Chris Elston

Chris Elston, a patient safety education lead, shares his journey on how he learnt and used thematic analysis in his trust, which led to him designing a lesson for his colleagues and then wider teaching outside his organisation. For many years I have thought that we could make a bigger impact on patient safety if we could examine low harm events or near misses in greater detail. Historically, they have often been left to local areas to investigate and close them. With all the time pressures and demands on them, it is hardly surprising that many get a superficial look rather than an examination. Thematic analysis allows us to do a good delve into these areas and so I sought to complete two analyses: one on falls and the other on pressure ulcers. I thought that they lent themselves to this style of analysis. I mean how hard could it be, a week or two and the analysis would be done. Simple, isn’t it? Well, I can only say how wrong I was. The first analysis took about three months to complete, the second one, a little longer. At this point, I will be honest—despite the raft of available data sources, I only used the adverse event reports (AERs). I think it may have been longer if other data sources had been used. I was pleased with the result; it showed lots of useful information that could be shared with the steering groups and individual areas to help inform their practice. Soon after this, the Patient Safety Incident Response Framework (PSIRF) was introduced and the use of thematic analysis was one of the tools that PSIRF recommended. This meant that a greater understanding of thematic analysis was required. So, after a brief hiatus, I started to research a little more about thematic analysis and its application and found there was much more to thematic analysis than I had first realised. Designing a lesson I wanted to design a thematic analysis lesson for my trust. What did people need to know before they could use it? I was no expert and I needed to learn before I attempted to teach it, so what did I need to know? My initials thought were: How do you define thematic analysis? What types are there? When could it be used? What are the advantages and disadvantages of thematic analysis? Where can we get data from? How can we code/map the data into themes? So began a journey; what should have been a short journey but has taken a few twists along the way. I developed a 2-hour lesson with what I considered to be the essentials of thematic analysis. This was then delivered in my trust, which led to some changes in our processes. This meant that thematic analysis became much more of a featured learning response. Following this, I was then asked to assist one of our wards on a project and we started with a … thematic analysis. I never dreamed I would be doing something like this. Expanding the training After a year or so, I answered a question posed on NHS Futures about thematic analysis training. I replied that I had a lesson and was willing to meet and discuss with people. I did not expect the response that I got. People from all sorts of healthcare organisations, within the NHS and outside of it, wanted to discuss thematic analysis. I was shocked and stunned at the response. I have often said, if we do not collaborate then we will never drive patient safety forwards at a great enough pace to safeguard patients and staff. So I elected to share some of my teaching. My trust offered to host some meetings, we discussed the training I could provide and what I felt comfortable sharing. There was just over 100 people interested in attending the meetings. As the time got closer, I became increasingly nervous. The imposter syndrome hit hard—I was going to be found out as a fraud and not nearly as switched on as many appeared to think. Was this such a clever idea? Conclusion We are now about 6 weeks from the last meeting and I can breathe a sigh of relief. Everything went ahead in a positive manner. Feedback has been good, although I think I could have made better use of technology and that is a lesson learnt for the future. Many in healthcare are willing to make the necessary changes but they want support in this; coaching and mentoring will be critical to delivering PSIRF. This is just one step on that path (motorway, could be a better analogy!). The experience has shown how powerful collaboration is. Further reading on the hub: Patient Safety: Emerging Applications of Safety Science "The greatest part of this adventure has been the sharing of information." Conducting a systems review of pressure ulcers in the intensive care unit

On the 8 September 2023, following on from the success of the Patient Safety Management Network, the Patient Safety Education Network (PSEN) was created. The PSEN is a network for those in patient safety education and training. Chris Elston, Patient Safety Education Lead for University Hospital Southampton NHS Foundation Trust, reflects on the past year that has seen the Network grow to over 470 members. Wow, as a colleague of mine used to say “Tempus fugit.” Time flies, doesn’t it just. Can it really be one year that the Patient Safety Education Network (PSEN) has been meeting and supporting each other? All I can say is that it has given me a range of emotions: Fear—what if it falls flat on its face? What if nobody turns up? Please no technical issues! Apprehension— it's 2 minutes before the meeting starts and the person presenting has not logged in yet? What can I do to fill the gap? Confidence—everyone turns up and the meeting is ended with great feedback from the audience. Pride—proud to have listened to the team that set this Network up and proud to be currently leading it. Surprise—that there are so many people willing to share information, resources and experiences, and all wanting to improve the way healthcare keeps our patients safe. We had humble beginnings following someone on the FutureNHS platform asking if there was any way that Trusts could share learning. Several discussions later, we had decided as a group that we would set up a Patient Safety Education Network and use this Network to share lessons, teaching methods and subjects. Learn from each other to promote good quality teaching, share lessons learnt, findings from learning responses and provide some peer mentoring and support. So how have we done? Have we achieved our initial plans? As a former military man, there is a phrase that has stuck with me from those days: No plan survives first contact! There is nothing false about that statement. The greatest part of this adventure has been the sharing of information. At our monthly meetings we have shared a Patient Safety Incident Response Framework (PSIRF) journey, observations and walk through talk throughs (WTTT or WT3, depending on your choice of acronym), engagement, a falls project, culture, SEIPS and AcciMaps, Swarms, Initial Safety Reviews, how to share learning. (As a member of the Network, if you miss a meeting you can access all the notes and presentation slides from these meeting—you will need to be signed into the hub.) I am not sure we have managed to provide everything we set out to, for example, the mentoring aspect of the Network, although the proof will be asking the Network members if we have. We have shared some learning from incidents but not much. There is scope to increase this and maybe we should have a standing item in the meeting for sharing these lessons. But we need to ensure that we keep to the Network rules of ensuring it is a safe space for all to be able to share their thoughts, worries and concerns. However, I think if we dedicated 10 minutes for the sharing of findings then it could strengthen the Network. It will need discussion and a decision from the Network members, as this is not a one-man band. I'd love to hear your thoughts. Highlights from the past year So, what has been my highlight, apart from getting this up and running? I would say there are two. I am not too keen on being in the limelight and leading things. I can and do, but I much prefer being a team member and offering help, support and guidance. So doing this, and having you all come back time after time, is a highlight. The second may be a little unusual. At the beginning of the year, I presented a slide about mittens—the now notorious mittens case. Someone asked a question about what this would look like as an AcciMap or SEIPS. So why is this a highlight? Well, it made me think. I made up an AcciMap and a SEIPS, it provided a kick start to my teaching and persuaded me that a new workshop/lesson was required at work. From this Network, my SEIPS and AcciMap Master Classes were born. Looking forward Future topics for the PSEN include venous thromboembolism (VTE), a culture change workshop, and change management and staff support. I am always on the lookout for new topics and people to present. I find myself listening to presentations and wondering how it would land with you, the Network members. Looking at my own development, I have had to improve my skills. My time management is a little wayward at times and that causes me a lot of discomfort. Everybody’s time is precious and I need to get the communications out to everyone, early enough to make a difference. Here is my opportunity to apologise for the late communications, at times. Final thoughts In summary, this has been a busy 12 months, a year of firsts (many firsts) and we have just had our first PSMN/PSEN symposium where I got to meet many of you face to face. The work that we are doing to improve the safety in healthcare for patients and their families, with the same effort put into the wellbeing of the staff, is immense and gathering pace. I am glad to be part of it and proud to be involved. I feel that we can move mountains with the tenacity, passion and knowledge that we possess, but the key for me, is the mutual support we give each other. From the smallest of roots grows the strongest of trees. Friday 8 September 2023 saw the first meeting of the PSEN with 28 members attending and a Network membership of 52. Today we have a membership of 479 and the meeting on the 13 September 2024 had 65 Network members attend. There remains only one other thing to say: Thank you and here is to another 12 months! How to join the Patient Safety Education Network Do you work in patient safety? If you are interested in joining the Patient Safety Education Network, you can join by signing up to the hub today. If you are already a member of the hub, please email [email protected]. You can also find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. These networks now include: Patient Safety Management Network – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members from more than 650 different organisations Patient Safety Partners Network – a group for Patient Safety Partners, paid and voluntary roles within NHS organisations aimed at improving patient safety. National NatSSIPs Network – a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Patient Safety Paediatric Leaders Network – an invited network for anyone who is a strategic-level decision maker in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality in the UK. VTE Specialists Network. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Application of SEIPS and AcciMap to a patient safety incident Is the NHS ready for PSIRF? A blog by Chris Elston “We’ve created an incredible pool of talented safety people who are up for collaboration.” Marking three years of the Patient Safety Management Network The voice of the patient safety frontline—An introduction to the Patient Safety Partners Network Patient Safety: Emerging Applications of Safety Science

We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF).  In my opinion, PSIRF is one of the biggest changes in patient safety that we have seen in healthcare since the NHS was introduced in Britain. The historical position has been that the last person to touch a patient or the last process that the patient underwent was the cause of the patient safety incident. The learning has often been focussed on the person: telling them to be more careful, referring them to policies and guidelines. Occasionally, there will be an attempt to make the system safer, but often this is an introduction of a checklist or some statutory training. The problem with these approaches is that only one person changes their practice and, in several months, that person may have rotated to a new placement or secured a new role, meaning that the learning from the incident disappears with them! So PSIRF has introduced systems thinking to the NHS. This is where several different factors are examined for their influence on the way that people work: more commonly referred to as ergonomics or human factors. Every day at work we all make a series of transactions, probably more so in healthcare. We have many different priorities and can flip from a routine situation to an emergency in the space of a few seconds, and back again. There are many different activities that need to be co-ordinated from so many different teams and there are pressures we face daily, not least the well reported industrial actions, poor staffing levels, the recruitment/retention issues and the working conditions. So why would I think that Trusts and the wider NHS in England are not ready for PSIRF? We are now being instructed by NHS England to look at the wider context of any patient safety incident. This means looking at the system that we work in. Basically, the NHS is beginning to modernise its approach to patient safety. It has seen the progress that has been made in other industries and has found itself stagnating at the same time as seeing so many scandals enter the press and the public’s thoughts. Many of the scandals repeat similar themes. This shows that the NHS does not learn lessons but repeats the historical mistakes and errors. So what does looking at he wider context actually mean? A framework has been suggested to Trusts to use, this is the Safety Engineering Initiative for Patient Safety (SEIPS). This is a framework to give areas of interaction that should be looked at. It places the person at the centre of the work system but then shows how various other entities interact with the person. All of which then impacts on the processes and subsequently the outcomes. What this does is show that the often reported 'blame culture' of the NHS does not understand the complexity of the system. In fact, using SEIPS would suggest that most patient safety incidents are a culmination of factors and events that end with an outcome, either favourable or not. This means that the executive boards are going to have to pay attention to what is being said in the patient safety incident investigations, and in the learning responses from those patient safety incidents that don’t meet the criteria of a patient safety incident investigation. For instance, if we look at a drug error, how many times have people asked what is the experience level on the ward? Is the patient being looked after on a specialist ward with staff who have experience in this area or are they an outlier from a specialist ward to a different specialism–for example, a gastro patient on a vascular ward? A series of transactions Another factor that needs to be considered is that the work healthcare professionals do is subject to a series of transactions. The individual practitioner must weigh up many different, often competing priorities to achieve their workload. For example, in the emergency department does the observations of a patient that has been in the department for several hours get completed or does the incoming admission from the ambulance service take priority? One has a measurable target (15 minutes to turn the ambulance around), the other doesn’t. This is a good example of internal and external factors influencing decision making. We can even take the view further afield and look at the interfaces between the GP practice and the specialist service of the acute Trust. This could lead to factors outside the control of the Trust contributing, such as the expectation that GPs will follow up emergency department attendances with regular bloods but receive discharge summaries too late for the follow up, or how the GP is waiting for extended periods on the phone to make a referral which has an impact on their remaining workload. These processes happen hundreds of times in a shift and often there is no spare staff to do the other process; for instance, in the above example, the observations of the patient that had been in the department for several hours. So the admission is completed and then a patient develops chest pain and needs an ECG, again, the observations are delayed and there is no spare staff to assist. This is not an unexpected event but entirely predictable but staffing levels do not allow for this. What is the role of the executive board? So if we are identifying those factors that need to be addressed in the examples above – lack of experience, lack of knowledge, outliers, staffing levels – what does the executive board do? The solutions and ability to mitigate the risks are not wholly within their ability to give. So where does the message go? To the Integrated Care Board (ICB), NHS England or to the Department of Health and Social Care (DHSC)? How can that message be passed up to those higher echelons? There does not seem to be a channel for those communications. For those events that do not meet the threshold for a patient safety incident investigation and require a local learning response, how is that to be achieved? We are asking those over-worked, under-staffed clinical areas to release a member of staff (often someone senior) to complete the local learning response. Although there are new tools available to use, many of which will streamline the process of the investigation and mean it is quicker and easier to identify the lessons and frailties in the system, is this an example of another transaction as described above? Does the clinical area release a senior member of staff to complete the learning response and pay bank or agency staff to cover, or do they postpone the learning response? Which often leads to superficial investigation and nothing being learnt or changed – an often cited reason why people do not report patient safety incidents. The Sword of Damocles hangs over our heads every day! I wonder how many executive bodies are prepared to feedback to NHS England and DHSC that the current mandate to operate at greater than 100% and to reduce a backlog on the waiting list is possibly contributing to the safety incidents, alongside fatigue and the repetitive nature of tasks? Or the lack of beds as we maintain greater than 100% occupancy every day but are expected to maintain a resilience to a major incident, or the increased pressure often attributed to winter but experienced all year round now. The positives So this blog seems quite negative but there are some positives to this. Although I don’t think the NHS is mature enough at the moment to adopt PSIRF, there are too many documented cases of risk being identified and not actioned. There is a groundswell of opinion that something needs to change. We know that there is a retention and recruitment issue and in my opinion PSIRF gives us an opportunity to address this. I think morale would be improved if the workforce feel that their opinion is valued and acted upon – this is very much an avenue that PSIRF can improve. The need to understand the normal and the excellent to influence every day, means that staff can be involved to improve their own areas. Staff will be engaged and proud to tell people where they work, students will have a great placement with motivated and energetic staff, leading them to apply for jobs. The use of an appreciative style inquiry could lead to unobserved opportunities to be suggested to managers and senior staff. This in turn can lead to greater collaboration between wards, teams, care groups, divisions, Trusts and regions. This could lead to a rapid transfer of ideas across the country. Ultimately, if we can change the mindset and the culture to one of honesty, transparency and looking for what the data is telling us, then our patients will receive safer and possibly more effective care. A win-win for everyone. The words of President James Garfield seem particularly apt for healthcare at the moment: “Most human organizations that fall short of their goals do not do so because of stupidity or faulty doctrines, but because of internal decay and rigidification. They grow stiff in the joints. They get in a rut. They go to seed.” President James Garfield. I take this phrase to mean that we need to keep trying new, innovating things and, using a military phrase, 'remain rigidly flexible' to adapt, improvise and overcome all the challenges that we face. I am committed to striving for improved patient safety by understanding the work that we currently do and looking at how the different entities of the system interact. Although I am sure PSIRF is a step in the right direction, I do not think it is the complete journey. This will be a long process, introducing new tools and, more importantly, changing the mindset and the culture of a huge behemoth of an industry. Let's do this! Patient Safety Education Network Chris chairs the Patient Safety Education Network. The network is open to those who teach any element of patient safety or provide learning from patient safety incidents. The network is hosted on the hub. You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Education Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Read Chris's blog about the Patient Safety Education Network here.

Chris Elston, Patient Safety Education Lead for University Hospital Southampton NHS Foundation Trust, introduces a new network that is being set up for colleagues in similar roles.  Just over a year ago I found a job that seemed to be written for me. The job title was Patient Safety Education Lead. It combined teaching and human factors to improve safety – two big passions that I have. It was at the same time that the Patient Safety Incident Response Framework (PSIRF) was due to launch. What an opportunity, I had to go for it, and here I am 15 months later and I have some thoughts and concerns. At the many meetings that I attend I always seem to be the only person who has a sole responsibility for teaching the many different parts of patient safety. There are Patient Safety Specialists, Patient Safety Officers, Patient Safety Leads, some even have quality added to their job titles, but I have only met one other Patient Safety Educator. The question then gets asked, am I doing the job correctly? Where can I get peer support from? Don’t get me wrong the team I work in are amazing, but they are not full-time educators, and I am teaching them at times. They may not be the best source of support, all the time. I then saw a post from a Patient Safety Learning Coordinator (another job title), and although they have a slightly different role than me, there was discussion about a network of educators. This network could provide support to others in similar roles, share resources and possibly even become a voice to influence. I asked to be part of it. Little did I know what was round the corner… Here we are a few weeks later, and the seeds have been planted and the roots of a network are starting to grow. We are basing this network on the Patient Safety Management Network and will follow the principles that have been so successful for that network: no agenda no action log an informal setting no hierarchy cameras on no recordings drop in, drop out a summary note on a dedicated hub page for those that cannot attend Aims of the Network To support patient safety education roles. To support patient safety learning roles (learning from incidents). To offer peer support to patient safety educators. To share experience within the Patient Safety Education Network. To collaborate on new projects and ideas that enhance the learning from incidents and teaching of healthcare staff. To provide a pool of shared resources within the network. To create a community of patient safety educators who may influence policy. Membership The network is open to those who teach any element of patient safety or provide learning from patient safety incidents. The network will be hosted on the Patient Safety Learning hub. You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Education Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Commitment We propose to have a monthly meeting on the second Friday of the month. This will last an hour and be shaped by the members. There is no commitment required from members. You can sit in the background and watch/listen, you can participate in the group chat, you can present a topic of your choosing, (if you want to), you can join the meeting when able, you can leave when you need. We are aware that everybody has busy lives both in work and outside of work, so drop in and drop out, skip a meeting or join every meeting, it is your choice and we look forward to meeting you all. Final thoughts We are keen to have membership that is truly representative of the healthcare systems in the UK. Those that work in the community, primary and secondary care, mental health, learning disabilities, independent sector and higher education institutes are all welcome. So, if you are involved in education in any part of the patient safety process and if you want a friendly space to meet and share ideas, get support or even mentoring then this is the place for you.