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In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares with the hub what appreciative clinical auditing could look like in health and care I recently hosted a 'learn at lunch' with the amazing Clinical Audit Support Centre to broach the subject of what appreciative clinical audit could look like in health and care. Although I had arrived with some preconceived ideas (as everyone does), I hadn’t foreseen the engagement that would happen in the room when we started to talk about the potential for clinical audit processes that are recognised and built to seek the good. Clinical audit is described as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria" (Principles of Best Practice in Clinical Audit, 2011), but how often is that explicit criteria set to seek exemplary care? And what do we do with that information when it is witnessed and audited? My clinical audit colleagues shared that they are often viewed negatively when approached. That people deem audit to be a punitive experience. But my experience of clinical audit has been anything but that. One of the most meaningful pieces of work I had undertaken in the past few years was a clinical audit to review the care an Accident and Emergency department had delivered in a time of critical incident. Using the constructionist principle of appreciative inquiry that describes that there are multiple interpretations of what is real, I knew that "words create worlds" and if only the harm was sought, only the harm would be found. By leaning towards my senior clinical audit colleagues, we were able to design a clinical audit with a mandatory field that asked "what went well?". The auditor could not bypass or work round it, they HAD to seek for the good, and it was found… often. So, what could this look like in a day-to-day practice of clinical audit, and how could that affect senior leader decision making when receiving the data? The learn at lunch was a great place to start to dream, and the participants (who would know much more than me regarding what an appreciative clinical audit process could look like) dreamed big. Existing positive processes were identified and acknowledged. Questions were asked of what a future could look like "when not practicing in anxiety of what could go wrong". Ideas grew when picturing where appreciative inquiry could sit within a clinical audit process and setting, and thoughts considered what it could be like "if we spend time looking at compliance as well as non-compliance". But I want us to dream even bigger. I want senior leaders to consider how the data you are receiving is scoped from the very beginning. Is it that the data you are reviewing is focussing solely on the substandard and prioritising the ‘red’ on your RAG charts? Alternatively, are clinical audit output reports focussing on best practice and exemplary care? Could the future of clinical audit mean that the data your amazing audit teams are collecting and analysing could point towards your strategic vision and direction? I think health and care could be evidenced to be a lot brighter through audit that seeks and documents the magic and dedication that happens every day. Further blogs from Katy: Appreciative inquiry case study What could Appreciative Governance start to look like in the NHS? A blog by Katy Fisher

Join this webinar for presentations and a Q&A on The Positive Approaches to Safety. This webinar will describe some of the limitations of the traditional safety paradigm - to only explore and fix problems – and the idea that this misses vital opportunities to learn from what we do well or indeed to learn from everything. The faculty of this webinar has been instrumental in the development of the Learning from Excellence Quality Improvement methodology and the application of Appreciative Inquiry. Speakers: 1. Dr. Adrian Plunkett, consultant paediatric intensivist at Birmingham Children’s Hospital, founder of Learning from Excellence (LfE) (UK) 2. Dr. Chris Turner, consultant in emergency medicine at UHCW NHS Trust and co-founder of Civility Saves Lives (UK) 3. Prof. Suzette Woodward – highly respected healthcare safety expert, Board member at the National Patient Safety Agency and NHS Resolution (UK) Register

In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, explains how she became involved in Appreciative Inquiry and asks the question: what could Appreciative Governance start to look like in the NHS and what small steps can we all do to achieve that together?  I have spent nearly ten years in the world of clinical governance, patient safety, quality and risk, and, despite that, I am a humanist at heart. I am a Registered Nurse, but beyond the bedside. I have investigated harm and adverse events but believe that human beings are inherently good and seek meaningful connection and contribution. I am a collection of taboos. I have been given wide and varied feedback in the past. I need to be ‘more politically savvy’; I need to ‘understand the complexities in the room’; I don’t ‘fit the governance mould’. I took all feedback at face value and reflected mindfully on all. However, I am not like the structures I had studied for so long. I see the beauty, dignity and grace in not only a patient suffering from physical and mental illness, or a loved one in distress feeling helpless in a system that has failed their beautiful parent, but also the staff members who continually create safety for their patients despite structures or processes that potentially hinder it. Over time, the world of patient safety, although fascinating and crucial, started to weigh heavy on my shoulders, and also on the teams around me. I started to notice that the humanity was being missed to fit the existing governance structure. I began to seek out ways that I could lift the spirits of staff that were witness to incident after incident of harm. I found ‘searching for the good’, which I later learned was called Appreciative Inquiry. I initially treated this as a beautiful side-line to celebrate the good whilst I prioritised the essential processes examining the poor care. However, the two started to intertwine. During a comprehensive StEIS (a system used to report and monitor serious incidents in the NHS) investigation commissioned to review the potential harm caused during a critical incident in the midst of Covid, I requested that a simple addition be made to the terms of reference—to ‘review what went well’ in the same period. I built an audit reviewing the care within the emergency department. Within that audit, I created a mandatory field asking ‘what went well?’ that the auditors could not bypass. I expected from this to find one or two examples of potential Appreciative Inquiry, but there were so many examples of great care. Let me note here that great care does not have to be grand gestures such as bringing your patient’s pet horse to their death bed (although this was a wonderful moment). Great care is also the great unspoken—work as done that led to the patient's condition or mood improving. The everyday care that is neither studied nor often openly acknowledged. The many Appreciative Inquiries from this piece of work recognised at least 10 to 15 individual staff members involved in each patient’s care that allowed them to get home safely and well. What I also found was that the learning from the harm also mirrored the learning from good; NEWS2 response times, pastoral care, timely escalation and multi-disciplinary input. The study of good led to the same conclusions. So, did that mean that an appreciative and compassionate stance could bring real results? I thought it was at least enough to lean into the potential. I have since then contributed to books and spoken publicly at events regarding Appreciative Inquiry, but the question is still posed… what does Appreciative Governance look like as an organisational system? Is there a way to create a governance structure focusing on the human, living system that is the NHS; studying, monitoring and learning from individual and team’s strengths as much as the weaknesses in the same system. The Patient Safety Incident Response Framework (PSIRF) has brought us much nearer than we have ever been, utilising Human Factors processes, reviewing ‘work as done’, employing after action reviews, supporting the staff involved in adverse events and involving all stakeholders, including, essentially, the patients themselves. However, this is still founded upon a deficit-based approach leading to a sigh of relief when there is no harm found, rather than wonder and awe when we see the thousands of interconnected miracles delivered every day. I can reference numerous studies and reiterate hundreds of stories where people have learned from the good, but I am looking now to you, my esteemed colleagues and peers in the trenches of patient safety, quality, governance and care to ask—what could Appreciative Governance start to look like in the NHS… and what small steps can we all do to achieve that together? I see you carrying that weight, and I truly appreciate that you are doing it every day. Let’s build the structures to cherish what we see every day and learn and grow from the strengths of our living, human system. Further resouces on the hub: Appreciative inquiry case study — Read how Katy implemented Appreciative Inquiry into her Trust. Caring Corner: Exploring Appreciative Inquiry stories — podcast hosted by Katy and Kayleigh Barnett sharing real stories of Appreciative inquiry in health and care.

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