Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely / Edition 1

by Suzette Woodward

Overview

Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached.

Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely.

Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years.

This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like.

This book builds on the author’s first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the ‘how’.

Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the author’s personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.

Product Details

ISBN-13:	9780815376859
Publisher:	Productivity Press Inc.
Publication date:	09/11/2019
Pages:	256
Product dimensions:	6.12(w) x 9.19(h) x (d)

About the Author

Dr Suzette Woodward works in the English National Health Service (NHS). She is an internationally renowned expert in patient safety and has been studying safety in healthcare settings since the 1990s. Her particular areas of interest include implementation of patient safety and the translation of theory and public policy into practice. She has an exceptional ability to take complex issues and make them easy to understand as well as being able to weave together different threads in a unique and stimulating way.

Suzette is a trained general and paediatric nurse who specialised in paediatric intensive care nursing for over ten years. She has a Master’s in Clinical Risk and a Doctorate in Patient Safety and was the recipient of the Ken Goulding Prize for Professional Excellence in 2008. Her research focused on implementation of national patient safety guidance. She is also a visiting professor for Imperial College University in London. Suzette was awarded the Daisy Ayris Medal for services to perioperative nursing in 2011, named one of the top 50 inspirational women in the NHS in 2013, one of the top 50 nurse leaders in the NHS in 2014 and one of the top clinical leaders in the NHS in 2014.

Her first book, Rethinking Patient Safety, and the accompanying blogs have helped shape the conversation on thinking differently about safety in healthcare and she is a sought-after speaker at international and national conferences, workshops, symposia and meetings, having delivered over 200 keynote addresses on patient safety.

Table of Contents

Preface xv

Acknowledgements xix

Author xxi

1 Create a Balanced Approach to Safety 1

1.1 Part One Introduction 2

1.2 Failure 2

1.2.1 Negativity 2

1.2.2 Studies of Failure 4

1.2.3 Retrospective Case Note Reviews 5

1.2.4 Limitations in Measuring Safety 8

1.3 Safety Myths 11

1.3.1 10% of Patients in Healthcare Are Harmed 12

1.3.2 Incident Reporting Systems will Capture all the Things that Go Wrong 13

1.3.3 Incident Reports Can Be Used to Prioritise Solutions and Activity 13

1.3.4 Incident Reports and Investigations Provide Unambiguous Data (the Truth) 14

1.3.5 We Should Aim for a Rise in Incident Reports Because It Demonstrates a Good Safety Culture 16

1.3.6 A Reduction in Incident Reports Means We Are Learning 18

1.3.7 Incident Investigations and Root Cause Analysis Will Identify the Causes of What Happened 19

1.3.8 Linear Cause and Effect Models Will Work in Healthcare 22

1.3.9 We Simply Need to Learn from Aviation (Or Other High Risk Industries) 23

1.4 Concepts and Theories 24

1.5 The Three Models of Safety 25

1.5.1 Summary of the Three Models of Safety 26

1.5.2 The Three Models in Relation to Healthcare 26

1.6 Complex Adaptive Systems 29

1.6.1 Complexity Science 29

1.6.2 Simple, Complicated and Complex 30

1.6.3 Healthcare 33

1.6.4 Complexity and Dilemmas 36

1.6.4.1 A Local Dilemma 37

1.6.4.2 A Global Dilemma 39

1.6.4.3 Let's Talk about It 41

1.7 Safety I and Safety II 43

1.7.1 The Prevailing Approach to Safety 43

1.7.2 Erik Hollnagel and Resilience Engineering 45

1.7.3 A Different View 47

1.7.4 'Safety V and 'Safety II' 49

1.7.5 How Do We Do It? 50

1.8 Part One Summary 53

1.9 Part One Actions 56

2 Turn the Theory into Practice 59

2.1 Part Two Introduction 60

2.2 Implementation 60

2.2.1 What Is Implementation? 60

2.2.2 Implementation and Healthcare 62

2.2.3 What Can We Do Differently? 64

2.3 Narrow the Gap between Work-as-imagined and Work-as-Done 66

2.3.1 Work-as-Done 67

2.3.2 Work-as-Imagined 67

2.3.3 Work-as-Prescribed 68

2.3.4 Work-as-Disclosed 70

2.3.5 The Problems with Inspection 72

2.3.6 Why Is It Important to Narrow the Gap? 73

2.4 Models to Understand Work-as-Done 74

2.4.1 Ethnography and Simulation 75

2.4.2 Positive Deviance 76

2.4.3 Exnovation 80

2.4.4 Golden Days and Lives Saved 83

2.5 Functional Resonance Analysis Method 84

2.5.1 What Is the Functional Resonance Analysis Method or FRAM? 84

2.5.2 Terminology 86

2.5.3 The Four Steps 90

2.5.4 The Four Principles 92

2.5.5 Examples of Questions 94

2.5.6 FRAM and Safety 95

2.6 Measurement and Monitoring Framework 96

2.6.1 The Five Dimensions 99

2.6.2 The Five Questions 100

2.7 Change the Language to Change the Mindset 101

2.7.1 Patient Safety 104

2.7.2 Human Error 104

2.7.3 Honest Mistake 106

2.7.4 Violations 106

2.7.5 Zero Harm 108

2.7.6 Never Events 109

2.8 Part Two Summary 109

2.9 Part Two Actions 111

3 Urgently Tackle the Culture of Blame 115

3.1 Part Three Introduction 116

3.2 Culture 117

3.2.1 Healthcare Culture 118

3.2.2 Safety Culture 118

3.3 Blame, Shame and Fear 119

3.3.1 Blame 119

3.3.2 Shame 122

3.3.3 Fear 123

3.3.4 Impact on Staff 125

3.4 Incivility and Bullying 128

3.4.1 Incivility 128

3.4.2 Impact of Incivility 130

3.4.3 Bullying 131

3.4.4 What Can We Do? 133

3.5 Just Culture 134

3.5.1 Just Culture 135

3.5.2 Clinical Negligence 139

3.5.3 Accountability and Responsibility 140

3.5.4 Who Gets to Draw the Line? 141

3.5.5 Restorative Just Culture 142

3.5.6 Who Was Hurt? 143

3.5.7 What Do They Need? 143

3.5.8 Whose Obligation Is It to Meet the Need? 144

3.5.9 Mersey Care Partnership 144

3.6 Part Three Summary 146

3.7 Part Three Actions 147

4 Care for the People that Care 151

4.1 Part Four Introduction 152

4.2 Positivity and Joy 154

4.2.1 Positive Emotions 154

4.2.2 Positive Stories 155

4.2.3 Joy 156

4.2.4 Positivity, Joy and Safety 162

4.3 Kindness and Empathy 163

4.3.1 Kindness 163

4.3.2 Lack of Kindness 165

4.3.3 What Can We Do Differently? 166

4.3.4 Compassion 167

4.3.5 Empathy 168

4.3.6 Listening 169

4.3.7 Kindness, Empathy and Safety 171

4.4 Appreciation and Gratitude 172

4.4.1 Appreciation 173

4.4.2 Gratitude 173

4.4.3 Appreciation and Gratitude 174

4.4.4 Appreciation, Gratitude and Safety 176

4.5 Learning from Excellence 177

4.5.1 What Is Learning from Excellence? 177

4.5.2 Positive Feedback 178

4.5.3 The Learning Part of Learning from Excellence 179

4.5.4 Other Appreciation Programmes 180

4.5.5 Learning from Excellence and Safety 180

4.6 Wellbeing 181

4.6.1 What Do We Mean by Wellbeing? 182

4.6.2 Why Is It Important? 182

4.6.3 Hunger 184

4.6.4 Fatigue 185

4.6.5 Relationships 189

4.6.6 Psychological Safety 191

4.6.7 Loneliness and Isolation 193

4.6.8 Wellbeing and the Impact on Safety 196

4.7 Part Four Summary 197

4.8 Part Four Actions 199

5 Plant Trees You Will Never See 203

5.1 Legacy 203

5.2 A Call for a Movement 207

5.2.1 Why Am I Talking about Social Movements? 207

5.2.1.1 Why a Social Movement for Safety? 209

5.2.1.2 What Can You Do? 211

5.3 Conclusion 212

References 217

Index 227