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.

When your friend makes a mistake

When a colleague makes a genuine but serious error, start their rehabilitation inmediately. Make it your mission to tell them everything that is good about them. Then tell them again. Although they may deny it, they are suffering and they need your support.

Excellence reporting in a major trauma network

This guest blog post is from Dr Anna Greenwood, Anaesthetic Speciality Registrar and previous Major Trauma Leadership Fellow.

http://www.nyhtraumanetwork.nhs.uk

Introducing Excellence Reporting to a Major Trauma Network

Over the past 8 months the North Yorkshire & Humberside Major Trauma Network has introduced the concept of Excellence Reporting across three Acute Hospital Trusts. The initial Quality Improvement PDSA cycles resulted in an online form emailed to the Network in recognition of what staff perceived as excellent care both clinically and in supporting that work. There have been many examples of peer support, and our ‘five minute appreciate inquiry’ has allowed us to share ideas such as the use of a red badges to identify staff trained in TILS (Trauma Intermediate Life Support), to sharing ideas between sites about identifying elderly ‘silver’ Trauma Patients, who come in with less easily recognised Major Trauma. We have recognised and shared ideas for improved care and national audit data collection, and most notably recognised the great work of a non clinical staff member who identified an acutely unwell patient, allowing for prompt and potentially life saving care.

The challenges of introducing the concept across six hospital sites and including care from road side through the ED, to theatre, ICU, wards and rehab has included sharing information, identifying those reported as excellent and influencing different practices across the Trusts. This all benefitted from the committed individuals who attended monthly Network meetings across the region and disseminated the ideas back, and the hard working staff who recognised the brilliance of Dr Plunket’s original idea.

The next exciting development is the introduction of a ‘cloud’ web based reporting system at the Hull & East Yorkshire Hospitals NHS Trust. Through collaboration between senior Management, Safety Teams, IT, the Communications team, and clinicians on the shop floor we have started to establish the first wards for PDSA cycles before a trust wide launch in June with the launch of the new intranet system. The aim here is to join up the great work the Trust is already doing in recognising great practice, and its well developed and successful Communications team, with well-established safety teams to launch a quick & easy to fill in form that both reflects the great work going on, but also has a formal structure in place to feed this back and take on the learning points. We are using the name ‘greatix’ and thank the Leicester team for sharing their practice. I look forward to sharing these next steps in future, and would like to recognise the fantastic culture amongst the already established Excellence Reporting teams across the country who have shared their experiences and ideas so that we have more chance of success.

Dr Anna Greenwood

http://www.nyhtraumanetwork.nhs.uk

The story of LfE from the National Maternity Hospital, Dublin

This guest blog post is from Associate Professor Mary Higgins, Consultant Obstetrician and Gynaecologist:

In October 2016, inspired by the work of the LfE group, we decided we had to run a LfE pilot within our unit. The National Maternity Hospital, Dublin, is a tertiary level standalone maternity unit in Dublin with more than 9000 births per year. To say we are busy is an understatement, but we wished to remind ourselves that the “majority of healthcare interactions result in positive outcomes” and, that we needed to study high quality practice.

The last few years have not been easy for those working in maternity care. The high profile media coverage of adverse outcomes, reduction in public confidence and increasing complexity has provided many, daily, ongoing challenges for staff. On the ground it has resulted in increased frustration and burnout amongst both clinical and non-clinical staff. There is a real and heartfelt wish to continue to provide high quality evidence based care to women and their children, but the demands on the service and the expectation of perfection makes this a real challenge.

In common with others, our approach to clinical risk and safety is largely focused on a reactive approach to safety. In addition, we have seen the toll taken on staff after an adverse event. While the patient is, and always be, the primary focus of concern, staff involved may also be affected (the “second victim”) as well as the healthcare organization (the “third victim”) – we have chosen to call this the “Domino effect”. Second victims have been shown to have increased rates of anxiety, depression, post-traumatic stress, lack of clinical confidence and suicidal ideation.

The idea of “Safety II” being based on the concept of resilience caught our attention – the ability of an organisation to adapt to changes in conditions. Anyone who works in clinical care is familiar with “work around” – we do it on a daily basis to deal with our work. Maybe it was time to recognize that this workaround is ok, and should be applauded?

Research

We decided to run a whole hospital LfE pilot within one calendar month (October, 2016). Following an intensive review of the literature on “Safety II”, appreciative inquiry and the impact of second victims, as well as reviewing advice from the PICU team (which, in retrospect, probably should have included rereading the advice to start small), the project began with a hospital wide information campaign and included both clinical and non clinical members of staff. Email and face-to-face contact was made with all departments in order to inform them of the pilot, the evidence base supporting it and how to report examples of excellence. Forms were circulated requesting examples of both individuals and team excellence and there were weekly reminders during the month encouraging reporting.

As individuals and groups were identified, a “Gold Star” award was presented to the nominee(s) – these were both given directly to the nominee(s) and publicly published on a notice-board on the hospital canteen. If appropriate each nominated team/individual received a copy of the nomination form so that they could identify what were the circumstances of the specific area of excellence. Themes were identified by content analysis of forms. A hospital wide presentation was made at Grand Rounds in November, when all nominated teams and individuals were identified, and a short video on this presentation was made and uploaded to the hospital intranet for those who could not attend. Possible patient identifiers were removed in order to protect confidentiality.

Effect on the organization

Eighteen teams and 27 individuals received nominations for LfE; four LfE themes were identified. The first, “Excellence in Daily work”, was illustrated by examples from the operating theatre team, neonatal intensive care, Human Resources, postnatal wards, pharmacy and diabetes team amongst others. These examples illustrated the importance of high quality care every day – what is done every day makes a positive difference to women and their children.

The second theme “Identifying problems, proactively solving them” illustrated staff led initiatives to combat issues of importance to patients and staff – education for women on early labour, coverage of Cariban, morning antenatal classes, staff planning in Community midwifery.

The third theme “Emergency Care” used real life clinical scenarios where good communication and team work made a difference – staff were described as “excellent” and “calm, unflappable”, handover as “seamless”, care was “compassionate” and “supportive”.

The final theme of the LfE pilot reviewed “Educational Initiatives” where opportunities were taken to teach on the ground – use of epilepsy medications, care with urinary retention and a Medical Social Work conference on Domestic Violence. One of the most poignant examples was that of Chaplaincy running a debriefing session for staff – ten staff were anticipated, 35 arrived. There was minimal time to adapt to larger groups needs so ground rules had to be established. Guided meditation was used to “appropriately express emotions and confidently support each other, bringing session to dignified close”. Afterwards, a reflection by facilitators established that they had a common desire to provide the best possible understanding and professional support to their colleagues, in order to provide a good solid debriefing session based on collaboration and cooperation. Staff came away feeling understood, supported and minded

The effect of the LfE programme on staff has been incredibly valuable, resulting in increased discussion of positive outcomes, and a commitment to recognize what has been done well and to continue as well as improve our high quality care.

Having completed the pilot, the organizing group now plans to continue “LfE” into the future, in order to use appreciative inquiry and Safety II principles to balance teaching, learning and clinical care. In order to succeed an organisation needs a “Goldilocks” level of positive to negative feedback – too much positivity may become insincere, too little and there may be burnout. The LfE pilot and programme aims to return this feedback to a healthier balance in this maternity unit in order to continue to be able to provide high quality, evidence based patient centered care.

High fives, standardisation and emotions

Our latest blog posting is from Simon Blake:

In the middle of September, on a warm late summer’s evening in Staffordshire, a gathering of people came to find out a little more about LfE. Sponsored by the WMAHSN, this was also a chance to share – experiences, knowledge, successes as well as concerns – about starting or developing projects which facilitate the communication of appreciation of the ‘everyday excellence’ of frontline healthcare work. Whilst this is a determinedly positive approach, it is conducted in the knowledge that there are necessary constraints when working within healthcare organisations. Risk and uncertainty are ever-present reminders that ‘things could go wrong’. But the ‘reality’ is that healthcare professionals don’t enter into this demanding work intending for such ‘things’ to happen.

Management of risk takes many forms, but one approach that remains high profile in any risk-laden sector is standardisation. This usually takes the form of the standardisation of operational procedures using protocols and pathways. Influenced by sectors characterised by high reliability organisations, healthcare has caught the standardisation ‘bug’.

The reason for mentioning this? Rather than drifting off topic, it is actually central to my purpose. At the LfE event in Stoke, standardisation was raised as key to patient safety efforts. A questioner legitimately wondered out loud whether projects like LfE might be missing the point of the importance of something as significant as standardisation. Surely, the standardisation of ‘good practice’ just means the same thing as that work proposed by LfE? Part of Dr Adrian Plunkett’s response was that whilst there was a truth to this, the standardisation of appreciation for excellent work – that is, perhaps, of good practice under conditions of stress and strain in the system – might just be one of the things missing from healthcare. And therefore, by extension, that this adds something to patient safety that is not accounted for by the standardisation project.

Nearly a decade ago the World Health Organisation (WHO) set out the ‘High 5s’ – five key areas within healthcare identified as significant weak-points in relation to patient safety deemed likely to benefit from standardisation. The areas included hand hygiene, medication and surgical management, as well as clinical handover communication. In a recent review of movement towards globally-applicable Standard Operating Protocols (SOPs), Agnes Leotsakos and her colleagues reported upon some of the successes and the challenges which have emerged. Inevitably, concessions have had to be made (e.g. not all of the five areas of work were amenable to SOPs) and the final report isn’t yet available (it’s due imminently, in late 2016). However, even though the work was commenced in 2007, they claim this approach to quality and safety in healthcare is still in its early stages. This isn’t disappointing; rather, it’s realistic and seems to align with the experience of planning, delivering and evaluating frontline healthcare in the face of patient safety concerns. It takes time, but those involved believe it can be done.

Patient safety is itself a complex endeavour. Interest is beginning to be directed more systematically towards the emotional element of patient safety work. Heyhoe and her colleagues have recently offered a clear framework for understanding at least some of these elements. In taking a balanced perspective, they include both ends of the valence spectrum i.e. positive as well as negative emotions. Emotion, they suggest, can impact upon decision-making, patient outcomes as well as how clinicians approach and understand their work. The broader literature and evidence-base is building to give even more support to this take on healthcare.

And so, rather than seeing the work of initiatives such as LfE as being in some way a deviation or distraction from the agenda which is driving towards standardisation, there is another view. Recognising, supporting and appreciating the excellence evident in the everyday work of healthcare professionals can contribute towards positive emotions in and around that vital work. And this then augments and supports ‘good’ processes in patient safety work. It may even contribute towards the unlocking of a deeper understanding of the obstacles still being faced in attempting to introduce and implement standardisation in healthcare. As Leotsakos herself states, SOPs are a part of the process which itself recognises and advances excellence in healthcare practice.

LfE and standardisation aren’t then, if you are open to considering this perspective, in any way in opposition. They aren’t even just working (separately) towards the same goal. They are mutual and interdependent. Adrian was – and is – onto something ‘big’ here!

But we are very open to your thoughts on this…what do you think?

References and Links:

Heyhoe, J., Birks, Y., Harrison, R., O’Hara, J.K., Cracknell, A. and Lawton, R., 2016. The role of emotion in patient safety: Are we brave enough to scratch beneath the surface?. Journal of the Royal Society of Medicine, 109(2), pp.52-58.
Available from: http://eprints.whiterose.ac.uk/95456/1/YBjrsm13nov2015ACC.pdf
Leotsakos, A., Zheng, H., Croteau, R., Loeb, J.M., Sherman, H., Hoffman, C., Morganstein, L., O’Leary, D., Bruneau, C., Lee, P. and Duguid, M., 2014. Standardization in patient safety: the WHO High 5s project. International journal for quality in health care, 26(2), pp.109-116.
Available from: http://intqhc.oxfordjournals.org/content/26/2/109.long

World Health Organisation (WHO) ‘Action on Patient Safety – High 5s’ Link: http://www.who.int/patientsafety/implementation/solutions/high5s/en/