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Jon Holt

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  • First name
    Jonathan
  • Last name
    Holt
  • Country
    United Kingdom

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  • About me
    Patient Safety Manager at Birmingham and Solihull CCG who wants to connect with CCG colleagues in similar roles and share tools, resources, information etc.
  • Organisation
    Birmingham and Solihull CCG
  • Role
    Patient Safety Manager

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  1. Content Article
    Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff. Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS. Work-as-imagined This represents our imagination of others’ work and "is a gross simplification, is incomplete, and is also fundamentally incorrect in various ways, depending partly on the differences in work and context between the imaginer and the imagined." In the context of the NHS we could think about how the delivery of frontline clinical services is imagined by those not directly involved in delivering care, for example; senior managers, commissioners, regulators, patients and the public. This inaccurate mental model invariably informs decisions which impact upon frontline services such as decisions regarding how services will be delivered, funded, regulated, overseen and monitored. Work-as-prescribed This represent the rules, regulations, policies, procedures, checklists, job descriptions etc. which describe the 'correct' way to work. In the NHS context we could envisage this by way of Care Quality Commission regulations, organisational policies and procedures, clinical guidelines, NICE guidance etc. The fundamental limitation of work-as-prescribed is: "It is usually impossible to prescribe all aspects of human work, even work that is well-understood, except for extremely simple tasks". Moreover, "Assumed system conditions - staffing levels, competency, equipment, procedures, time - are often somewhat more optimal than those found in practice". In essence, work is invariably more messy and complex than assumed by rules, regulations and procedures that outline best practice. Anyone who has had experience of developing and implementing standard operating procedures will know that how things are supposed to be done as per the procedure and how they are done in reality often diverge. I think this also helps partly explain why so-called 'Never Events' happen at a regular frequency – the assumption that implementing national guidance based on work-as-prescribed will eliminate the risk of their occurrence is faulty. There are many error provoking conditions in the workplace that cannot easily be eradicated. Work-as-disclosed This is an intuitive concept, it represents what those doing the work are prepared to disclose to others about how they do their work. Inevitably this is limited and partially based on "what we want and are prepared to say in light of what is expected and imagined consequences". We can think about this in the context of the NHS as to how staff may relay their activities to senior managers, regulators, commissioners, patient groups etc. The message is tailored to the audience and when it comes to being scrutinised by others we will inevitably say what we think will paint us in the best possible light. Work-as-done This represents the reality of how day-to-day work is actually done as compared to all of the above. Inevitably there are shortcuts, variations, deviations based on reality of working conditions, expectations and demands of others. The key insight here is that work-as-done is actually quite hard to understand: even where there is observation this can change behaviour and there may be technical and practical limitations to our understanding when work being done is complex or unsafe to observe. Shorrock includes a very interesting quote from Hollnagel in his article as to how we account for differences between work-as-done and work-as-imagined or work-as-prescribed, we typically do this: "by inferring that what people actually did was wrong – an error, a failure, a mistake – hence that what we thought they should have done was right. We rarely consider that it is our imagination, or idea about work-as-imagined, that is wrong and that work-as-done in some basic sense is right.” This is an important consideration to bear in mind when it comes to the investigation of patient safety incidents in the NHS, it is commonplace for fault to be found in the aberrant behaviour of staff who did not adhere to policy or procedure. A more meaningful insight into what has happened would be derived from understanding why this happened and what conditions led this to occur. Were the policies and procedures themselves based on a limited understanding of work-as-done and the real-life working conditions which staff are faced with? In relation to all of the above, it is important to understand that there can be a disconnect between all of these varieties of human work and that when it comes to decision-making and activities which can impact upon how services are delivered and overseen we need to be humble and recognise the limitations of our knowledge. In practical terms, what might these mean for those who work in roles which are detached from the work-as-done of frontline staff? Some suggested considerations are below: Recognise that assurance visits, observation and discussions with staff only give a partial and limited picture: firstly, observation changes behaviour and work-as-disclosed to those outside an organisation may vary considerably from the reality of work-as-done. Be aware that any prescriptive requirements regarding how work is to be done may have unintended consequences or create perverse incentives. There needs to be the involvement and engagement of those who are directly involved in delivering frontline services and/or those who can articulate on their behalf when it comes to prescribing how work is to be done. It isn't possible to develop all-encompassing prescriptive requirements of how work is to be done which are realistic and achievable. Where a prescriptive top-down approach is taken, based on a ill-informed view of how frontline services are being delivered, the results will not be good so a collaborative approach is needed. When it comes to the investigation of patient safety incidents, acknowledge that adherence to policy and protocol is driven by a variety of complex factors. An effective investigation needs to understand why policies and procedures have not been followed from a human factors and systems perspective including consideration that the policies and procedures themselves may be inherently flawed. In summary, we need to be humble and recognise the limitations of our knowledge and work in partnership with others in a collaborative way rather than trying to instil or enforce change via a limited mental mode of how work is done.
  2. Content Article Comment
    @HelenH the network of patient safety managers is essentially already happening via the creation of patient safety specialists, they will be the key group to take initiatives from the national strategy forward. so it's essential they have the right training, support, networks and opportunities to take things forward. time will tell but think it is a positive step
  3. Content Article Comment
    @Jerome P I think the national strategy and new framework can help here - they certainly have the right ambitions. Trusts need to build more expertise and knowledge in human factors, systems thinking, quality improvement, safety science etc which can be applied to lead to more effective investigations which identify the genuine root causes and appropriate solutions. Ultimately though to achieve the kind of change required it will require sustained support and focus including from national and regional teams to continue to drive this agenda
  4. Content Article Comment
    @Clive Flashman this doesn't surprise me. ultimately, it is down to providers and commissioners what contractual requirements they locally identify. I think in this instance the provider really needs to be more assertive when it comes to negotiating this to identify that this is something which isn't helpful. Equally some of the behaviours of CCG's when it comes to what they measure and the requirements they place on providers can be unhelpful and counterproductive even if well intentioned. This is where the new framework is intended to help - the idea is that where the underlying causes of an issue are the same there should not be a requirement to investigate each incident individually with more of a focus being placed instead on implementation of quality improvement plans. I can certainly see the benefit of an approach where not every single category 3 or 4 pressure ulcer is investigated via an in-depth RCA but alternative forms of review are used instead and the focus is on addressing underlying common themes. The devil will be in the detail though when it comes to implementation though but the apsiration is the right one in my view
  5. Content Article Comment
    @Jerome P in my experience most trusts do have mechanisms in place for tracking actions and do endeavour to see things through but things can also fall by the wayside where there are other competing pressures and priorities and the immediate time pressure to complete the RCA has subsided. However, I think the bigger problem is that the recommendations and actions generated from the RCA are often not addressing genuine root causes and are not system focused. They can be supeficial or ineffective actions focused on individuals and developing and revising policies etc. This is because investigations often stop at the point of identifying what went wrong and how rather than focusing on the working conditions, environment, team dynamics, culture and other human factors / systems factors which need to be explored to identify why things went wrong and generate meaningful solutions.
  6. Community Post
    @Mary-Jo Patterson a contact from NHSE&I has advised me that they are looking at some kind of event up in new year to share learning from early adopters although nothing has been communicated formally yet so don't think this is set in stone. It may be worth putting the feelers out with any contacts you have at NHSE&I whether anything is being planned in your region too
  7. Community Post
    Hi Helen My understanding of the guidance is that in-depth investigations will be limited to incidents of greatest severity and potential for learning. To support this organisations will have to develop an investigation strategy which defines what they would prioritise for investigation which links to national priorities too. There will be scope for organisations to investigate incident types that aren't in their priority list but idea is they focus on areas of highest risk. So, in reality the most severe forms of incident would still trigger an in-depth investigation. For less severe / lower priority incidents alternative forms of investigation or review could be used, especially where there is a quality improvement programme linked to that area of work. So, for example, if a trust has a comprehensive improvement programme related to reducing occurrence of pressure ulcers and previous investigations have shown similar causes which they are focusing on addressing then the idea would be to spend more time on improvement than investigating to find same causes. I think the idea is that trusts do too many investigations of poor quality with a RCA conveyor belt approach and their should be fewer high quality investigations undertaken by staff with specialist skills. In terms of patient and family engagement there is a stronger focus on that in new framework. It is also intended to facilitate better cross system investigation too by CCGs and NHSE&I playing a coordinating role. There certainly is an industry of Serious Incidents at the moment and this is intended to move away from that. I think there is potential for this not to deliver everything it is aiming for but the status quo isn't really delivering so I welcome the new framework. I think the key will be effective implementation and support / coordination and willingness to adapt and refine the framework based on assessment of how it is working in practice
  8. Community Post
    What are the unintended consequences and risks of failure that you foresee? I think it's positive that they are piloting this and intend to make changes based on experiences from the early adopters. My main concern is that in order to drive up quality of investigations you need to professionalise investigation and have much more rigorous training. Can organisations currently churning out poor quality investigations make a step change to something much better? Will there be a national commitment to support that? A national patient safety syllabus, patient safety specialists and accredited list of trainers all seem steps in the right direction. However I think real improvement would need sustained support and focus and some national / regional coordination. If trusts are left to get on with it you'll end up with same mixed bag we have now
  9. Community Post
    Yes, Trusts and CCGs have been written to asking them to identify their patient safety specialists by November 2020 with intention that those identified will be working full time in the role by April 2021.
  10. Community Post
    I know that trusts and CCGs have been contacted regard identifying patient safety specialists. Once these are established there will be nationally supported networks set up. I would guess patient safety specialists will have a role in supporting effective implementation of PSIRF
  11. Community Post
    Early adopters are identified on the national website here and I've copied below: https://www.england.nhs.uk/patient-safety/incident-response-framework/ If anyone has contact details for any of them and are happy to share (not via a public post) it would be really appreciated List of early adopters We are working with groups of organisations in each NHS region as early adopters, together with one organisation that works nationally. Listed by region, the early adopter organisations are: East Norfolk and Suffolk NHS Foundation Trust East Suffolk and North Essex NHS Foundation Trust Essex Partnership University Foundation Trust West Suffolk NHS Foundation Trust NHS Suffolk and North East Essex CCG/ICS London London Ambulance Service NHS Trust North West London Collaboration of CCGs Midlands Chesterfield Royal Hospital NHS Foundation Trust Derbyshire Community Health Services NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust Derbyshire Health United University Hospital Derby and Burton NHS Foundation Trust NHS Derby and Derbyshire CCG/STP National Care UK (Independent provider of healthcare in prisons) North East and Yorkshire Leeds Teaching Hospitals NHS Trust NHS Leeds CCG North West East Lancashire Hospitals NHS Trust NHS East Lancashire CCG South East Isle of Wight NHS Trust NHS Isle of Wight CCG South West Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust NHS Kernow CCG
  12. Community Post
    The introductory version has been published today here with guidance below: https://improvement.nhs.uk/resources/patient-safety-incident-response-framework/ "Introductory version of the PSIRF While we are not asking organisations other than the early adopters to transition to the PSIRF yet, we want to help providers outside of the early adopter areas to plan for this change. We have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021. Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework."
  13. Community Post
    Hi A national consultation on the patient safety specialist role has now opened until 12th March 2020. You can view the patient safety specialist role draft requirements document and access the online survey to feedback here: https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-specialists/ NHS organisations have until June 2020 to identify who their patient safety specialist will be
  14. Community Post
    Hi The 500 character limit is excessively restrictive in my opinion for something which is supposed to be a key driver for achieving a step change in patient safety across the NHS. There is the facility to send comments via e-mail which I have done instead. I've reproduced my feedback below in case it is of interest to others. Overall, I think what is there is good but it seems to be missing some key elements in terms of supporting the kind of changes described in the national patient safety strategy: "Positive aspects: - The syllabus focuses on the role of organisational culture and its impact on patient safety - The inclusion of hierarchy of control when thinking about interventions to make services safer - It refers to proactive risk management rather than simply reacting when things have gone wrong, however, this element needs to be strengthened (see below) - There is a strong focus on systems, human factors and just culture when investigating incidents in order to promote learning and move away from a blame culture. Areas for development: - The syllabus does not mention Safety II or associated key concepts such as difference between work as imagined and work as done - The syllabus builds on and reinforces what we already have in place within the NHS rather than setting out a step change - It needs to describe more of how we would learn from things which go well (learning from excellence) and day to day work rather than focusing simply on accidents and incidents where things have gone wrong, i.e. via utilising techniques from Safety II. - No mention of appreciative enquiry, quality improvement methodology or other methodologies which could be used to deliver improvements which can enhance safety of services. This would be an important part of a proactive focus when it comes to safety Overall I think Safety II and quality improvement are key elements for inclusion in a patient safety syllabus and should be included to reinforce the direction of travel set out in national patient safety strategy"
  15. Community Post
    The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey
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