness and compassion underpin both “philosophies”.  Through practicing mindfulness and meditation, one gains awareness of one’s mind, and over time it becomes easier to exist in a peaceful state, in which it is easier to be kind and compassionate to others.  Forgiveness also becomes easier.  Kindness reveals itself as our natural state.  LfE is a positive approach to patient safety, in which colleagues (and patients) highlight areas of practice which are working well.  LfE reports are almost always characterised by gratitude and appreciation.  The vast majority of reports focus on non-technical skills and interventions, and one of the commonest themes is kindness.

So what is the significance of this common ground between LfE and ancient wisdom?

I have always maintained that LfE is not a new idea, and we have always described the initiative as a “philosophy”.  I like to think that this reflects an underlying awareness that the ideas behind LfE stem from an ancient axiom: that kindness and compassion are fundamental to wellbeing, and therefore worth recognising and promoting.



On exnovation


I attended an excellent meeting in OLVG Hospital, Amsterdam recently. It was a convention of healthcare practitioners with an interest in LfE and safety-II. Delegates shared some presentations on LfE implementation and some related topics, including Appreciative Inquiry and joy in work. It was a stimulating and inspiring day, and as I reflected on what I had learnt, I became aware of a stream of thought about LfE and related endeavours: there is no single way to “do” LfE, Safety-II, appreciative inquiry or “joy”.  None of them is a panacea, and none should be ‘done’ in isolation. But they share a common thread of positivity: a kind of positivity that naturally emerges in a deficit-based culture. This type of positivity is not a highly energetic, celebratory force (although, I’m sure that sort of positivity has its place); it is a calming, warming, appreciative, nurturing sort of “everyday” positivity.

This thought has been with me for a while, just out of reach. But it started to take shape during the seminar while I listened to a lecture on exnovation, by Professor Mesman.

I first came across the term exnovation when I read Hollnagel’s “Safety-I to Safety-II”. It was listed, along with Appreciative Inquiry, as a methodology which may be used to facilitate safety-II. I confess that I never found the time to investigate further, and so I was pleased to find myself listening to a lecture on the subject.

I learned that exnovation is, in some respects, opposite to innovation. Where innovation may be considered to be the creation of novel improvements; exnovation is the process of improvements based on understanding current solutions within a system; many of which we don’t see because we take then for granted. Exnovation is a process to help us see what is right in front of us.

Exposing (or unmasking) these solutions, for the purpose of improvement, is the business of exnovation. Prof Mesman demonstrated how this can be done with in situ video ethnography. In other words – filming daily activities and then reviewing and analysing these videos in order to understand what is working.  The beauty of this approach is that the “solutions” or “recommendations” already exist and can be shared more widely.

Reports from the LfE initiative often focus on “everyday” excellence, and therefore, the potential to collaborate with the process of exnovation is worth further exploration. A vital part of exnovation is the recognition of something which works, and this is also the business of LfE. In both LfE and exnovation, the recognition of something good comes from the staff who are actually doing the work. This makes the process highly valid and relevant.

I returned to work inspired to see if I could turn my appreciative eye to some everyday excellence: something apparently mundane which I could learn from, or could share with colleagues. Whilst I was bemoaning the length of our ICU ward rounds, I noticed that a colleague routinely delegates certain tasks to team members during a ward round. This simple act saves vital time, minimises stress and inspires team members to engage with the round. Such a simple act is typical “everyday excellence” and I immediately adopted into it my practice.

Have you seen everyday excellence recently? Try actively looking for it, by watching your colleagues go about their work; and you might be pleasantly surprised about how much you learn.  Feel free to share examples (or other comments) below.


How do we know this works?


“You can’t use an old map to explore a new world.” Albert Einstein

Why do we need evidence?:

Whilst the majority of colleagues intuitively understand LfE, a minority of colleagues reserve judgement and request to see “hard evidence” to support its implementation.

“…show me the interventions for all this touchy-feely stuff; I need hard facts and tools”  NHS senior leader (anonymous)

Initially, I ignored these comments as the benefits of LfE were obvious to me, and the rapid uptake of the initiative was evidence that it was perceived as useful by many staff in the NHS.  However, over time, I became curious and set about looking for evidence to support LfE. 

This blog post is a summary of the evidence I presented at the #LfEconference18 in November 2018 at Birmingham Town Hall.  This is by no means an exhaustive presentation and I hope that, over time, our Community of Practice will collectively build on the evidence presented here.  The library section on this website is updated regularly; please contact me if you wish to suggest articles / data / other evidence for our site.

How to articulate the message:

Whilst researching the evidence base for LfE, I also started thinking about how best to articulate the message to those who don’t intuitively understand it.  It seems that we do not all speak a common language.

A recently published report from the Carnegie Institute describes two different languages (or “lexicons”) used by policy makers: the rational lexicon and the relational lexicon.  This report (written by Julia Unwin) is primarily about kindness in public policy.  Whilst not directly about healthcare, the content of the report was useful in highlighting different ways to articulate the potential benefits of LfE to policy-makers and leaders in healthcare. 

Occasionally I hear about a colleague who wishes to implement LfE in their organisation, but their manager puts a block on the implementation due to a lack of evidence or “rational” metrics (see the quote above).  According to the Carnegie report, the manager in this example is fluent in the “rational lexicon”, but may have difficulty listening to or understanding a rationale presented in the relational lexicon.  In the words of Julia Unwin, framing arguments in the relational lexicon (e.g. about kindness) may be perceived as “unhelpfully interrupting the adult flow of conversation”.

Taken from the Carnegie report, here are the characteristics of the rational and relational lexicons:

From Kindness, emotions and human relationships. Carnegie Report.

Both lexicons have their risks and benefits if they are used exclusively, and I believe it is possible to recognise both types of language when communicating about LfE (or any other initiative or activity).  In reality the distinction between the two lexicons is not absolute, and it shouldn’t be taken as a fixed dichotomy.  Nevertheless, I have found the model very useful when discussing the potential benefits of LfE and the evidence to support it.

To the evidence:

The evidence collected in this blog post is divided into the following sections:

  1. Stories / anecdotes
  2. Staff survey data
  3. Data from the PRAISe study
  4. Related science and research from outside the LfE movement

Stories and anecdotes:

Although anecdotal evidence does not stand up well to academic critique, story-telling can be a very compelling way to articulate a message.  Each LfE report is a short story: a story describing an episode of excellence.  Simply reading a report, and discussing it with the staff members involved, is often enough to demonstrate worth of the initiative.  The excellence described in the reports is typically a type of non-technical skill, and recipients of reports frequently report “going about their work differently” as a result of receiving recognition.  Often, they were not aware that there actions had had such a positive impact until they received the report.

Within the Community of Practice, there is a growing collection of stories of impact of the initiative, within various different healthcare settings. One example is captured in this excellent podcast describing the implementation of LfE in Derby.

We have also uploaded a few videos of staff describing their personal stories and insights related to LfE on our youtube channel.  Stories describing impact of LfE are often shared informally, and we would like to start compiling some on our library page of the website.  Please contact us if you wish to share stories of impact of LfE.

Staff surveys:

Many staff surveys have conducted across the LfE Community of Practice, some of which have been displayed at our conferences (see our conference poster compilation).   At BCH, we have conducted two large surveys of our PICU workforce.  These surveys were conducted in 2015 (1 year after implementation) and 2018.

The BCH staff surveys show highly positive perceptions of the value and impact of LfE within our department.  The 2018 survey is still under analysis, and is being replicated in other centres currently, but here is a summary of a selection of questions from the surveys along with the proportion of positive responses:

Year of survey Question % of positive responses
2015 By reporting excellence, I am helping to improve patient care 86%
2015 I learn best from studying examples of good practice 87%
2015 Excellence reporting can improve team morale 93%
2015 Excellence reporting can boost my motivation 87%
2018 Receiving excellence reports increases the likelihood of me practising in a similar way in the future 89%
2018 Excellence reporting leads to improvements in the safetyof care we provide 85%

We will be carrying out further analysis of the 2018 survey, and to replicate it in other centres over the next few months.  Please contact us if you wish to use the questionnaire.

PRAISe project data:

The PRAISe project was designed as a proof of concept project to measure the impact of LfE interventions (positive reporting and appreciative inquiry) on an area of clinical interest.  We chose antibiotic stewardship / sepsis as a test area due to a connection with my clinical interests, but the PRAISe methodology could be applied to almost any Quality Improvement situation. 

The project is summarised in full in the Health Foundation report, and we are currently writing a manuscript for submission to a peer-review journal, but some of the results are shared below.

We found that positive reinforcement via excellence reporting and appreciative inquiry interviews was associated with an increase in quality in some of our measured processes (all of which were orientated around behaviours of healthcare professionals). There seemed to be a dose-response effect, in the sense that the largest improvements were seen in the processes receiving the highest concentration of positive feedback. 

The best example was seen in improvements in antibiotic prescribing: the rate of gold standard prescriptions increased during (and after) a period of positive feedback (the red arrows show the start and end of the intervention period):

Our summary interpretation of the PRAISe project is that “if you show staff what they are doing well, they will do more of it”.

Related science and research from outside the LfE movement.

Theoretical evidence from neuroscience:

“Failure is the best teacher”

Some scepticism about LfE emerges from the assumption that we learn best from failure, and therefore we should concentrate our efforts on recognising and interrogating episodes of failure (e.g. error and harm).  This is compelling to anyone who has ever made an error (i.e. all of us).  However, it ignores the fact that success is actually highly instructive – in fact, it is probably more instructive than failure.

Experimental evidence from neuroscience shows that success leads to faster and stronger memory formation (i.e. learning) than failure.  However, this learning can only take place if feedback has been recevied – i.e. we need to know if we have achieved success or failure.  Without feedback we are not aware of the outcome.  The outcome of many of our interactions in healthcare is not always made known to us – this is especialy true for interactions relying on non-technical skills.

This is where LfE reporting has a unique advantage: very commonly, recipients of LfE reports state that they were unaware of the positive impact of their intervention or behaviour. 

LfE therefore provides the feedback to allow learning from success – in an environment where the prevailing approach to learning is to highlight failure.

Staff engagement:

One of the key functions of LfE is to provide recognition to staff (individuals or teams) who have performed excellently.  We know from the thousands of reports we have received, that many of these episodes of excellence are everyday activities – e.g. lending a hand; supporting a peer; going above and beyond;  showing kindness to a patient or colleague…

Thus, the LfE report serves as a means of recognising a colleague’s excellent work.  Recognition is a key factor in staff engagement: staff who feel recognised are more engaged in their work.  This has been demonstrated in several large studies; a compelling example comes from the WorkTrends (TM) survey from IBM:  – a survey of >19,000 workers in 26 countries, from a cross-section of industries.

The survey results demonstrate the positive relationship between recognition (measured as  agreement with the statement, “I receive recognition when I do a good job”) and staff engagement.

The importance of staff recognition is also shown very clearly in this report from Gallup:

Employee Recognition: Low Cost, High Impact.

But, does staff engagement correlate to any meaningful (and measurable) outcome?  In short, yes.  West and Dawson’s 2012 report for the King’s Fund (Employee Engagement and NHS Performance) clearly demonstrates the positive relationship between staff engagement in the NHS, and multiple  important outcomes including quality of services and quality of financial performance:

West, Dawson. King’s Fund 2012.

Thus, LfE provides recognition for staff members; staff recognition is related to staff engagement, and staff engagement is related to multiple important, measurable outcomes.

In conclusion:

I have described evidence to support LfE from within the initiative, and from sources outside the LfE movement.  But, this is not an exhaustive report:  I have scratched the surface, and there is a lot more to discover and explore.  I have also not looked at the potential risks of LfE.  There may be a shadow side of which I am not aware.  Whilst I continue to look for evidence and data from this initiative I welcome comments below and via our forums.



There is no error?


I recently attended a FRAM workshop. FRAM is a form of resilience engineering, which allows us to create a model of a complex system. It stands for Functional Resonance Analysis Model; but don’t let that put you off! I spent the first half of the workshop feeling rather confused, but ended up with a basic understanding and an enthusiasm to try the method to create models to better understand my work.

FRAM is underpinned by several principles, the most striking and interesting is: the equivalence of success and failures.

This may not seem intuitive, as we are conditioned to evaluate failure as more significant than success. (E.g. see loss aversion, from Kahneman). But actually, I believe this principle is true for work in complex systems. And it is profoundly important as it provides us with a way to understand our work (and improve it) without having to apportion blame for error. The tendency to apportion blame is, in my opinion, a major hindrance to progress in safety and healthcare in general.

If you make a serious attempt to make rules for every aspect of your work, you will soon realise that is impossible to explain every single action for every possible environment and situation. Thus you will see that in order to go about your work successfully, you will need to continuously make small adjustments. (In FRAM this is called ‘approximate adjustments’). These adjustments are usually successful but occasionally they lead to failure. But whether or not they lead to success or failure, they are essentially the same adjustments.

If we are able to understand this part of our work we will start to have a method for removing blame from error. In fact, this approach removes the idea of error. There is no error; there is only adjustment which may lead to success or failure.






This guest blog is from Rachel Pilling and Dan Wadsworth – founders of a fantastic social movement in healthcare called 15seconds 30 minutes (@15s30m).

So firstly Dan and I are really excited to be writing a blog for Learning for Excellence.  We’ve admired from afar and can see the huge impact this sort of social movement can have on staff and patients alike.

It connects with our social movement really neatly – we are all about Joy in Work – the third leg of Quality Improvement, alongside Patient Safety and Cost Effectiveness.  The role of Joy in Work in underpinning staff engagement, performance, sickness and workforce retention has been championed by the IHI, and the newly published NHS Improvement Health and WellBeing ( brings it under the spotlight for the NHS.



But lets go back a few steps…what is our social movement?

It’s an idea called 15 seconds, 30 minutes or 15s30m for short.  It asks any member of staff to think of a small 15 second task they can undertake which will save someone else 30 minutes later on, and in doing so reduce frustration and increase joy for themselves, colleagues and patients.  We call these tasks 15s30m Missions and anyone, from chief executive to porter, can get involved.

Here’s an example:  a few weeks ago, we had a power cut at 815am, just as the eye clinic reception was about to open.  The shutters were stuck down and only one PC was working.

Our brilliant receptionist Carol decided that she would stand at the front door and spend 15 seconds greeting patients as they arrived, taking down their name and date of birth on a note pad, and passing it round to the receptionist behind the shutter to start booking patients in – this not only meant that the nursing staff could begin to check visions and put in drops, but when the power came back on we knew who was in the department and there wasn’t a big queue of patients waiting to check in…..but more than that, patients weren’t left “in the dark” (literally!), unsure if clinic was open, worrying that someone might not know they are there. The impact of her 15 seconds was felt across the clinic – what could have been a frustrating day for everyone, was instead a really smooth run session.  Carol is one of our 15s30m Heroes – she sees when something needs doing to make the experience better for the patient, doesn’t wait for permission,  and other people follow her example.


We know that the people who know how a department, ward or office is best run is the people on the front line.  By standing on a hospital corridor asking staff, we have collected a list of ideas – 100 ideas in 100 days in fact – and we think some of them will work for any organisation.  We’ve made some little videos on YouTube – go and have a look.  We also invited staff to come to our workshops, where we help them reconnect with the Joy of work, why they enjoy being in healthcare, how they know when they’ve made a difference, what makes a “good day”.  We help them express an idea they have to improve the way work is done – a mission – and empower them to launch it!

What started as a silly conversation about a WashBasket (you’ll have to check out the website, launching July 2018 has grown out from our trust, into our CCG, community nursing homes and other trusts. But this isn’t “our” social movement – its yours. This isn’t a “Bradford” idea, it’s a global one.  We know every hospital has heroes like Carol – people who can make those small changes which have a big impact on someone else – the NHS is built on them.  So we want to help make it easier for people to make the changes, to have the confidence to tell someone how we can make it better. 

There’s lots of ways you can get involved.We’d love you to follow us on Twitter – @15s30m – there’s lots of ideas we post. We are running a 15s30m Festival on 3 October in Bradford – a longer version of the workshop sessions, with a “headline set” from Helen Bevan – and some tools and hints you can take away to start your own @15s30m movement in your local organisation.

Or just drop us an email to – we’d love to chat about your idea, help you get going – or just tell us what you’ve done so we can start planting 15s30m Heroes in trusts up and down the country.

Rachel Pilling  is a consultant Ophthalmologist and Dan Wadsworth is a Transformation Manager for Bradford Teaching Hospitals NHS Trust.  Their social movement 15seconds 30minutes was the winner of the NHS Improvement  Sir Peter Carr Award in 2017, recognising a clinician-manager partnership and offering personal development opportunities for them to improve their leadership and managerial skills.

Choice architecture


It’s very easy to focus on the negative aspects of one’s experiences. It’s the path of least resistance – it actually takes more effort to refocus one’s attention onto the vast amount of excellence which occurs everyday. Much has been written on the reasons for this negativity bias, and I won’t explain it here. And I do concede, very willingly, that much of our progress in healthcare (and in society in general) has resulted from our ability to notice the negatives; so I would never say that we should stop doing it.

But there are also many benefits from noticing the good. When you notice what is working, you learn something new. When you show appreciation or gratitude for the good, you improve your mood and that of those around you. Unfortunately, it takes effort to use the lens of positivity. Can we make it easier to access our positive worldview?

I contend that we can use choice architecture to make it easier for us and our colleagues to CHOOSE to see the positive aspects of their work. Providing easy access to an excellence reporting system, and making sure that the system works (i.e. positive feedback is forwarded in a timely manner) are key steps to making it easier to recognise excellence and to show appreciation. Linking the excellence reporting system with the adverse incident reporting system also provides an easy opportunity for staff to balance their observations of their workplace.

We know from 4 years of experience (and thousands of excellence reports) that this does not reduce the amount of adverse incident reports- it simply adds more intelligence to the reported data.  It also  makes it easier for staff to chose to notice what is working, and to show appreciation to colleagues.