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The first presentation draws on a recent National Institute for Health Research (NIHR) funded mixed-methods evaluation of the translation into practice of several ‘post-Francis’ policies that have aimed to improve openness in the NHS, and identifies key conditions necessary for policies to make sustainable impact on culture and behaviour. The second presentation reflects on material from a forthcoming book which will offer unfiltered accounts from patients, carers and healthcare professionals about their good and bad experiences of how care is organised, from birth up to the end of life. Their testimonies indicate the salience of kindness and attentiveness combined with efficiency and competence. Finally, the context for a culture of openness and for patient-centred services will be presented, alongside the development of a culture change programme which is being used in 70 Trusts in England. Significant and unacceptable variations in the availability of high quality care and in staff wellbeing persist across the NHS and social care, exemplified by very different COVID-19 experiences across the sector. How far does this kind of research on culture and these kinds of programme interventions help us to gain whole system traction in this important area of laying the conditions for reliably compassionate patient care? How can positive cultures and new working practices that have developed during the COVID-19 pandemic be sustained?

In this short video, Dr Donna Prosser discusses these questions below. 1. Healthcare workers are under extreme stress these days as they deal with the COVID-19 pandemic. Can you share some insight about what they are dealing with right now? What are you hearing from the frontline? 2. What are some tips that hospitals can employ to mitigate some of this stress? 3. What are some ways that healthcare workers can better support each other at this time?

The benefits of team events like briefs and huddles are documented. Briefs, or briefings, are planning events that occur before a case (for example, in the operating room), a shift, a procedure, a day in the clinic/office, or before an intervention. The brief allows the team leader to explain what is going to happen, cover pertinent contingencies, get input from each member of the team (including the patient), and ensure that each team member knows his or her roles and responsibilities. Huddles are team events for problem solving and updating the plan. Anyone can call for a huddle to deal with new issues, added complexities, unusual circumstances, or any need to adapt the earlier plan. Huddles occur frequently throughout the health care system and many times throughout the day. Briefs and huddles can be used in virtually any health care venue. The Briefs and huddles toolkit contains everything you need to implement briefs and huddles in your health care organisation. The toolkit includes: Toolkit overview Toolkit user guide Briefs and huddles facilitation guide Briefs and huddles facilitation slides Handout Briefs and huddles quick review Additional resources Action planning guide Toolkit evaluation form.

What is an ad hoc team? An ‘ad hoc’ team is a team that is made up of various healthcare workers that have never met before. An example of this is the medical emergency team or the cardiac arrest team – doctors, anaesthetists, nurses and other allied health professionals scrambled from around the hospital expected to assess and treat a patient in crisis. Often, we don’t know each other’s names, roles or what skills we each have. What we did in Brighton is to get to know each other… We had a MET meeting every morning. We all got together and introduced ourselves, found out what skills we all had and made full use of any learning opportunities that arose. The ad hoc team worked well. We all knew what to expect, even when a complex situation arose – we all knew who to contact and how we could get the best for our patient. Then in comes a pandemic... Staff have been redeployed; rotas have been changed; the usual rhythm of the hospital has disappeared. Our regular meeting doesn’t happen. This causes problems: Who is who? What skills do people have? Has everyone been fit tested? Where do we get the PPE from during a MET call? How do we communicate to each other? What is the guidance to take blood, do an ECG, defibrillate, order an X-ray during the pandemic? All these questions and anxieties could be discussed at this meeting, but due to a change in working patterns, the change in doctors seeing different patients (Green and Red – COVID + or COVID –), its not possible to meet up. Our technical skills are not a problem – the team have great skills in advanced life support, using life saving equipment. What we are finding difficult is the non-technical skills: communicating, tone of voice, body language. It was hard enough to communicate in a high stress situation before all this pandemic… now its even harder and so much more important! Simulation Simulation has been a large part of how we train in low volume, high risk scenarios in hospital. Cardiac arrests, medical emergencies, emergency intubation, transfer, pacing… you name it we have probably simulated it here at Brighton. I have been on the medical emergency team for 9 years now. I like to think I have experience in most emergencies and know what to do and who to call. All of a sudden, I feel a novice. I don’t even know how to go into the room correctly, I don’t know what I should take in to the room, I don’t know what I should wear; every action, every protocol I would normally do can't happen due to current constraints. I am worrying so much that I feel paralysed to do anything for fear I’m doing it wrong. We have simulations every day at 3 pm at our hospital. These simulations are very low fidelity and include how a medical emergency or cardiac arrest in the COVID-19 patient should run. Simulation can never replace what a real-life scenario will feel like. What simulation can do is allow you to understand what needs to happen, in what order and lets you make mistakes in order for you to learn. Most adults learn from ‘doing’ and from experiences – I am so glad we had this simulation as I was about to attend my first MET call a few days later. My experience attending an airway medical emergency The call went out. "Medical emergency XXX ward – COVID positive". Shortly followed by "Anaesthetic emergency XXX ward- COVID positive". I ran faster knowing that as a team we all had to get there and put full PPE on before we could attend to the patient. If the patient has an airway problem, they will not be able to breathe properly and be at high risk of stopping breathing. I remembered at the simulation exercise that one person needs to be the ‘gate keeper’. I decided to take on this role as I wasn’t sure who had attended the simulation before and knew about this role. My role as gate keeper is to make a note of who is in the room, what role they have and to take messages in and out of the room from the doorway. The notes are not able to be taken into the room, so it would be the gate keeper's role to get the information across to the team inside. I was opening and closing the door and trying to hear muffled voices; I was equally trying to convey important medical information, but they couldn’t hear me well enough. It didn’t help that for many of the team English is not their first language; this made it even more difficult. Our anaesthetic team simulate situations on a regular basis as part of normal work. They turned up at the call already kitted up in PPE and wheeling a trolley with everything they needed on it; all their drugs and equipment were there. One of them – the lead anaesthetist – had a headset on which was connected to a walkie talkie. This made conversing with the team so much easier. We could ask questions from outside the room into the room and vice versa without having to open the door. Clearly, they had rehearsed this scenario before – they too couldn’t hear well so had solved the problem by obtaining walkie talkie devices. They asked for equipment, called for X-ray or asked for more information and I could either relay information, pass equipment or order tests for them – so much easier and safer. The patient had a complex airway and needed to be seen by a specialist. A consultant arrived; one I had not met before. He arrived anxious. He was worried about donning the PPE in the correct order and in swift time. I helped him donn and, while I did that, I reassured him on who was in the room, what had happened and what treatment the patient had had. He entered the room knowing he had the right gear on and what he was facing. This enabled him to think clearly and treat the patient. When it was time to transfer the patient to intensive care, we came across a problem. We had two differing protocols. One was from yesterday, the other was rewritten this morning… which was correct? This was quickly cleared up by calling the author of the protocol, but what would happen at 3 am if this was to happen again? Reflections It was my first time as gate keeper. To be honest, I didn’t know what I should be doing… some of the information from the simulation flew from my mind. Looking back, I should have asked for the name and role of who walked into the room and wrote it on their PPE or used stickers. People were in such a rush to get in and save the patient's life that it didn’t feel like a priority at the time. The walkie talkies were a genius idea from the anaesthetists – this is something that I will take back and see if we can implement the same for all MET calls (anaesthetists do not attend MET calls normally). It reduced the opening and closing of the door, which reduced the amount of aerosoled particles to come out from the room that may increase risk of infection to others. Flattened hierarchy – the moment I had with the consultant outside that room was something I hadn’t experienced before. I noticed his vulnerability, he looked for me – a nurse – for reassurance and guidance which was given with no judgement. At that moment we knew we were one team. Protocols keep changing. We are working where national guidance and local policy changes daily. Without robust ways of disseminating this information we run the risk of doing the wrong thing. As clinicians we are not at our desks monitoring for changes in guidance – we need ways of getting this information to us. We use the ‘workplace’ app – we have a ‘microguide’ for all our up to date policies. This is great to use in normal circumstances but when dressed in PPE we are not always able to access our mobile phones. I wasn’t inside the room. I could see the patient. I could see that he was scared. He couldn’t breathe, he was unable to talk anyway due to his altered airway. How were the team communicating with him? How was he being reassured? Our facial expressions say a thousand words – behind a mask the patient sees nothing. I have heard of the CARDMEDIC flash cards, but can we use them in an emergency? Perhaps we could add them on to the cardiac arrest trolley? The patient is doing well on intensive care now. It would have been ideal for us to debrief; however, half the team go with the patient the other half of the team need to get back to other sick patients, so this can't happen. So much learning comes from these calls; we haven’t got this bit right yet.

What will I learn? The IHI White Paper 'Framework for Improving Joy in Work' Video by Don Berwick MD, IHI President Emeritus and Senior Fellow, 'How does joy in work advance healthcare quality and safety?' Video by Stephen Swensen, MD, IHI Senior Fellow, 'How to build Joy into work' Video by Derek Feeley, IHI President and CEO, 'How will we know when there is joy in the healthcare workforce?' Video by Trissa Torres, MD, IHI Senior Vice President 'Impediments to joy in work'

Key points Language influences the perceptions of the accident process. The use of punishment can be harmful to individuals. Punishment does nothing to help achieve future safety. Accident analyses are not independent from the organisation politics.