Work as done and work as imagined: a role for LfE?

Much has been written on the concept of work as done (WAD) vs. work as imagined (WAI). Essentially, the idea is that the work done at the sharp-end / on the shop floor (i.e. WAD) differs significantly from that which is documented in standard operating procedures (WAI). Understanding this difference is key to understanding why adverse events occur, yet this approach is often overlooked: the prevailing approach to adverse incident analysis is often based on an assumption that WAI is the reality.

Understanding WAD is not easy and probably requires a completely different approach to commonly used methods like Root Cause Analysis (RCA). WAD depends on variability of performance including improvisation and work-arounds. This variability is essential for socio-technical systems (such as health-care) to function, but this variability can also be the source of failures. Unfortunately, adverse incident analyses tend only to highlight the negative side of human variability, so efforts to make systems safer often result in the imposition of more and more constraints.

How can we understand WAD better? In particular, is it possible to capture the positive side of variable performance?

Capturing WAD necessarily requires real workers describing how real work is done. Hence, the understanding must come from the ‘sharp-end’. Various methodologies exist, but I would advocate the value of excellence reporting. The vast majority of LfE reports describe non-technical skills whereby success has occurred despite difficult conditions. These non-technical skills (e.g. generosity, kindness, going the extra mile) are not featured in WAI, yet they are assumed. It is my contention that positive human interactions are a core component of WAD and should be actively noted and appreciated. LfE is designed to do just that.

Adrian

Hawks and Doves

I just spoke about LfE to some laboratory staff. There was an excellent question from the audience (paraphrased):

“I perceive excellence as rare and exceptional. As a ‘hawk’ this makes sense to me. Is LfE about capturing this stuff, or more about the everyday ‘good’ activities?”

In my answer I tried to articulate that excellence is subjective. It doesn’t come with a priori definitions. It also doesn’t have to be intimidating. We have thousands of LfE reports from our institution and the vast majority describe a simple episode of non-technical activity involving one or more colleagues. On the face of it these reports often seem to be descriptions of ‘people just doing their jobs. But in every case, there was something excellent about the episode, in the eyes of the reporter.

That is all that is required to trigger an excellence report. The positive feedback is powerful and informs the recipient about the impact of their actions, the extent of which is often not known by the recipient until the report arrives.

Hawk or dove, you can use LfE to show appreciation to colleagues, based on your own definition of excellence.

Adrian

Story of implementation in County Durham and Darlington NHS Trust

Here is a guest blog from Dr Richard Hixson, describing the rapid implementation of excellence reporting in his trust – County Durham and Darlington NHS Trust.

Excellence Reporting; conception, implementation and experience.

Working as a Deputy Medical Director in Patient Safety was eye opening and rewarding but at times confusing. We focussed on the incidents, the actions and learning but however we dressed it up, it always felt as though we couldn’t shake the negative. An averted incident could only be reported as a near-miss and there was simply no mechanism to understand how somebody’s positive actions had prevented harm from occurring. The machine that processed incidents responded rapidly whilst individuals cited in patient experience documents remained blissfully unaware of the praise they were receiving. We simply had an imbalance in our processes.

Wrapped up in the world of Serious Incidents, complaints and mortality, I was totally unaware of concepts such as ‘Safety 2’ and ‘Learning from Excellence’. I repeatedly expressed frustration, tagging a slide onto every presentation I gave stating we needed a smaller stick, a bigger carrot, a focus on learning from the positives and a mechanism to recognise the good stuff. One stairwell rant was overhead by a dietician, Jennie Winnard who was aware of the work taking place in BCH. We therefore decided to team up and pay the Executive Body a visit. Our vision was presented in June 2016 and we were immediately challenged with creating a fully functional excellence reporting platform for the largest trust in the Northeast of England. We had just over 2 months to deliver over the summer holidays working to a budget of £0.00.

Utilising our Patient Safety colleagues and Ulysses, the company behind Safeguard, we succeeded in creating a module that sat alongside incident reporting and whilst being similar in aesthetics was much, much simpler to complete. Due to the time pressure, there was little fanfare accompanying the September 1st launch as we relied upon simple communications: emails, trust bulletins, screen savers and word-of-mouth. We sat back and waited to see whether anyone else ‘got it’ eager to see how our initiative was received by colleagues.

Fast forward 16 months and the results can only be described as staggering. In the first year alone, 1131 reports were filed naming 1634 members of staff with 75% for ‘going the extra mile’ and ‘team work/peer support’. Summaries were being provided to Care Groups and integrated into governance meetings, bulletins ran short stories on ‘the good stuff’ whilst surveys revealed recipients felt more positive about themselves, their colleagues, their job and even the Trust for weeks or months after receiving a report.

What started as a pure ICT portal has now extended to ‘ER cards’ which can be used for staff such as domestics who do not access email. Even without re-marketing, excellence reporting continues to gather pace with increasing numbers of reports filed every week. Positivity is addictive with recipients looking out for and recognising the excellence in others which simply manifests as high-quality care being provided by ‘ordinary staff’ who feel they are ‘just doing their job’.

As one of our recipients reported – “Of all the changes in the Trust, the little addition of excellence reporting has made a tangible difference to the working lives of many. Most of us, including me would not like to tell the world how good we are at what we do. Excellence should be perceived by others. Excellence in patient care should remain our motto and inspiration”.

On reflection, it just seems so obvious that this is just what the staff and Trust needed. I just cannot believe it took us so long to appreciate and implement.

Richard Hixson, Consultant in Anaesthesia and Critical Care.

County Durham and Darlington NHS Foundation Trust.

richardhixson@nhs.net

Is Learning from Excellence “Safety-II”?

Learning from Excellence is often described as a “Safety-II” initiative. I can see why this is the case, but the truth is that I implemented LfE before I had even heard of Safety-II. That’s not to say the Safety-II was an underground movement; I was just a bit slow to find out about it.

The principle aims of LfE are to improve quality (through gaining insight by looking at hitherto under-studied parts of our system) and to improve morale (through formal positive feedback). Safety-II is a concept based on the idea that safety can be considered a condition where as many things as possible go right; rather than the prevailing approach to safety – Safety-I – where we consider safety a condition where as few things as possible go wrong. In the history of ideas, Safety-II is a very new one. Whilst its theoretical principles are increasingly well defined, there is a distinct lack of practical application – particularly in healthcare. How does one actually “do” Safety-II? While we wait for the answer to this question, which may take years to come, we are tempted to “fit” initiatives, like LfE, into the Safety-II label.

Does LfE fit into Safety-II? I think the answer is yes and no. But a bit more yes than no. LfE is about identifying success, and viewing it through a learning lens. The name of the initiative suggests that it tends to identify extremely good (i.e. excellent) examples of work. Indeed, this was the original idea of the initiative. However, after looking at over 2000 reports, I have concluded that we are not capturing rare episodes of excellence – we are actually capturing “everyday excellence”. The vast majority of the reports are a description (or short story) of a small work-around, improvisation, or a generous human touch which allowed success to occur in difficult circumstances. It turns out that neither difficult circumstances, nor generous human touches are hard to find in healthcare. The success of the initiative is due to the fact that these have been happening since the start of organised healthcare, but have been unrecognised through formal reporting systems.

In the Safety-II construct, we could make our systems safer by understanding day to day work better. Since success happens most of the time, we should be studying and understanding what happens most of the time, in order to recognise the work-arounds / adaptations / improvisations which create (and underpin) the conditions which allow success to happen.

If most of our LfE reports are about everyday work, I would argue that we have essentially created a system for “doing Safety-II”; at least in part. What we haven’t created is a system which understands every element of everyday work. This is someway off.

The fact that LfE is not a perfect practical solution for Safety-II is not a reason to change it. On the contrary, it continues to grow and spread positivity and positive change in healthcare (and beyond), so there is no need to make it fit into anything.

Show me the “learning”

Questions from the sceptics: 2. Show me the “learning”. This is the second in a series of short blogs about common questions we receive about LfE.

I’m sometimes asked to demonstrate the “learning” from learning from excellence. Often, LfE is regarded as a mere “pat on the back” for a job well done: a harmless initiative, but not of any tangible utility. What is the actionable intelligence? Where is the “learning” which can be transferred from one situation to another? This view of LfE is missing the effect of feedback on performance.

The core of LfE is a simple, formal positive feedback tool, which allows peers to show appreciation to each other. Recipients of excellence reports are made aware of the positive effects of their actions. This gives them the opportunity to reflect and think about why their actions were so well received. This may prompt comments like “I was just doing my job”, yet staff members often go on to make changes in their future behaviours based on the new awareness they have of their positive actions.

So the principle type of “learning” in LfE is the same as the learning we experience from any type of feedback. The main difference is that LfE is exclusively positive feedback – an extremely rare phenomenon in today’s NHS.

Adrian

On stone cutting in PICU

This guest blog post is from one of our PICU colleagues, Dr Heather Duncan. Heather reviewed some of our LfE reports, and wrote this blog post:

It’s not what we do but how we do it….

Reading the recent LfE reports reminded me of the story about the three stonecutters who are asked what they are doing. The first one says, “I am cutting a stone.” The second one says, “I am cutting this block of stone to make sure that it is square and it’s dimensions are uniform, so that it will fit exactly in it’s place in the wall.” The third stonecutter grins and replies, “I am building a cathedral.”

Each of us with our small tasks contributes to a much greater achievement. It is in particular not what we do, or even that we do, but how we do our work that we identify as excellent. Rather than stonecutting, in BCH the reports are about receiving and sharing patient feedback, being a team leader, a band 7, Admin colleague and consultant on both ordinary and difficult days in BCH. I have collected words from these IR2s about how we do our tasks that makes them notably excellent. Try reading them aloud. Calm, run smoothly, energy, positivity, helpful, resilient, considered, accepting, listened, sensitive, unruffled, go the extra mile, pleasure to work with, enthusiastic approach, empathy, compassion and respect. They are all descriptive words of how actions look and feel when we excel.

There are a few tasks in each of our roles that feel like cutting stone. Next time I come across one of those tasks I’m going to try to remember these positive words and see whether I can remember to do the routine with the energy and positivity; learning from excellence. Like the third stonecutter the tasks we perform every day are part of a whole and necessary for the grand picture of what we do, “building a cathedral.”

Heather Duncan

Could Learning from Excellence be enabling compassion to flow?

I’m delighted to introduce a guest blog from Andy Bradley from Frameworks 4 Change. Andy’s blog starts with his thoughts on a recent LfE event in London:

Could Learning from Excellence be enabling compassion to flow?

To change an organisation, change its stories

Gary Hamel, London Business School

I spent four minutes in total listening to an orthopaedic surgeon at a workshop on Learning from Excellence at a national patient safety conference. I did not find out the surgeon’s name but here is what I did discover:-

He had received some positive feedback in writing from a patient who had felt anxious about her planned surgery. The feedback thanked the surgeon for his calm, caring demeanour and the patience he showed in answering the patient’s questions and allaying her fears. As a result of receiving this feedback I discovered that the surgeon felt happy and proud. As a result of our conversation, in which he spoke and I listened, the surgeon had decided to go back to the team he works in to suggest that they start gathering data specific to how well prepared patients feel for surgery – he was thinking about a likert scale with space for a qualitative comment – he was thinking that the importance of preparation in terms of the patient experience could be overlooked and that by focusing on this area a range of improvements were possible.

We had been asked in our pair to think about:-

A story of excellence in care

How the story made the story teller feel

What could be done to create more of the moments shared in the story

The Learning from Excellence Philosophy

Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. It is time to redress the balance. We believe that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale’

Does pride helps us to deal with shame and release compassion?

‘Your mind is like a garden, whatever you focus on grows’

Matthieu Ricard, Bhuddist Monk

The fear referred to in the Learning from Excellence philosophy drives the dominant narrative in health care – the rules and rigidity increase in relation to the fear which often manifests in the individual as guilt (I have done something bad), internal shame (I am bad) or both.

In their book the Archaeology of Mind: Neuroevolutionary Origins of Human Emotion Jaak Pansepp and Lucy Biven throw light on the neural sources of our human values and basic emotional feelings. The ‘primary processes’ which are located in deep areas of the brain include fear, rage, grief and care. The secondary process in which we make sense of these primal feelings and begin to integrate our experiences are empathy, trust, pride, blame, guilt, and shame.

Primary processing in medicine is complex – when culture and practice is healthy care is clearly central but when things go wrong fear and panic can set in and cultures can become toxic. In these circumstances secondary processing in healthcare is dominated by blame, guilt and shame – which may help to explain why the system is experienced by many as institutionally defensive.

Learning from Excellence fosters pride in accomplishment and is grounded by noticing and giving voice to appreciation – this may help practitioners to come to terms with guilt and shame. Paul Gilbert OBE, the founder of the Compassionate Mind foundation has concluded from research that the number one block to the flow of compassion (self to self, self to other, other to self) is shame.

So, here is what I am thinking now….

by generating pride and making appreciation explicit could Learning from Excellence help to balance the health care system by enabling the flow of compassion?

Andy Bradley

Frameworks 4 Change

Isn’t this all just a bit “touchy-feely”?

Questions from the sceptics: 1. Isn’t this all a bit touchy-feely?

This is the first in a series of blog posts, reflecting on some of the comments we hear about Learning from Excellence. This one is from Emma Plunkett

I talk about Learning from Excellence (LfE) a lot these days. I’ve presented the concept and the practicalities of the initiative at many different local, regional and national meetings and am generally met with a positive response. People can usually see the value in having a system for acknowledging and appreciating the work of colleagues. In addition, more people are becoming aware of the concept of safety-2 and understand the importance of learning from when things go right.

But naturally, as with any new idea, there are sceptics. Some people just don’t get it. Or maybe they can’t. One of the recent questions I have had from people struggling to understand the point of the initiative has been, “Isn’t this all just a bit touchy-feely?” When people have a really different perspective from mine, I try to understand their paradigm. I’ve found it hard this time, perhaps because the question came after a presentation describing all the uses of LfE (that’s another blog in itself). I find it hard to understand why someone wouldn’t agree that excellent work is to be appreciated, valued and investigated, so we can make more of it happen.

I’ve been thinking about how I should answer this if it comes up again and I’ve realised that my problem with the question is twofold. Firstly it’s the negative connotations associated with the phrase “touchy-feely”, which is often used to belittle the importance of emotional connections. It’s strange how a positive initiative can be “touchy-feely” in a somewhat undesirable way, whereas something with negative emotional consequences would never be described like that (or at least I hope it wouldn’t). Why can’t we equally value positive interactions? And not dismiss them as something sentimental that carries less value. It also implies that the praise is unrestrained or overstated. Importantly, this is not the case with LfE. The honest and sincere nature of the reports we see is key to their value; exaggerated or artificial praise becomes patronising and does not work, and LfE is not about this.

My second problem is with the word “just”. There are elements to the initiative which are deliberately and importantly emotional. But there is much more to it. “Just” in this context represents an excuse to dismiss LfE as something trivial and although some reports are about small events, all of them have made a difference to the people involved, and none of them should be rejected as inconsequential. LfE can’t be pigeon-holed into being “just” one thing – it is about reflection, appreciation, improving morale, improving quality, service development and creating a culture of learning.

For me, work is made worthwhile through connecting with others, be they patients, relatives, or colleagues, and making a difference to their lives. LfE involves showing genuine gratitude for the work of others, enabling a positive connection to form. Success at work also relies upon constantly learning, developing and improving and helping others to do the same. Learning from what we have done and using it to inform our future decisions. These are the key principles behind LfE.

So how will I answer the question next time? I think I will try to explore what is meant by “touchy-feely”. If it means insincere or inappropriate, effusive sentimentality , then that is not what LfE is about. But I’m not going to pretend that LfE doesn’t involve expressing positive emotions. It’s one of the keys to its success. And if that’s what being touchy-feely is, then yes it is a bit, and that’s why it works.

Dr Emma Plunkett

On celebration

I’m all for celebrating fantastic achievements and well-earned successes. But if we celebrate something (or someone) everyday, we devalue that which we are celebrating. Whenever we create winners, we also create losers. For every award-winner, there are countless colleagues going un-rewarded; under the radar.

The Learning from Excellence movement is not concerned with celebrating success. In fact a key feature of the initiative is that the positive feedback from each report is privately shared with the staff member who has been reported for excellence. There is no overt celebration. No league-tables or performance charting. Learning from Excellence is a way to show appreciation. Appreciation is more subtle than celebration. It is not a reward. It is not a prize. It is noticing the good. Showing our colleagues that we have noticed their good work is a powerful motivator, because it shows that they are valued in their work.

Intangibles and ‘ordinary excellence’

I recently received an excellence report (IR2) from one of our nurses. The report detailed how I had supported the nurse after she had been involved in a medication error. Within the report was a description of what I had done, and why it was helpful. The final words were ‘he probably doesn’t know how helpful this was. Thank you.’ This was true, I hadn’t realised that I had done anything out of the ordinary. I considered my actions to be normal and I felt that I was ‘just doing my job’.

A common criticism of excellence reporting is that we have created a system which serves to ‘reward’ staff for simply doing their job. A brief review of the reports would suggest there might be some truth in this – many of the reports describe normal activities and tasks. But this view is missing an important point: excellence is defined by the reporter. Objectively defined outliers of high performance are rare, by definition. Whilst these are occasionally captured in excellence reports, they are a relatively infrequent theme. Much more common is ‘ordinary excellence’: a description of what would be considered a normal activity, but there is something intangibly ‘good’ about it. This intangible quality is the trigger for writing the report.

Why is important to capture and report these events? To answer that, you have to speak to the recipients of the reports. In the majority of cases they will tell you that they didn’t realise how appreciated their action was and that they will make small changes to their practice as a result. I write this as a recipient of such a report: I now conduct myself differently as a result of this simple act of appreciation. I am also more confident that this aspect of my practice will benefit staff and patients.