Story of implementation in County Durham and Darlington NHS Trust

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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 couldnt 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

 

Excellence reporting in a major trauma network

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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

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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.

Lessons from excellence in trauma leadership

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My name is Chris Turner and I am a consultant in emergency medicine.

In the transfer window of 2011 I found myself with the quite unexpected opportunity of joining the team at University Hospitals of Coventry and Warwickshire. This was both exciting and simultaneously daunting; exciting because UHCW was in the process of becoming one of the 3 West Midlands adult Major Trauma Centres, daunting because it came with a reputation for excellence which I wasn’t at all sure I could live up to. As the starting date approached I became a little more anxious. Surely they wouldn’t be all that good? After all we had all had similar training and all had the same post graduate exams and life support courses.

Anyhow, the day came when I started. I settled down into the miasma of new systems and became lost in the process of learning a new job. That is, until the trauma call went out. Fortunately, I was not running the call and as such was able to watch. I settled against the back wall, happy that my lack of height would be a further defense to exposing myself as a charlatan in resus, whilst secretly hoping that I might recognise the process and feel that it was not out of reach.

What I saw was far worse than I had imagined.

Gary Ward walked in, took control of his team, ensured everyone knew their role, was happy with it and felt able to contribute. He then delivered text-book trauma leadership, creating, at its core, a small oasis of calm in the otherwise frenetic environment of a busy resus. Dialogue flowed back and forth, team members were addressed by name and there was consistent clarity of purpose. The patient had their primary survey and initial workup in less than 10 minutes, making it into the CT scanner in less than 12. I was horrified, this wasn’t just good- this was outstanding.

I decided that I would watch a few more traumas being run; after all, Gary came with a reputation for excellence and perhaps I could find someone with a more realistic level to aspire to. The next person I watched was Caroline Leech. Once more I stood in the background and watched as, in a slightly different style, another masterclass in initial trauma management was delivered. Over the next few days and weeks I watched as Rob Simpson, Louise Woolrich-Burt, Jim Davidson and others each brought their own style to the basics of ATLS/ETC to create what felt like amazing teams from groups of disparate individuals. They did this rapidly, succinctly and in a way that allowed the whole team to feel valued. The sense of being out of my league only grew.

At some point, I realised that there were things that each was doing that appeared to help the team to come together. From discussing with the trauma team leaders however, it was also clear that they were not quite sure how they did it “It’s just my style” and “I just do it how I do it” being amongst the replies I received when I asked about this.

Just asking the leaders wasn’t going to get the answers I was looking for. So, working alongside Dr Amy Randle (then an ACCS trainee), we developed an anonymised qualitative questionnaire that was distributed to members of the multi-disciplinary trauma teams. We asked what they liked, what they didn’t like and whom they thought was the best trauma team leader. We received over 100 replies and they are summarised below.

Positive attributes:

positive

Negative attributes:

negative

It may seem odd, but seeing this written down has been a great help. It has provided a structure to consider our behaviours and to think about the atmosphere we create in real time. But we did much more with this- we used it to form part of our peer review process and have had collective discussions so that everyone can learn from each other. By describing both the good and the bad we have given clarity to the behaviours that encourage and inhibit excellence.

And the best trauma team leaders?

Well, Gary Ward :garyand Caroline Leech:carolineBut now we know their secrets…

Chris Turner, April 2016

chris