Prof Justin Waring, Nottingham University Business School Making Healthcare Safer, St Andrew’s University

1. The gaps within, and future directions for, patient safety research Prof Justin Waring, Nottingham University Business School Making Healthcare Safer, St Andrew’s University

2. Patient Safety: looking back, looking forwards • We have thrown a lot at patient safety!!! • Research • Patient Safety Research Portfolio • Patient Safety and Service Quality Centres • Policy & Regulation • National Patient Safety Agency • World Alliance for Patient Safety • Practice • National Reporting and Learning System • Patient Safety First; 1000 Lives; Health Foundation • But, have we seen the system-wide improvements hoped for?

3. Patient Safety: looking back, looking forwards • The story so far… • Chapter 1 – understand the scale of the problem • Chapter 2 – understand the sources of the problem • Chapter 3 – understand & evaluate the answers to the problem • New ways of thinking about the problem • Complexity of healthcare organisation & practice • Knowledge, Culture, Power • Neglected or forgotten areas of research & practice • The positive contributions to safety • Emotion • Professional networks • Organisational complexity and spaces between care processes

4. Chapter 1: Understand the scale of the problem • What is the scale of the problem? • E.g. Harvard Medical Practice Study • Where is it happening? • Identify common events or situations • What are the different types? • Develop taxonomies of diagnostic, treatment, management errors, etc • Key activities • Case reviews, significant event audits • Early reporting & risk management systems

5. Chapter 2: Understand the causes of the problem • Re-conceptualisation of safety & risk • Human Factors & Ergonomics • Active risks • Individual & Group Behaviours • Latent Factors • Organisational complexity • Environmental Factors • Culture & Resources • Risks and faults in existing systems • Failure to think in terms of systems • Blame Culture • Lack of systematic learning

6. Chapter 3: Understanding & Evaluating the solutions • ‘Hard’ technological Interventions • ICTs to facilitate communication, monitoring & checking • Pharmaceutical & Medical Device, e.g. SUDs • Process & Activity Interventions • Alerts & Safety Notices • Guidelines & Checklists, e.g. Safe Surgery Saves Lives • ‘Soft’ skills & competency based Interventions • Culture change – Safety training • Leadership development • Organisational Learning Interventions • Reporting & Learning Systems • Knowledge & Risk Management

7. Important Developments • Theory & Conceptualisations • Active & Latent Factors • Systems Thinking • Methodologies and Methods • Case Reviews • Observational techniques • Measuring safety cultures/climates • Evaluating technological change • Formative and Summative findings • Evidence of change & Improvement • Evidence of culture change • But is it enough? Are we learning? Have we missed things out?

8. A ‘measure & manage’ orthodoxy? • Threats to safety are amenable to objective & scientific measurement • Does this acknowledge the complexity of organisational life? • Is there sufficient ‘depth’ to measurement & analysis? • Reification & Reductionism • Treats knowledge & culture as abstract variables • Underplays the dynamics of power and control • Problems in the introduction of safety interventions • Reporting systems • Culture change • Safety Interventions • Its about context!!! • Where do safety events come from? • What inhibits safety improvement?

9. Three critical perspectives? • Knowledge • Knowledge about safety is both ‘slippery’ and ‘sticky’ • E.g. barriers to reporting • Culture • Cultures are not things to be managed, but are lived and breathed in day-to-day work • E.g. normalisation of risk • Power & Organisation • Power & Resistance to change can stymie service improvement • E.g. resistance to checklists or guidelines • Critical of and extend orthodox thinking, critical for service improvement

10. The next steps for patient safety research • Thinking ‘outside the box’? • Patient safety is not simply a clinical problem, nor is it a problem of ergonomics or Human Factors • Recognise complexity of social and organisational life • Emotions • Relations & Networks • Tribes & Cultures • Organisational & Institutional risks • Partnerships & engagements • Work with clinicians and service leaders • Encourage those on the front line to lead patient safety • More bottom-up, less top-down? • But avoid dualisms of professionalism/managerialism

11. A new menu for patient safety research? • Sense-making and how safety is perceived ‘on the ground’ • Communities of Practice and learning from mistakes • Identity & Belonging in the face of safety events • Rituals & Responsibilities for safety • Jurisdiction & Legitimacy to enact change • Knowledge about safety and its relations of power

12. Four Gaps in patient safety research & policy • 1. Thinking about the sources of safety • Learning from what works • 2. Thinking about the role of professional-practice networks • How clinicians interact and learn from one another to deliver a service • 3. Thinking about the role of emotion • How clinicians respond and cope in the face of safety events • 4. Thinking about the threats to safety between care processes • A truly inter-organisational, systemic and institutional approach to safety

13. 1. Thinking about the sources of safety • Conventional focus on what fails and why • Ethos of ‘Learning from mistakes’ • Incident reporting, RCA and error-chains etc • Deficit model of safety! • But what happens when this go right? • Reason’s Organisation Safety Model • Factors that shape both failure AND resilience • Systems that help organisations navigate the risks and encourage safety • We can also learn from ‘what works’ • What promotes resilience in the face of systemic risk?

14. Exnovation & Patient Safety • Make visible what is already present • If innovation is about novelty, exnovation is about understanding what already happens • “The process of making existing strength of practices explicit by mapping the tacit resources of practitioners” (Jessica Mesman) • Spatiality and Temporality in neonatal ICU (Mesman) • Time/space infrastructure and trajectories on which safe practices can unfold • Hidden structures of effective clinical practice • Capabilities and Creativity of clinicians • Collaborative actions & teamwork • Diagnostic work & Problem-solving

15. Examples of safety supporting practices • Fire-fighting & creativity in the operating theatre • Rescue safe working despite system failures • Accommodate and Innovate in response to system failure • ‘Going the extra-mile’ • Personal sacrifice for service consistency • ‘Small cogs’ • Junior members of staff who ensure consistency and safety of practice • Problem-solving at the coal face • Corridor committees & watercooler learning • Importance of professional-practice networks

16. Valuing ‘what works’ in patient safety • Maintaining safety when things spiral out of control • Extra effort required by clinicians to compensate for latent risks • Hidden and adaptive coping strategies • Heroic work!?! • Normalises the idea that clinicians can cope • Plastering over the cracks in the system – lack of systems thinking • More blame when things do go wrong • Razor’s edge of safety!!! • Promotes patient safety • Conceals underlying risks and limits learning • Future research ideas • The relationships between active & latent sources of safety & risk

17. 2. Thinking about Professional Practice Networks • Patient Safety interventions often create new working practices or organisational systems • Guidelines & checklists • Improved teamwork & communication • Formal reports systems • Established professional groupings inhibit safety • Silos, epistemic communities & knowledge hoarding • Cultural bias of professional interests above the patient interest • But this might neglect the role that ‘natural networks’ • Knowledge sharing • Problem-solving • Learning and development • Not necessarily the answer, but might be source of resilience

18. Networks in the organisation & delivery of healthcare • Health services are produced “by webs of humans connected personally via technologies, interacting in multiple ways” (Braithwaite) • Communities of Practice (Lave and Wenger) • High-trust & mutuality • Shared understanding & knowledge • Common forms of identification & belonging • Intra- and Inter-professional networks • Often reinforce boundaries, but research shows how & why boundaries are crossed within the networks • Contributions to patient safety • Active problem-solving & Learning • Intrinsic appeal to members

19. Quantitative ‘problem-solving’ networks

20. Network Attributes & Qualities • A messy picture of organisational and clinical practice! • The building blocks for shared values, ideas and practices • Where issues of safety & resilience are enacted • Core & Periphery groups • Core staff (nurses) more likely to share knowledge & engage in problem-solving • The importance of daily contact and occupational background • Between groups interaction • Common where clinicians work side-by-side & functional proximity • Problem-centred & relative interactions • The role of boundary spanners and brokers • Managers & leaders have important hub and brokering roles

21. Qualitative accounts of problem-solving interactions • Knowledge sharing routinely occurs ‘at the backstage’ • Small chats • Corridor conversations • Coffee room banter • Informal knowledge sharing is embedded in practice • Shared or common understanding • Links to work activities • Translates quickly into decision-making & problem-solving • But it is not necessarily the answer • Can lack critical reflection, systems-thinking or deeper analysis • Limits system-wide learning • Can hoard knowledge

22. The contribution of the backstage interactions

23. The importance of professional-practice networks • Networks and learning • Knowledge is often shared rapidly and easily within close networks • Problem solving close to the action • A significant source of resilience • Harness not replace networks • How can they be used further to engender learning or culture change • Safety solutions from networks • Future research: • How they can be used to disseminate & translate knowledge into practice • Networks and emotions

24. 3. Emotional aspects of patient safety • Blame is a prominent issue in patient safety policy & research • Clinicians held to account for individual failure • Regulatory and disciplinary systems lack systems thinking • Encourages clinicians to conceal mistakes • But there is more to emotion • Inherent feature of clinical practice and patient harm • Complex and diverse expressions of emotion • Calls for more subtle and delicate forms of management • A Complex Sorrow (Paget) • Phenomenology of safety events • A desire that things had turned out differently • Clinicians need to learn to cope with failure

25. Models & Approaches to emotional research • Not individual reactions, but grounded in shared expectations and values • Plutchiks psycho-evolutionary theory • Stimuli • Cognition • Physical reaction • Emotional reaction • Behaviour • Emotional labour • Emotional intelligence

26. Emotions in the context of patient safety • Surprise • “I didn’t expect that” – “What just happened” • Safety events uncertain & unexpected • Sadness • Physical reactions of crying and distress • “Let the patient down” ~ let themselves down? • Anger • Physical and emotional outbursts • Blame or vent frustration with others • Anticipation and Optimism • “The save” – got away with that one • Things might get better - reporting

27. The importance of emotion • Impact of emotion • On clinicians • On service • On learning • The importance of professional-practice networks • Shared experience & understanding • Cathartic outlets • Trust and Psychological safety • Future research: • Attention to emotional labour in the context of patient safety • Attention to emotional intelligence of service leaders

28. 4. The spaces between care processes • Patient safety research has tended to be narrow in focus • The operating theatre OR emergency room OR care home • The use of SUDs, guidelines, or training interventions • The Human Factors orthodox can limit analytical focus • Should focus on latent system factors • But often stops at local environmental or team factors • Risks located between care processes and spaces • Between professional groups • Between care organisations • Between sectors • Latent factors are often rooted at this wider institutional level

29. The inter-organisational dimension • Healthcare processes are often long & complex (esp. chronic care) • Primary, secondary and specialist care services • Pharmacists, therapists and support workers • Ambulance and transport • Home and social care services • The interaction and coordination of these elements is essential for efficient and safe healthcare (Audit Commission) • Various activities to promote inter-agency working • Mandated networks (cancer services) • MDTs (children’s safeguarding) • ICT and communication media (prescribing) • New guidelines and procedures (ESD)

30. The example of hospital discharge • The problem of hospital discharge • 7-8% of all reported patient incidents related to hospital discharge (massive under-estimate!) • Notifying external agencies most common issue • Common risks • Falls associated with inappropriate home adjustments • Medication associated with failure to communicate with GPs • Personal care, sores & ulcers associated with failure to arrange social care services • Communication, Knowledge sharing & Shared decision-making • Need to identify and understand various stakeholders • Determine barriers associated with differences in knowledge, culture and service organisation

31. Getting to the complex roots of patient safety • Getting to the roots of patient safety • Go beyond local environment or team factors • Understand role of managerial, organisational and policy factors • Need to consider how services are configured at system-level • Inter-organisational • Inter-sectoral • The role of various agencies with different commercial, professional and political influences • Institutional sources of risk and safety • The regulatory, normative and cognitive context • The role of institutional actors in making change happen!

32. Conclusions • Patient Safety research and practice has come a long way! • Significant advances in theory, methods and practice • But need to look to new models and approaches • Go beyond the Human Factors orthodox • Look at forgotten or neglected issues, e.g. Emotion & networks • Where’s the patient in patient safety? • The importance of context • What are the institutional and organisational constraints? • End dualisms: • Not a return to professionalism, or more management!!! • Learning from what works in healthcare practice and looking at change from within rather than from above