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This webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar

After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: [email protected] Register

Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. A year ago, you implemented a new approach to auditing at Barnsley. Can you tell us what prompted it? In healthcare, we tend to measure safety by looking at negatives. The number of falls, the number of category 2 pressure ulcers, the number of adverse events etc. Our whole system is built on it, from local auditing and Datix reporting, to CQC inspections. But counting the number of pressure ulcers for example, doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe. Where did you start? We started with pressure ulcer reduction. Our Tissue Viability team and I looked at the learning from Root Cause Analyses and worked together to create a list of all of the things we can do to help prevent pressure ulcers. Skin assessments, pillow positioning, moving patients etc. If we ticked every box for every patient, would we prevent pressure ulcers altogether (unless the patient doesn’t follow the advice)? I took this list and worked with the digital app company, Perfect Ward to build a simple-to-use auditing tool. It allows us to measure safety by our standards of care and interventions rather than counting negative outputs. If our standards of care are high and a lot of people are still getting pressure ulcers, we have assurance on the standard of care being delivered. How did you implement the pressure ulcers audit? Once we had created the list of standards and preventative measures, we used the app to do an audit of around 35% of patients on each ward. At the start of the project, we found that teams were on average hitting 64% of the standards. The digital app provides a performance rating system, with red with red (less than 70%), amber (greater than 70% but less than 90%) and green (90% or more). The performance of the team against these ratings dictate how we would support each team moving forward. For example, if an audit showed a team to be performing at the lowest level (red), we made a commitment to support them on a weekly basis until they were performing at the highest level (green). How have staff responded? Staff have responded really well. This system provides recognition, and credit where credit is due. It can help staff to feel confident when they are providing high standards of care and to know that they are doing the right thing for the patients. Where there is room for improvement, the Perfect Ward app makes it is easy to see where the gaps in the delivery of interventions exist so they can be tackled. The tissue viability nurses are there to support, coach and to help problem solve. There may be certain interventions that are consistently missed which can sometimes be a sign that the wider organisation needs to help solve the issue. Safety is a shared responsibility, and we need to make sure we have the systems in place to support success. What support have you needed along the way? It’s really important to have passionate people who understand and believe in this approach to auditing. You need to have an Executive Team who are prepared to look at measuring outcomes differently. I’m lucky, our Director and Deputy Director of nursing are very supportive. It’s also important to acknowledge that it is not a silver bullet; change takes time. That can be frustrating for some people who want to see results quickly. It’s taken a year but teams are now hitting on average 94% of the standards set out by the auditing tool, and we are starting to see decreases in category 2 pressure ulcers (per 1000 bed days) since June 2020. What have you learnt? It has been really important to constantly engage staff and build good relationships, to make sure we understand everyone’s competing priorities. The approach has been a great enabler for quality improvement methodology, empowering teams to find their own solutions and really own the results. What’s next? This approach to auditing is not rocket science. It can be used to raise standards of care in most circumstances within health and social care – without focusing on the negatives. We have successfully applied it to both pressure ulcer and falls prevention at Barnsley and just started on nutrition and hydration. In the future I’d like to see it used in other areas, to identify what excellent dementia care in hospitals looks like for example. It could also be used to ensure that staff have a good understanding of the Mental Capacity Act and safeguarding processes. Or to make sure patients are being well-fed. It really is just a blueprint that can be used to raise standards of care, and safety in any circumstance. Final thoughts? I personally don’t like to look at my work as reducing harm. I prefer to look at it in terms of improving the standards of care we give our patients. The difference is important. Photograph of the Tissue Viability Team. Above is an example of a checklist used for pressure sores. The graph above shows the trust average on delivery of the pressure ulcer prevention interventions across adult inpatient wards over a 12 month period. The 'distribution of score' graph above shows the percentages scored across the adult inpatient wards for each month over a 12 month period. This graph shows more areas achieving 90% (or more) and fewer scoring 70% or less as time has progressed.

In this blog, Farrah Pradhan, Project Manager for Clinical Quality, Education and Projects at RCOG, describes her work with maternity professionals, namely obstetricians, and through undertaking an MSc in Patient safety. Farrah’s focus was on their 'work as done' to see if the concepts of Safety-II (capability mindfulness and resilience engineering) helped them to work more safely. ‘Work as done’ Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for. ‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is because clinicians are flexible and can vary their performance that allows the system to function albeit with acceptable or adverse outcomes. As healthcare is intractable (not easily controlled), performance adjustments are vital. Things often go well because obstetricians make sensible adjustments in response to the situations to ensure safety, often within a highly pressurised environment. These adaptations and performance variables, under complex circumstances, are not well understood. Combining the concepts of capability mindfulness, positive deviance and resilience engineering as the principles of safety-II and understanding the 'work as done' and the performance variability of obstetricians’ (that results in good or successful outcomes), may bring insights that can be used to help build adaptive capacities and capabilities in obstetricians when working in unpredictable and unanticipated stressful clinical environments. Compassion against a backdrop of complexity My first encounter with an obstetrician was over 21 years ago when I was pregnant with my first baby. The attention and kindness that I received by the obstetrician and his team were incredible; I was cared for with gentleness and understanding. He spoke to me with compassion, and in moments of delivering uncertain news, he placed his hand on my shoulder, showing his empathy for my circumstances. I saw him regularly until it was time for my baby to be born, twelve weeks early. This experience, although very traumatic, opened my eyes to a caring profession that surpassed any expectation that I could ever have imagined. When I came to work at the Royal College of Obstetricians and Gynaecologists nearly seven years ago, I had the privilege of witnessing more of these encounters. I visited maternity units, listening and watching obstetricians and their colleagues work tirelessly for women and their babies against a backdrop of complexity and variation. Intrigued by this, I decided to pursue a Master’s degree in Patient Safety. I wanted to understand what it was that gave obstetricians this skill; to work effectively while maintaining a constant awareness of situations, identifying and managing emergencies and providing day-to-day care, all at the same time. Proactive safety management My dissertation (under the supervision of Professor Suzette Woodward) focused on obstetricians’ use of proactive safety management concepts (termed Safety-II). Taking a safety-II approach includes looking at 'work as done’ [1]. These are the adjustments, compromises, workarounds, actions and decisions that obstetricians make, to meet the needsof the women they care for. Obstetricians have to make prompt decisions, organise multiple activities and co-ordinate care rapidly, all within an already complex system. ‘Work as done’ is achieved because of a combination of expertise, clinical decisions, experience and tacit knowledge and because obstetricians vary their performance, depending upon changing circumstances, that allows the system to function. Reliability, adjustment, and safety Studying ‘work as done’ brought insights into how obstetricians build adaptive capacities when working in complex settings. This adaptation is an essential factor in the interaction between complex infrastructures and human behaviour. Because healthcare is intractable, clinicians are relied on to adjust to situations (emergency cases, staff shortages, high patient numbers etc.) to create safe outcomes, as well as recover from unexpected events. Reliability is a necessary requirement of safety and is concerned with the likelihood of occurrence of failure [2]. Clinicians are vital to creating high reliability and a resilient system. Through my research with obstetricians, I found that they successfully demonstrated their adaptive capabilities to respond to unforeseen, unpredictable and unexpected demands and recover from high-risk situations, also known as resilience engineering [3]. The ability of obstetricians and their teams to be in a state of constant alertness, sensitive to changes in women’s conditions, continually re-evaluate their safety supposition, and respond as appropriate, is a key resilient strength that was evident. It also requires an organisational culture that nurtures a climate of trust and respect. The importance of culture and relationships During interviews, obstetricians described the importance of trusting relationships, which fostered excellence in team working, and the ability to be collectively and consciously alert to risks and mitigations. Overall, they demonstrated excellent leadership attributes, valued safe care centred on the woman and her baby, good working relationships and the feeling that they made a positive difference. "It was having the willingness to step in and take that level of responsibility in that situation. … it was also familiarity with the team and communication with the team, and drawing in the expertise of cardiologists and the anaesthetist so that we did have a cohesive joined up plan that we'd all agreed on and we'd communicated out to everyone." (Consultant Obstetrician, Manchester) “It’s about staying calm, understanding what the whole situation is, … it's about gaining the trust of the woman and the staff, gaining the trust of the staff is much easier if it's a team that you know, who you've worked closely with, who know you as well, because they know what your skill set is.” (Consultant Obstetrician, London) Improving maternity safety – some final thoughts My research concluded that a systems approach to maternity safety including human factors and safety management must be adopted to understand 'work as done'. Safety can be improved through ‘learning from excellence’ as a way of cultivating habits in focussing on the activities that promote good outcomes, hence strengthening resilience as well as continuing to learn from the inevitable errors. I suggested using human reliability analysis, a technique looking at a process of care and systematically examining the process, to pinpoint and foresee possible failure points to proactively manage safety within a unit. Excitingly, the NHS Patient Safety Strategy [4] is striving to embed safety-II principles, and healthcare regulators are considering how proactive safety management can be measured and developed as part of their inspection frameworks. Indicators for resilience engineering [5] are also emerging which will assist with assessing a resilient work environment and provide metrics for safety measurement. You can read Farrah's full dissertation paper in the document attached towards the end of this webpage. References 1. Hollnagel E, Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net; 2015. 19 2. Vincent C. The measuring and monitoring of safety. UK: The Health Foundation; 2013. 3. E. Hollnagel JB, R Wears. Resilient Health Care: Ashgate Publishing Limited; 2013. 225 p. 4. NHS Improvement. The NHS Patient Safety Strategy Safer culture, safer systems, safer patients. July 2019. Available from https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf 5. Ranasinghe U, Jefferies M, Davis P, Pillay M. Resilience Engineering Indicators and Safety Management: A Systematic Review. Saf Health Work. 2020;11(2):127-35.

Ben Watson is a Strategy Implementation and Quality Improvement (SIQI) Manager in the Scottish Ambulance Service. He is currently responsible for supporting operational services in the West of Scotland, to see how they can improve patient care, existing processes and develop new ways of working that benefit both staff and patients. In this interview, Ben explains why they’ve started collecting positive feedback through a peer-to-peer system called GREATix.