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.





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 (http://www.nhsemployers.org/your-workforce/retain-and-improve/staff-experience/health-work-and-wellbeing/health-and-wellbeing-framework) 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 www.15s30m.co.uk) 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 15s.30m@bthft.nhs.uk – 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.

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?


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.



The following guest blog post is from Dr Clarissa Chase , an ST5 trainee in paediatrics, at Southampton General Hospital.  Clarissa conceived a positive reporting system called “FERF”. The story of FERF is below:


It seems almost every day that a negative healthcare story makes its way into the headlines; missed diagnoses; missed opportunities; repeated failings that suggest a lack of learning from previous serious incidents.

While the issues raised by these stories may be significant, the articles rarely present a balanced account. The distorted information is presented for maximum impact and consequently effects public perception of us all.

As healthcare professionals, we have no right to reply or publicly defend these cases. As we are in the business of preventing harm and striving for clinical excellence it is difficult to know how to manage such misrepresentation. Not least because the barrage of negative press stories and distorted perceptions of NHS care must be having a negative effect on the morale of our workforce.

I don’t think anyone would deny that learning from mistakes is essential.

Reviewing failings, whether in the form of a formal inquiry or simply personal reflection, is necessary to identify hazards or risks and target improvements to address these and prevent any recurrence. Patient safety is paramount and we have a myriad processes to direct our focus at this; adverse incident reporting forms; patient complaint processes; the National Reporting and Learning System to name but a few. All these processes have been designed around identifying adverse events. Perhaps we are guilty ourselves of propagating this endless focus on the negatives, thus further perpetuating dwindling morale.

A 2007 survey for Hospital Doctor suggested 69% of doctors in the UK reported falling morale. The reasons for this are likely to be complex and varied, but might at least in part be a result of a relentless attention on adversity, both within the NHS and in the wider public forum.

So what if we turned that on its head? Redress the balance and recognise that it is as important to learn from the things that go well; the good things we all do every day that get little or no recognition: instead of learning from an example of incorrect care of a post-operative patient resulting from poor handover of information on arrival to the ward, identify the cases where the handover is exemplary and evaluate what makes it so, in order to encourage the process to happen in this way each time. Identify the details of specific positive examples, use them to educate and we will all learn from good practice.

Positive reinforcement is a well-recognised concept first described by psychologist BF Skinner that describes the reinforcement of a specific desired behaviour using a reward; a positive event that follows a particular action will reinforce it and make it more likely to happen again.

Putting this into context within the NHS would seem simple: if the reinforcement takes the form of specific positive feedback, for example: ‘I think you managed that consultation well – you involved the patient in the decision making and summarised all the information clearly’ then we will start to recognise all the things that we all do well every day, while we emphasise what works well and, in so doing, ensure continued good practice. The side effect of this process might be to increase morale and confidence. It will change the way people think about one another and build a stronger team.

I remember an incident as a junior registrar in 2012 when one of my consultants was admitting someone unexpectedly to the ward after clinic. As I was the registrar covering the evening shift she came and found me and took me to the clinic room to meet the parents and their baby. While we were in the clinic room she explained the reason for admission to me, in front of the parents and explained her proposed plan for overnight. I was then able to accompany the parents to the ward and introduce them to the ward staff. It struck me that her actions had a big impact on the very anxious parents. They clearly felt reassured that the discussions had both happened in their presence, and involving them.

Two other things struck me that day: 1) did my consultant realise the positive impact of her actions and 2) what a shame that I was the only person around to learn from her brilliant practice. I wanted to find a way to recognise, emphasise and learn from positive events.

And so the idea of Favourable Event Reporting Forms (FERF) was born. The concept was simple: a paper reporting form to identify positive practice and the individuals involved that could be filled in by any member of the team. A multidisciplinary team would then review the forms monthly and the learning points for each of the events drawn out. These learning points would then provide feedback both to the individuals involved, and to the rest of the team. The individual would receive a letter from the clinical leads of the team. The event and learning point would also be summarised and displayed on a noticeboard for staff, patients and visitors to see, as well as being discussed in Mortality and Morbidity meetings and education sessions.

The FERF initiative has been extremely well received in many different clinical areas. As well as enabling learning from positive practice, FERF provides a mechanism for individual professional development and has increased morale among all members of the multidisciplinary team. In addition to being used by patients and relatives and for patients and relatives, many have commented on how pleased and reassured they are to see both examples of positive practice and learning from positive practice.

While striving for clinical excellence we should recognise and celebrate our successes, learn from one other and from the hundreds of brilliant things we all do every day. If we change the way we value each other perhaps we will change the way others view us too.

On sincerity


This morning I opened my email inbox to find two unread excellence reports. The first was from a consultant surgeon. He had reported excellence in his theatre staff for staying late to finish some cases. The patients had benefited from this sacrifice and the consultant surgeon wanted to say thank you. He could have gone to each individual and said thank you directly – perhaps he did – but he chose to make it more formal by reporting this through our excellence reporting system. The second report was from a nurse who had cited the Chief Executive Officer of the trust for excellence in dealing with a particular issue in her department.

Both of these reports were essentially a formal notification of thanks.  At first glance neither of these reports contain much ‘actionable intelligence’. These are just thank you letters between members of staff. All very nice, but where’s the learning?

The key to these reports is their sincerity.  The excellence reports require free text entry, so the reports are written in the words of the author. There is no forced categorisation; no drop-down menus. Just free writing. This allows the sincerity to shine through. The reports are delivered verbatim to the reported staff member. So the theatre staff and the CEO will soon be receiving the same copy of the reports I read this morning. What will their reactions be? How will they feel?

My bet is that they will feel appreciated. Appreciation is different from reward. Appreciation is being positively noticed (or not being ignored,  depending on your perspective). This taps into intrinsic motivation and makes us more likely to want to repeat our actions. Reward, in contrast, is an extrinsic motivator; a carrot, from the stick and carrot concept. Reward works to a point, but ultimately we tire of these motivators. Reward and punishment are management concepts from the industrial age, and they are now outdated.

Don Berwick recently wrote an opinion piece about eras in healthcare. http://jama.jamanetwork.com/mobile/article.aspx?articleid=2499845 He proposes that there have been two historical eras in healthcare: era 1, characterised by professional trust and prerogative; and era 2, characterised by accountability, scrutiny, measurement, incentives, and markets. He suggests that it is time for era 3: a moral era. The article contains nine suggested changes to move to the next era, one of which is to protect civility. Berwick writes, “Medicine should not…substitute accusation for conversation”.  Whilst this may seem obvious, the truth is that it is often forgotten in reality.  Under pressure, civility is often one of the first things to buckle.

How can we protect civility?  A starting point would be to encourage a culture of appreciation for our colleagues.  “Thank you” and “well done” are usually followed by positive dialogue which can form a strong foundation for learning how to improve.  Indeed, the recognition of good practice is likely to increase the prevalence of further good practice.  It may well be the simplest quality improvement intervention there is.


A teaspoon of excellence…


Our latest blog post is from Dr Gabriella Morley, a foundation doctor who carried out a quality improvement study at BCH, using excellence reporting as the primary intervention.

A teaspoon of excellence helps the medicine improve  Dr Gabriella Morley

I’ve been a doctor for 22 weeks now, and it sure has been a steep learning curve! But, you know what I’ve noticed most, during my short NHS employment, I’ve noticed that healthcare professionals go the extra mile. Day in, day out. Excellent practice happens all the time. Perhaps we take this excellence for granted, because it appears to me that it often goes unremarked. Of course, we should always be striving for excellence, and excellence should be happening daily in order to provide the best care we can for our patients. However, healthcare systems do not seem to acknowledge excellence, instead there is a focus on error, blame and mistakes. Being told off all the time is not good for anyone. It just does not motivate. So is measuring error the only way we can improve healthcare? Or, can we drive better care by measuring excellence too?

We wanted to test this idea, that excellence can help medicine improve, with a quantitative study. We looked at the drug chart documentation of antimicrobials against an audit standard in a Paediatric Intensive Care Unit (PICU). An antimicrobial prescription which met all 11 audit standards was deemed a ‘gold standard’ prescription. We determined the prevalence of gold standard prescriptions both before and after a few weeks of ‘intervention’: positive reporting via the IR2 forms. These IR2 forms are a source of positive feedback which describe excellent clinical practice. The IR2 can be filled in by anyone and are passed on to the individual via the clinical governance team, creating a positive feedback environment.

In this study the IR2 forms were used as an intervention to detail the prescriber’s gold standard documentation – their clinical excellence. After this intervention we found that there was a significant increase in the number of gold standard prescriptions on PICU. This demonstrates that positive reporting can have an impact on clinical practice and could improve patient safety.

Measuring excellence can be done and, most importantly, reporting excellence can drive better care.