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.


Thoughts from the Critically Careful Forum


On 22nd January I was privileged to attend the first national Learning from Excellence event hosted by Dr Adrian Plunkett at Birmingham Childrens’ Hospital.  As a former West Midlands paediatric trainee who has rotated through BCH PICU twice I was aware of the fantastic work Adrian and the team had undertaken and had witnessed first hand the positive effects this had on staff.  On joining the Paediatric Emergency Medicine team at Leicester Royal Infirmary I was keen in some way to introduce the learning from excellence philosophy.  This idea complimented the Critically Careful Forum which Dr Gareth Lewis was already running in the department.

It was the story of our journey and experiences with the Critically Careful Forum, the good and bad, ups and downs that I was able to share with the audience on the 22nd.  I am aware that running a regular ‘Awesome and Amazing’ style meeting in an emergency department for many will be common practice.  Unfortunately there was nothing being delivered locally to provide multidisciplinary education for our staff.  Originally this monthly meeting was slow to get off the ground however it has gone from strength to strength.  This is a little scary as there is a definite expectation now from the staff who for the majority attend in their own time.

Ultimately we reflect on what has always been a busy previous month in the department.   We highlight a selection of cases which traditionally have been some of the more difficult and challenging ones with relevant learning points.  We have noted that there have been struggles to fully adopt a learning from excellence approach due to the self-deprecating nature of many of our staff.  Even those working in a paediatric emergency department struggle with the concept that not every child gets better.  There is often a feeling of, “what did we do wrong?” or “what could we do better?” when the answer is “nothing!”

We are increasingly however pushing ahead with learning from excellence as it is these cases that we believe we have most to learn from.  In the past 6 weeks we have introduced a new sepsis bundle and last month saw evidence of its success.  A patient with severe sepsis was identified at triage, prioritised for senior medical review and transferred to resus where ultimately care progressed to PICU level support with intubation, ventilation, antibiotics, fluid boluses and inotropes within 35 minutes of the child arriving.  This care will be highlighted and discussed at length but we will also recognise the wider staff efforts; those that ‘stepped-up’ to maintain excellent care for the other children in the department.

In this way I feel we have been able to maintain staff morale at high levels during a busy and challenging winter period.  I believe that this is an under-recognised benefit of the learning from excellence process.

I hope I was able to inspire some in the audience with our experience from Leicester, certainly I came away invigorated with lots of great ideas I am already setting into motion to allow us to better recognise and highlight the great work in our immediate and wider team.

Let’s get together on 22nd Jan 2016 – save the date!


For the last few months we’ve been talking about whether there would be any benefit of holding some sort of “conference” or “gathering” of like-minded teams and individuals, to discuss this initiative in detail.  During that time, we have been receiving regular email and telephone calls from other centres who are either interested in starting excellence reporting, or have already started and are keen to share their results.

So, the time has come to get together – the first “conference” of Learning from Excellence will take place at Birmingham Children’s Hospital on 22nd Jan 2016.  Please save the date!  We will hold the meeting in our education centre between 10am and 4pm.  Unfortunately, we don’t have any funds for lunch or travel.

We are currently working on the agenda for the day.  Please let us know if you have any specific topics you would like to discuss, by leaving comments below (or by email).  We would like to give all attendees a chance to ask questions / share data / offer insights – so there will be a “spotlight” session for all who wish to contribute.  We would also like to spend some time looking at how we can get the most our of methodologies like Appreciative Inquiry.

Closer to the time, we will be seeking a list of attendees for registration. Meanwhile, feel free to contact us if you wish to attend.