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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.

Over the Christmas period I caught up on ‘interesting emails’, the ones with content that needs you to put thinking time aside to inwardly digest rather than cramming it in between Christmas baking. One of these was from Mike the Mentor, one of the great people who trained me as a coach a good few years ago, asking a very simple question: How is it that, despite being committed to change, we so often fail to make the changes we are committed to? He offered a great answer, taken from from Kegan and Lahey's book, Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization. If you are just following a simple recipe there’s no need for this but if you are going to take advantage of new opportunities and deliver a bigger change then this is worth a look. Just as with New Year’s resolutions, we often look at the behaviour that we want to eliminate as bad. This book is all about growing into your aspirations, knowing what makes them possible and what is getting in the way. There is a four step process to understanding the space between the change to which you are committed and actually making it happen, then a journey of a few months to make that change either with your team, with a coach or in quiet contemplation. Step one Identify your improvement goal. The thing you are really motivated to change, the one that is worth getting out of bed for, that scores five out of five, and its simply no longer tolerable to leave things as they are. For example: I am absolutely committed to improve x in our system. Step two Take an honest look at the things that you are doing or not doing that work against that goal. The more concrete you can be the better. Be honest, you don’t have to share this with anyone. But, if you can, seek out people who you trust who can add things that they see you do or don't do that are getting in the way of this being delivered. These are your hidden competing commitments. For example: I don’t actively engage. When I engage I tell people what needs to happen OR I rush through what I have to say. Step three Well done. Now confront these. What are your fears behind them? Identify that loathsome feeling lurking in the background, what would be the biggest risk for me in this? For example: I worry that people won’t take me seriously. Step four Behind step three will be one or two big assumptions that you hold to be true. These need to be identified. For example: I assume that if I don’t get this right others will reject what I hold dear because they know more than me. These steps then become the route to changing your mindset that is working against your goal. Do take a look at Kegan’s TED Talk ‘An evening with Robert Kegan and Immunity to Change’ and take a moment to reflect on the space between you deciding to do something that’s important to you now, and actually doing it. You can also go to the Harvard website where you'll find a helpful immunity mapping tool to download. Please leave a comment below or message me through the hub @Sally Howard, I'm very happy to talk further about this approach.

Kegan proposes that there is a deep need for us to understand what it is that gets in the way of a person's genuine intention and what they can actually bring about. He looks at how we might address this gap, which he refers to as an 'Immunity to Change'.

The diagram outlines key recommended activities relating to patient safety.

We know from our own experiences and those of others that patient safety fears are growing daily across the NHS and social care. Staff shortages and burnout are all taking their toll on patient satisfaction, safety and standards of care. I had the pleasure of joining a webinar arranged by the Health Foundation last week where the National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey, outlined the up and coming improvement framework for the NHS. A good framework provides a skeleton on which to build. His presentation included the importance of: leadership both at the Board and at the front line people who are empowered and engaged a culture built on collaboration and continuous improvement, where it’s safe to learn co-production – engagement, empowerment and ‘lived experience’. Workshops, seminars and conversations across social media will follow in 2020 to build the thinking. So, be ready to contribute and help make sure patient safety is coming through as the top priority. And as you do, keep a copy of Roy Lilley’s latest blog in your hand. For those who don’t follow him, Roy is a health policy analyst, writer, broadcaster and commentator on the NHS and social issues. He recently posted this summary, outlining NHS electoral promises. Please do as he suggests – pin this up and bring it out every time you see a politician and whenever you have the opportunity. This way we can all ensure that these promises will be delivered.

Still not safe: includes a critical history and examination of the patient-safety movement in American medicine attributes patient-safety initiatives to the changing (and diminished) place of doctors within the larger healthcare system at the end of the 20th century integrates three streams of thinking about healthcare mistakes: clinical reasoning; objective understanding from a safety-science perspective; patients' and families' stories of injury and suffering gives a critical and lively voice of dissent in physician-led conversations around medicine and healthcare reform and expense.

The Measuring and Monitoring of Safety Framework consists of five dimensions that prompt you with a series of key questions to conceptually address any problem you have in safety. These questions move the discussion from assurance to inquiry. The primary questions are: Has patient care been safe in the past? Are our clinical systems and processes reliable? Is our care safe now? Will our care be safe in the future? Are we responding and improving?

Speakers and presentations from the day: Moira Durbridge, Director of Safety and Risk at University Hospitals of Leicester NHS Trust – Moira introduced the event and gave some initial thoughts from her perspective about the new NHS Patient Safety Strategy, noting that she and the delegates were looking forward to seeing the implementation plan, timescale and any associated resources. Khudeja Amer-Sharif, Patient Partner at University Hospitals of Leicester NHS Trust – Currently working with the National Patient Safety team and others to develop the basis of the Patient Safety Partners (PSP) framework, Khudeja shared the work being done to co-produce principles for involving patients both in their own safety and in the wider delivery of healthcare. Helen Jones, National Investigator at Healthcare Safety Investigation Branch (HSIB) – Helen's presentation focused on how the Patient Safety Incident Response Framework (PSIRF) will run alongside the investigation expertise at HSIB and the implications of the proposed changes set out in the Health Service Safety Investigations Bill. She shared the recommendations that HSIB have made and the delegates discussed the accountability framework for their implementation as this is outside of HSIB’s current remit. Helen Hughes, Chief Executive at Patient Safety Learning – Helen shared how the work of Patient Safety Learning links with the Strategy and how the hub, their recently launched online platform and community for anyone committed to patient safety, can support Trusts improve patient safety across all specialties. She welcomed all delegates joining the hub and sharing the opportunity to do so widely within all their organisations. Browne Jacobson LLP will be hosting another discussion forum in the new year to consider the detail of the PSIRF once the guidance on this has been published more widely and the early adopters have experiences that they can share. Some delegates had expressed concerns about the delay in publication of the PSIRF and noted that this presented a challenge to anticipating its implications on their work.

We have a new app within Homerton which is featured on the hub. The Homerton University Hospital (HUH) Action Card App is an initiative that aims to bridge the gap between information/processes with clinical members of staff without the need to log into a computer, access the intranet, and finding the long black and white document which is never ending. The Action Card App has easy to read, 1-page coloured documents relating to local and national/local incident trends and Never Events. We entered the Patient Safety Learning Awards on the back of seeing the hub and finding content on there that was incredibly useful on a day to day basis. We genuinely weren't expecting to hear anything back from the Patient Safety Learning team as we are a small trust that not a lot of people know about, and we thought the standard of patient safety initiatives would be high, with many trusts miles ahead of us. I have to say, the team at Patient Safety Learning were nothing but lovely, from the moment the conversation started about the prospect of entering the awards. They all took the time for correspondence and they treated you as a person, as oppose to an entry. When we got the information that we had won the overall prize, we were gobsmacked and elated. The app team were overjoyed with the sense that our hard work had paid off and someone had taken the time to appreciate the work we have been doing at Homerton. We were asked to prepare a presentation prior to the awards, which showcased our work and to share with the attendees of the conference. The day arrived, with so much great work, inspiring talks and a general atmosphere of wanting to do more to keep our patients safe. I would like to thank everyone who heard our presentation (some may say performance) and thank everyone in the Patient Safety Learning team for their help with this process.

Presented by Sidney Dekker, Safety Differently: The Movie tells the stories of three organisations that had the courage to devolve, de-clutter, and decentralise their safety bureaucracy. It is a story of hope; of rediscovering ways to trust and empower people and of reinvigorating the humanity and dignity of actual work.

This report identifies key factors needed for successful change and explores why they are not consistently present in the NHS. It sets out how national bodies can help make successful change more likely, in part by boosting the support provided to organisations and focusing on NHS staff leading change. It draws on: Workshops focusing on what helps and hinders change in the NHS involving commissioners, leaders in quality improvement and people who had participated in Health Foundation leadership programmes. Interviews with clinicians, academics, improvement leaders, commissioners, managers and leaders in national bodies about how change happens and what could be done differently. Our experience of funding, researching, supporting and evaluating improvement projects. Specific analysis of provider transformation, based on interviews with senior leaders from a range of acute providers. A scan of available empirical evidence about the barriers to making change in the NHS.

Part I illustrates why improving safety is so difficult and complex, and why current approaches need to change. Part II looks at some of the work being done to improve safety and offers examples and insights to support practical improvements in patient safety. Part III explains why the system needs to think differently about safety, giving policymakers an insight into how their actions can create an environment where continuous safety improvement will flourish, as well as how they can help to tackle system-wide problems that hinder local improvement.