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A Promise to Learn, a Commitment to Act – what does that mean for leaders?

Author: Jo Flemming

CNS and Service Redesign Project Nurse

Birmingham Children's Hospital


In the August 2013 report published by Don Berwick on behalf of the Government, he suggests as leaders we have to put patient safety at the top of our priorities. What does that mean to those leaders who are closest to the “sharp end”?


Firstly, those leaders should be present. Sounds simple enough, but we do get it wrong, even when we think we have it right.


If you lead staff who work shifts, they will feel they have not seen you for ages, even when you haven’t had a day off for weeks! That’s important though, because it means you haven’t been able to use your persuasiveness and relationship to ask how they are doing and discover those niggles that are making their life difficult and potentially making patient experience less than optimal!


It also gives us the opportunity to model behaviours; the Chief Nursing Officer for England has committed a lot of time and effort to embedding values into staff caring for patients and many Trusts have emulated this work by promoting values into everything we do. As leaders, we will have to challenge those who don’t share our passion for demonstrating those values, but we can always remember that it might be our child, mother, father... whom the staff member is caring for. That’s a great incentive for challenging bad behaviours.


But back to patient safety being our priority. If we are sloppy in appearance or behaviour, we are likely to be sloppy following systems and processes in care delivery. Some of those systems and processes may already have inbuilt errors and by deviating further we risk causing harm. Patients notice that, and Berwick has written the people of England giving them the permission to challenge us. But we are closest to our patients and carers, and even more importantly in paediatrics is this message that we can give to them. We care for a vulnerable group of people; children are often too young or underdeveloped to speak out and tell us when we get it wrong, so their parents are our greatest ally to help us make care safer. We can give them permission to challenge us.


We already accept, gladly, that they know their child better than we do and we encourage our staff to listen to their concerns; now we need to engage with them to help them tell us what they see.


They spend hours by their child’s side, watching the comings and goings on the ward, talking to other parents, trusting that we are not making errors. Some organisations are working on programmes where parents can activate an incident report themselves if they see any areas of concern, particularly around environment issues. We are working here on a system where parents can activate the rapid response team if they are concerned that the actions taken by staff have not been effective for their child or if they are worried they are not being heard if they see their child deteriorating. But we are not there yet, we are missing out on a huge chunk of intelligence by not involving them in our reporting mechanisms.


As leaders, we are often bound by rules and regulations and we lead our teams employing these. Berwick identifies ways in which we can shift our behaviour to be more innovative, by infusing our commitment to those we lead and by encouraging a learning environment.


And there’s the common theme. Learning. In everything we do, we learn something from the experience, but learning by making mistakes can be dangerous and soul destroying. We talk about a tale of two stories, the effect of the error on our patient and the lesser talked about effect of the error on our staff. As leaders of staff who make errors, we support them by telling them reassuring things like – you’ll have learned from this, and you’ll never do it again. What we should be brave enough to do is encourage them to tell more people what they did, and more importantly why they did it, not so they can be blamed but so that other staff can begin to understand the root causes and we can put things in place to remove the error traps.


We can take the learning from these events and the knowledge of our leaders to identify where those error traps are and begin to teach our staff how to be safe. Then we can go further and begin to look for hidden risks, but we need more people to understand how to do this, and that’s where the learning comes in.


Berwick talks about changing the culture and the challenge in doing this. We all work flat out, with little time to reflect and learn, we spend a lot of time doing things the way we always have. There are a number of champions in organisations who are telling us things aren’t right. Now it’s time for sharp end leaders to reflect on their own areas, and think about what’s not right, and listen to those closest to that care delivery - our staff, parents, carers and patients.


Organisations will have to find a way to help their leaders learn about improvement science and patient safety, how the two are linked and how continual improvement programmes make an impact on safety. They will have to learn to measure safety rather than continuing to only measure harm.


We have national and international advisory groups and official recommendations to access as resources. The tools are there for us to use, we just need to choose the right ones for our teams and then give them the space to use them (e.g. Cincinnati Children's "Intermediate Improvement Science Series (I2S2)", Ohio Children's Hospitals' Solutions for Patient Safety (OCHSPS), etc.)


Investment in learning is priceless but does come at a cost. But that cost will be offset by the enthusiasm that the leaders will infuse in their department staff, in the improvements in care that the frontline staff can see, but have no power to change, in the experience that our patients will receive and by beginning to involve our frontline leaders in the ultimate goal – Continually Reducing Patient Harm.


Related Links:

-Berwick review into patient safety

-Dixon Woods M, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf. published online Sept. 9, 2013

-Cincinnati Children's "Intermediate Improvement Science Series (I2S2)"

-Ohio Children's Hospitals' Solutions for Patient Safety (OCHSPS)

-NSW "Between the Flags" (See also: Standard Paediatric Observation Charts (SPOC))   

-IHI "Mentor Hospital Registry"

-Josie King Foundation "Programs"

-Quaid Foundation/TMIT