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There is a lot to be uncertain about these days: school, work, health, family. However, in July one thing was certain: the streaming release of “Hamilton” in the US was going to be epic. The acclaimed musical production tells the story of a U.S. founding father Alexander Hamilton, intensely American, exploring themes of love, anger, arrogance, heroism, betrayal, mistakes, politics, policy, devotion, family, sacrifice and death. In some ways, it sounds like healthcare in the era of COVID-19. While months of the coronavirus pandemic are behind us, the uncertainties caused by the pace of change and the expected surge of further infection spread bring continued stress, fear and frustration. Disruptions to services, processes and relationships are rampant. They demand continued experimentation across healthcare to address concerns to keep patients, communities and healthcare workers safe. And the lack of a coordinated collective policy response to the crisis only perpetuates discomfort about the unreliability of actions to improve safety and the substantial costs the future holds in store. Ambiguities and dread due to the pandemic are problematic and will be for some time. Continued patient avoidance of care is evident and could be contributing to lack of timely care and diagnosis. An ImproveDx article summarises how fear is keeping patients from getting the care they need, and highlights the importance of recognising that rebuilding trust will take time. To anchor this effort, leaders must view risk as individuals see it rather than just an academic exercise to inform reentry strategies in the months to come. The unsettled nature of care and access to loved ones during COVID can make end-of-life planning particularly fraught with uncertainty. Stanford University School of Medicine has developed the GOOD framework for clarifying steps forward when working with patients and families facing palliative care decisions during the pandemic. Its four elements – Goals, Options, Opinions and Documentation – provide an effective structure for clinicians to have conversations with patients and families to address care management when the path forward is unclear. Prolonged uncertainty can degrade healthcare staff mental and physical health. In Hawaii, one health system sought to make antibody testing available to staff as a strategy to decrease anxiety and improve sensemaking around the crisis. Hawai`i Pacific Health in NEJM Catalyst explores the reasons why those who were tested opted into the programme. The authors found “curiosity” to be a primary motivator. Knowing something – whether positive or not – can reduce one aspect of uncertainty, which the article posits will help clinicians and their community think beyond the doubt to achieve a modicum of control. This single piece of stability will enable a willingness to gather information, to plan and to act. Despite the challenge uncertainty brings, there are individuals who consistently believe the future holds promise. People who are able to act and make a difference despite uncertainty. Much has been said about those in the midst of the COVID-19 crisis, but others continue to address persistent uncertainties and unreliableness of care – beyond the pressures of the pandemic. There are many whose tenacity shores up the foundations of the healthcare system to improve its safety. One such leader from the US, John Eisenberg MD, is celebrated every year through an award programme in his name. John was a founding father of patient safety in the US. Through his leadership, national research and improvement programmes were developed and funded to lead government efforts to improve quality and safety. In July for the first time, the John Eisenberg Patient Safety and Quality Awards were bestowed virtually. These awards recognise individuals, local efforts and national programmes whose work provides evidence of the value and commitment to engage in work to improve safety. This year’s recipients demonstrated values core to improvement and perseverance in their work toward achieving healthcare that is safe. The awardees have accomplishments that focused on diagnostic error and sepsis reduction. Each of these stories started in tests and trials motivated by commitment to getting healthcare to a better place. For example, Tennessee-headquartered HCA Healthcare was recognised for its SPOT (Sepsis Prediction and Optimization of Therapy) algorithm as a mechanism to identify sepsis quickly to enhance quality and patient safety. Through this enhanced use of technology, SPOT uses basic laboratory and clinical data in real time to provide teams with the information they needed to reduce sepsis mortality across their 173-hospital system. Data triggered alerts that initiated actions to decrease response times by approximately 6 hours rather than relying on shift change as the information sharing mechanism. The SPOT algorithm enhancement to the electronic medical record partnered well with existing sepsis management processes to arrive at improvements. In the climax of Hamilton’s first act, the battle of Yorktown culminates in a chorus of “the world turned upside down”, with the hope that the cacophony will ultimately result in a new country with new freedoms only imagined prior to crisis. It is certain that COVID disruptions will continue to test us all worldwide. Can we challenge ourselves, our peers and our leaders to experiment as necessary to confront COVID-19 while guaranteeing that what was learned will be used to create something better?

Over the last 3 months we have seen NHS organisations work at lightning speed to adapt and serve their communities in response to the COVID-19 pandemic. With the shutting down of routine surgeries and outpatient services, care providers have adapted in an extraordinary way. Wards have been emptied as beds have been made available, while theatres and recovery rooms have been turned into intensive care beds – capable of looking after acutely unwell ‘level 3’ patients – overnight. These unprecedented changes deserve praise and commendation but, beyond this praise, what can we learn from COVID-19 and the scale of change we have seen? It was famously argued that it takes 17 years for research to impact frontline services.[1] . Due to this, immense interest has centered around how innovations, or new ideas, are diffused and how this process can be sped up.[2] Various barriers exist to the spread of new ideas and change – not limited to bureaucracy, a lack of resources to create change, and cultures – for example organisational culture. Due to these barriers the NHS and its subsequent organisations can appear as monolithic – slow to change or adapt to any innovations. But COVID-19 has turned this assumption on its head, with expansive structural and procedural overhaul seen in the last few months alone. It has led observers to ask how this has happened and, more importantly, how we can facilitate change in the future. As we reflect on these months, the psychology of a crisis can be helpful in understanding staff behaviour. There are three stages – emergency, regression and recovery.[3] In the emergency stage, energy and performance goes up as staff ‘fire fight’ in the crisis. However, the move towards the regression and recovery stage will see staff become tired and lose their sense of purpose before needing direction on how to recover and rebuild. These latter stages are symptomatic of the current state for NHS staff. Utilising theories of change, perhaps we can identify why this change happened so quickly. The impending doom felt by staff was palpable in March. The Nightingale field hospital was being built to cope with the immediate storm of COVID-19 patients needing ventilatory support and providers were told to free up beds. In business, this is coined the ‘burning platform’ and is a key driver of change. A burning platform is a term which describes the process of informing people of an impending crisis and is used to cultivate immediate change. This ‘burning platform’ is a simple analogy and based on an incident in 1988 of an oil rig worker who, when faced with an impending burning platform, jumped into freezing water. Whilst of course this sense of urgency can’t be replicated every time change needs to happen, for professionals working at the start of the pandemic, this is exactly what was replicated. Perhaps change happened so fast as professionals and staff had no other choice but to respond to the burning platform of COVID-19. Creating a sense of urgency is also argued as being integral to another organisational theory of change – Kotter’s 8 Step Process for leading change. The first stage – creating a sense of urgency – is characterised by a distinctive attitude change which leads workers to seize opportunities to make changes imminently. But NHS staff have already responded to the immediate urgency presented by COVID-19, so what happens next will be telling. Apart from creating the NHS’s own burning platform, adaptations that can be seen across the NHS are not following any other theory of change. The NHS – a highly complex and bureaucratic set of organisations – has seen providers innovate, change and adapt without the traditional ‘red tape’ of the NHS. NHS providers are no longer following a model, instead working out what is best for the patients they serve. For community providers and primary care this includes virtually treating patients to limit their risk to COVID-19. Changes that have taken years to discuss are now happening overnight – for example some hospital providers integrating IT systems to improve cohesion. With so many innovations, it is crucial that we learn from what is happening. Organisations should be supported to identify and collect information on the changes that are happening on local levels. With this wealth of information, organisations can learn what made local change possible and what the drivers of innovations were. This insight is undeniably useful as it can help us all understand the drivers of change locally and galvanise change in the future. This must be made into an organisational priority. While organisations remain in firefighting mode, now is a crucial time to take stock, capture these changes, and hold on to what is useful as the NHS – and wider society – recovers. References 1. Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011;104:510-20. 2. Turner S, D’Lima D, Hudson E, Morris S, et al. Evidence use in decision-making on introducing innovations: A systematic scoping review with stakeholder feedback. Implementation Science 2017;12. 3. Wedell-Wedellsborg M. If You Feel Like You’re Regressing, You’re Not Alone. Harvard Business Review [Internet] 2020.

We will need to work in different ways from usual and the focus should be what information you share and who you share it with, rather than how you share it. The following advice sets out some of the tools that you can use to support individual care, share information and communicate with colleagues during this time. This includes communications tools where data is stored outside of the UK. This advice is endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital.

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.

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.

Topics include human factors, learning from deaths, neonatal and maternal patient safety, patient safety in primary care, medicines safety, safety in social care and patient engagement. 2. Master Slides (3).pdf AC_Salfordsafety_primary_care (1).pdf CW - Salford Apr 2019.pdf JH - Meds Safety Salford.pdf MT - Maternal and Neonatal Health Safety Collaborative Break out session.pdf Ursula Clarke PSP Patient Safety April 2019 final.pdf VC - Salford University Patient Safety Conference Glos_ Hosp_ Workshop_ 23 _April _2019.pdf

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.