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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.

Often, there are many perspectives that we need to consider before we have a complete picture. 'The Blind Men and the Elephant', and earlier versions of this parable, show us the limits of perception and the importance of complete context. This also applies when we are facing a difficult or complex issue in relation to patient safety. As part of the Patient First programme at Brighton and Sussex University Hospitals NHS Trust, we used A3 problem solving. Many others do too. It’s a structured problem-solving tool, first employed at Toyota and typically used by 'lean' manufacturing practitioners. Flexible and succinct, it captures everything you need on a single piece of paper – A3 in size, hence the name. It also brings together some widely used improvement tools – cause and effect diagrams (fishbone diagrams) the 5 whys and small change cycles (Plan, Do ,Study, Act). Most recently, I've had the pleasure of using it with teams wanting to improve elements of their services such as time to triage, discharge or wanting to minimise avoidable harm (e.g. patient falls). I have also used it with families and clinical teams wanting to take forward a key service change. Its’ real power is that, rather than jumping in with solutions in hand (which are, more often than not, shopping lists of resources required), you don’t move forward until you have absolute clarity on what the ‘problem’ is you are trying to solve. Plus, this is a team activity. It is rare we know everything about our issue and the power of an A3 derives not from the report itself, but from the development of the culture and mindset required for its successful implementation. There are several formats around – just google A3 problem solving. I have summarised the first 4 steps below: Step 1: Problem Statement Set out why this is important? A couple of sentences about the size of the issue, how long it has been going on, impact on patients, their families and staff. For example Over the last 4 months we've seen a reduction in patients triaged from X% to Y%. There was a near miss event last week that would have been averted had triage been in place on that shift and staff are concerned that there is no single process for them to follow. OR Our surveys over the last 6 months indicate that only X% of our clients are fully engaged in the development of their care plans. We need to address this urgently in order to ensure best outcomes for our clients and support family members and carers who are willing and able to participate. This is your call to action – if it isn’t making your staff and clients sit up and want to engage then it needs more work. Step 2: Current Situation What you know about the issues, what staff are saying, what patients and their families are saying (small surveys are great), what the data is telling you, any protocols or algorithms, and anything else that you need to know. Step 3: Vision & Goals Vision: A softer statement of quality AND Goal(s) : Measurable goal(s) and when you are aiming to deliver, for example: From June 2020: ‘X% of patients to be triaged within Y minutes of arrival‘ AND ‘Y % of patients triaged to the correct clinical pathway’ Step 4: Analysis: Top Contributors & Root Causes Use a cause and effect (fishbone) diagram to ensure you are capturing the many causes For example, the methods in place that may not be working quite so well, things to do with the environment, equipment and the people, both patients and staff. Once these are all out on the table then you can use root cause analysis to get underneath them. It’s only at steps five and six that you start to think about the actions that you will take forward and how you might fix some of these big issues. The full A3 is pasted below: And finally, it goes without saying that step nine, ‘insights’, is key. In my experience, people get best benefit if they complete this as they go along. There is always learning, for example people you might have engaged sooner, early identification of others who are already on top of the issue and able to share their work with you so you can adapt for your own use – we used to call it ‘assisted wheel re-invention’ when I worked for the NHS Modernisation Agency. Please leave a comment below or message me through the hub @Sally Howard if you want to know more. I'm very happy to talk further about this approach.

Vanessa Sweeney, Deputy Chief Nurse and Head of Nursing – Surgery and Cancer Board at University College London Hospitals NHS FT decided to share a example of positive feedback from a patient with staff. The impact on the staff was immediate and Vanessa decided to share their reaction with the patient who provided the feedback. The letter she sent, and the patient’s response are reproduced here: Dear XXXXX, Thank you for your kind and thoughtful letter, it has been shared widely with the teams and the named individuals and has had such a positive impact. I’m the head of nursing for the Surgery and Cancer Board and the wards and departments where you received care. I’m also one of the four deputy chief nurses for UCLH and one of my responsibilities is to lead the trust-wide Sisters Forum. It is attended by more than 40 senior nurses and midwives every month who lead wards and departments across our various sites. Last week I took your letter to this forum and shared it with the sisters and charge nurses. I removed your name but kept the details about the staff. I read your letter verbatim and then gave the sisters and charge nurses the opportunity in groups to discuss in more detail. I asked them to think about the words you used, the impact of care, their reflections and how it will influence their practice. Your letter had a very powerful impact on us as a group and really made us think about how we pay attention to compliments but especially the detail of your experience and what really matters. I should also share that this large room of ward sisters were so moved by your kindness, compassion and thoughtfulness for others. We are now making this a regular feature of our Trust Sisters Forum and will be introducing this to the Matrons Forum – sharing a compliment letter and paying attention to the narrative, what matters most to a person. Thank you again for taking the time to write this letter and by doing so, having such a wide lasting impact on the teams, individuals and now senior nurses from across UCLH. We have taken a lot from it and will have a lasting impact on the care we give. The patient replied: Thank you so much for your email and feedback. As a family we were truly moved on hearing what impact the compliment has had. My son said – “really uplifting”. I would just like to add that if you ever need any input from a user of your services please do not hesitate to contact me again