Overview

1. Potential and limitations of a social science perspective ‘in or on’ patient safety researchSDHI Conference, St Andrews, Scotland Jane Sandall, Simon Turner, Naonori Kodate, Bryan McIntosh and Nicola Mackintosh, King’s Patient Safety and Service Quality Research Centre 27 June 2011

2. Overview The problem of the implementation gap What next after understanding and explanation? What is the role of the social scientist in implementation science? Risks and benefits of engaging social scientists in patient safety research

3. Governing medication safety and professional communities SDHI Conference, St Andrews, Scotland Simon Turner, Angus Ramsay, Naomi Fulop 27 June 2011

4. Background • Over the past decade, the systems approach has become the orthodoxy in managing safety: • Shifts attention from individual to organisational causes of errors inc. governance mechanisms • Improve learning by replacing ‘blame culture’ with ‘safety culture’ • Criticised for neglecting social processes e.g. distributing agency away from professional communities to systems

5. UK context • In the English NHS, the systems approach fits into a broader regime of regulating provider organisations: • NHS boards are responsible for implementing local systems for improving safety • However, these systems are guided by central priorities and externally regulated (e.g. CQC’s annual health check) • This top-down, often target driven approach means that frontline professional communities have been neglected

6. Medication safety in the English NHS • ‘Medication errors occur when human and system factors interact with the complex process of prescribing, dispensing and administering drugs to produce an unintended and potentially harmful outcome’ (DH, 2004). • 9% of hospital inpatients experience harm due to medication errors (Kohn et al, 2001) • Additional days spent in hospital due to harm cost the NHS £500 million/year (Audit Commission, 2001)

7. Medication safety and NHS boards • Encourage staff to participate in local and national (NRLS) incident reporting systems; • Embed an open culture of learning e.g. conduct executive ‘walkabouts’ to raise awareness; • Design or modify systems to help prevent errors e.g. introducing quality committees and standardising clinical processes; • Comply with external priorities and regulatory regimes (e.g. NPSA alerts and CQC standards).

8. The implementation gap • DH has taken a top-down, often target driven, approach to medication safety • Critics point towards the continued salience of bottom-up learning, tacit knowledge, and need for professional autonomy and self-regulation • This dualism, based on formal governance processes on the one hand, and the ‘informal’ governance processes of frontline clinicians on the other, impedes the implementation of solutions

9. Professional communities • CoPs are important sites of learning that underpin the delivery of care. However: • CoPs have different social norms and expectations of safety (e.g. due to academic training and socialisation) • CoPs include ‘informal’ hierarchies e.g. juniors may defer to seniors and nurses may not challenge doctors • CoPs respond differently to formal governance processes e.g. attitude towards using protocols vs tacit knowledge • CoPs are influenced by organisational resources (‘internal’ cultures can be stronger where services are under-resourced)

10. Exploring the relations between governance and communities • Understanding that professional communities have different sociologies of safety can aid the design of governance interventions • Equally, recognising the downside of professional communities implies a need for interventions to improve safety (inc. ‘club cultures’ identified by Bristol Inquiry) • For example, low reporting among doctors may not only be due to fear of ‘blame’ or other cultural barriers but perceived weaknesses in the reporting system

11. Thank you! For further information, please contact us: NIHR King’s Patient Safety and Service Quality Research Centre - Governance Programme Simon.turner@kcl.ac.uk Naomi.fulop@kcl.ac.uk

12. Using Incident Data to Improve SafetySDHI Conference, St Andrews, Scotland Dr Nao Kodate & Dr Janet Anderson King’s Patient Safety and Service Quality Research Centre 27 June 2011

13. Background • Reporting of incidents and near misses seen as crucial means of improving patient safety • Literature emphasises • Design of incident reporting systems (Braithwaite et al. 2008) • Classification of incidents (Giles et al. 2006) • Staff willingness to report and culture surrounding reporting (Schectman et al. 2006; Waring 2007) • Little research on how incident data are used to address weaknesses in processes and make care safer

14. Aims of the study Using a multi level system approach, identify how incident data are used at two trusts (acute care and mental health) • How are responsibilities for reviewing incident data organised? • How are incident data reviewed and analysed? • What are staff perceptions of the effectiveness of incident reporting?

15. Observation of risk meetings - method • Semi-structured observation – items developed by scoping study of several incident review meetings at both trusts • Observation period – September, 2009 – April, 2010 • 28 meetings observed

16. Observation of risk meetings - results • Hospital wide meetings • Strong leadership on safety • Robust debate • Accountability • Cross departmental co-ordination • Team meetings • Lack of organisation, resources, training, clear remit • Large number of incidents to review • Tolerance of recurring incidents • Problems that require co-ordination across departments are difficult to address

17. Interviews - method • Semi structured interviews • Dissemination of safety information to staff • Sources of learning about safety – sharing across org • Perception of effectiveness of incident reporting • Perception of corrective actions • Impact of incident reporting on care/practice • Sampling – purposive, snowball • Thematic analysis

18. Interview results – positive impact on care • Changes to practice – hospital wide, cross departmental, team, individual • Changes to attitudes and awareness • Individual – vigilance and awareness of risks • Team – reinforce good practice, reinforce openness and team culture, better understanding of risk • Assists management • Goal setting to reduce problems • Reinforcing good practice • Increase in resources

19. Interview results – challenges (examples) • Resources – especially in the mental health trust “…it's an extra thing. So they've no actual timetable time to be free to do that… I suppose if you have somebody who clinically had time set aside to do that kind of thing it might be a bit easier but it's an organisational headache.” (Consultant, MH) • Input of expert knowledge in the process “Investigation can actually bypass me, which I think is a bit odd. We had a death of a child … and I wasn’t involved in that investigation at all. It was done at a higher level and then presented to the Trust meeting.” (Consultant, AC). • Balance between blame and feeling responsible “I know that the people who write SUIs work very hard not to blame and not to use names and not to … but if you are involved I know from mine that you do feel very much responsible for something that has happened and you do question, hopefully most people would question their own practice anyway throughout that.” (Team Leader, MH)

20. Interview results – room for improvements

21. Conclusions (1) • Overall, staff view I.R. systems positively (more so in acute than in mental health trust). • In mental health trust, less embedded as a learning tool, and focuses on SUI investigations. • Staff use I.R. not only as an instrument for making changes and fixing problems, but also as a tool for raising awareness and changing attitudes

22. Conclusions (2) • Learning is inhibited by the large number of incidents, the complexity of the organisation and processes of handling incident data, lack of input from clinical staff and external pressures for accountability. • Time to shift the focus of discussions from using incident data as an indicator of safety to how to make it more effective as a learning tool?

23. Thank you! For further information, please contact us: NIHR King’s Patient Safety and Service Quality Research Centre - Risk Programme janet.anderson@kcl.ac.uk naonori.kodate@kcl.ac.uk

24. Lean Healthcare fad or panacea?SDHI CONFERENCE, ST ANDREWS, SCOTLAND Dr Bryan McIntosh and Professor David Guest 27 June 2011

25. Lean involves • “creating a culture of value and eliminating waste in order to maximize quality of service.” • “…determining the value of any given process by distinguishing value-added steps from non-value-added steps and eliminating waste so that ultimately every step adds value to the process”. (Institute for Healthcare Improvement 2005: 2)

26. NHS England The NHS has prepared five principles that should guide Lean: • Lean philosophy as the foundation. • Level out workloads - match demand with capacity.. • Grow lean leaders and managers. Necessary to sustain the gains off the implementation. • Lean thrives when there is strong leadership support. • Get quality right the first time. Plan customer value into your process.Standardise tasks. No rigidity just lean- removing non-value adding steps in the process.

27. Lean Literature (1) Extensively and apparently successfully applied in industry, especially motor industry: • Lean is used in reference to Lean principles, concepts and notions of Leanness do not necessarily refer to the five principles of Lean Thinking. • There is still relativity little evidence of the complete Lean philosophy being applied within the health sector. within the current literature there appears no over whelming support towards either accepting or rejecting lean as a concept that can be applied to the health sector. However, while Lean concepts, tools and techniques have been applied it has only ever be 'piece meal' due to the need of service processes being able to cope with variety and uncertainty.

28. Lean Literature (2) • The writings related to the prerequisites of Lean implementation can be considered in two ways - one related to the organisation and one to the improvement activity. • The barriers to implementation and adoption include; culture; lack of focus; excessive procedures; people working in silos; too many targets; lack of awareness of strategic direction; staff are overworked; lack of understanding of the effect of variation.

29. PSSQ policy The Crisis Resolution and Home Treatment Teams (CRHTTs) consisted of a group of professionals including support workers, community psychiatric nurses, social workers, psychiatrists and managers. The teams aim was to provide comprehensive and timely crisis resolution and home treatment for individuals presenting in the acute phase of mental illness. The change merged the three CRHTTs into one borough-wide CRHTT service.

30. Aims of Change • Improved efficiency (e.g. through better coordination and sharing of best practice). • Improved clinical input and multi-disciplinary skill mix (e.g. through improved team composition). • Operational sustainability and flexibility (e.g. as more able to handle capacity fluctuations).

31. The impact of change • Data suggest reduced average Length of stay since teams amalgamated. • Significant reduction in accepted referrals of patients with schizophrenia and a reduction in percentage of male patients accepted post merger. • Reduction in total number of accepted referrals since merger reflecting capacity of a smaller team.

32. Drivers - Economic factors • “It’s regrettable but being involved in the NHS nowadays is as much about balancing budgets as it ever was about professional standards of quality or safety.” Practitioner ‘B’. • “As a manager I must ensure a cost-effective, quality service; my job isn’t about social justice as laudable as that would be. Sadly and unfairly this means people are priced out of the market. All change at one level or another is all down to economics”. Practitioner ‘C’.

33. Conclusions On this limited research: The study reinforces the economic/cost-cutting aims rather than the quality aims. However, the preliminary data looks as if there is change in a positive direction.

34. Thank you! For further information, please contact us: NIHR King’s Patient Safety and Service Quality Research Centre - Workforce Programme Bryan.mcintosh@kcl.ac.uk David.guest@kcl.ac.uk

35. Structuring And Mediating Boundaries Within The Acutely Ill Pathway: Implications For Patient SafetySDHI Conference, St Andrews, Scotland Nicola Mackintosh, Jane Sandall 27th June 2011

36. Patient safety policy focus on ‘Failure to rescue’ Widespread evidence of ‘failure to rescue’ i.e. failure not only to recognise warning signs, but to interpret and institute timely clinical management once deterioration in a patient’s condition is identified (NCEPOD 2005, NPSA 2007). Junior staff report difficulties mobilising appropriate responses, limited by professional and occupational hierarchies. Introduction of numerous strategies in patient safety programmes e.g. early warning scores, intelligent assessment tools, emergency response teams, track and trigger systems – paucity of evidence of effectiveness. Structured communication tools (e.g. SBAR) suggested as a solution – designed to provide nurses or midwives with the license to demand a review from the medical team.

37. Research - Aim & Design • Aim: To investigate how certain safety strategies and tools are adopted into the workplace and explore their impact on the context of work • Two year project; 2 stage approach – medicine then maternity • Two acute medical wards in 2 inner city acute hospital providers • Period of 10 months between February and December 2009 • > 150 hrs observation of unfolding “work drama” of 2 wards (Hughes 1971), including days, night shifts and weekend duty, shadowing of medical staff • Interviews with staff (37) including doctors, nurses, managers, health care assistants • Attendance at meetings, document review

38. Safety Tools used

39. Intelligent Assessment Tools – the rationale facilitates appropriate graded medical response based on the severity of the condition of the patient. Alerts preset and linked to a central surveillance system; designing out variability in practitioners’ responses to the information

40. IAT – the process

41. ‘Managing Complications in Maternity & Acute Medicine’ – the SBAR safety solution

42. Findings Tools promoted uniformity, formalised understandings, provided a mandate for escalation of care by junior staff ‘Once you tell the nurse, ‘‘This patient is scoring 4, 5,’ then they jump to hear that score, they literally just jump’(HCA) Importance of wider social context of health care Explicit e.g. leadership, training, regulation & audit Implicit e.g. compartmentalisation of medical work, temporal-spatial ordering of ward care, boundaries between specialties

43. Findings Tools marginalised other indicators, harder for staff to escalate without ‘objective evidence’ of the score / protocol ‘if you’re handing over [using] the phone in the middle of the night [to] someone you’ve never met before … they don’t know your judgement and your experience … [the EWS] does help in that respect. But when it’s low but [the patient’s] not quite right it’s harder to get things. [The doctors] say, ‘Well they’re only scoring 2’(Staff Nurse) Tools formalised escalation processes across certain boundaries – others remained largely hidden “When we weren’t so clued up on making referrals there were some really horrible ones, like people would just shout at you, tell you they were busy. But now when you make a referral you have to have every possible bit of information” (Junior Dr)

44. Deterioration In patient’s condition Identify deterioration Referral Review Observation Response Treatment Rescue EWS IAT EWS Escalation protocol IAT EWS Escalation protocol IAT SBAR RRS Safety Solutions Treatment guidelines RRS EWS - Early warning score IAT - Intelligent assessment tool SBAR - Communication tool RRS - Rapid response system Focusing beyond Gaps in knowledge Focus of Audit

45. Role of tools within wider meso systems • Tools socially situated and embedded in relation to other practices, groups, professionals, and patients’ • Cultural scripts shaped new social orders – role of IAT in ward routines, prioritisation of codified knowledge • Opened up surveillance of certain practices previously hidden from scrutiny – but ‘selective’ blame • Tools offered opportunity for boundary work; enabling lower level staff to gain authority and ‘symbolic capital’ (Gieryn 1999, Bourdieu 1998) • Colonisation - potential for staff to become controlled by the very tools introduced to facilitate working routines (Bourdieu 1977)

46. Conclusion Focus sights on management of the original problem rather than management of the problematic solution (Tsoukas 1997) I think we need another safety tool here!

47. Thank you! For further information, please contact us: NIHR King’s Patient Safety and Service Quality Research Centre - Innovations Programme Nicola.macintosh@kcl.ac.uk Jane.sandall@kcl.ac.uk