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Maternal and Neonatal Health Safety Collaborative West of England LLS 3

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Our West of England Maternal and Neonatal learning system provides an opportunity to improve maternal and neonatal care across the local maternity systems, and a forum for local improvement to thrive.
Our Local Learning System is part of the three year National Maternal and Neonatal Health Safety Collaborative, whose mission is to create and embed the conditions for all staff to improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide high quality healthcare experience for all women, babies, and families across England.

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Maternal and Neonatal Health Safety Collaborative West of England LLS 3

  1. 1. 27 February 2019 Maternal and Neonatal Health Safety Collaborative Local Learning System
  2. 2. Previously at the Maternal and Neonatal Health Safety Collaborative Local Learning System
  3. 3. SWMCN – Working together for Better Births in the South West Nine national programme work streams to support the implementation of Better Births locally
  4. 4. SWMCN – Working together for Better Births in the South West • Maternity Transformation Programme –Better Births - Local Maternity Systems • Maternal and Neonatal Health Safety Collaborative – Local Learning Systems –Five Clinical Drivers
  5. 5. SWMCN – Working together for Better Births in the South West • To improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity care settings in England”
  6. 6. SWMCN – Working together for Better Births in the South West
  7. 7. “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of care, top to bottom and end to end.” A Promise to Learn, A Commitment to Act Don Berwick, August 2013
  8. 8. SWMCN – Working together for Better Births in the South West Each of the 15 areas will have a named Patient Safety Collaborative lead • Local Learning Systems (LLS) • Hands-on support for LifeQI • Support for QI training • Support through the SCORE process for debriefing
  9. 9. SWMCN – Working together for Better Births in the South West West of England Local Learning System South West Local Learning System Wessex Local Learning System (Dorset and SHIP LMSs)
  10. 10. SWMCN – Working together for Better Births in the South West • By 2020 each trust, local maternity system and network should have: • significant capability (and capacity) for improvement • detailed knowledge of local cultural issues • developed a locally sensitive improvement plan • made significant improvement to local service quality and safety • data to share with their board, staff and commissioners that reflect these improvements • …to create the conditions for a safety culture and a national maternal and neonatal learning system
  11. 11. SWMCN – Working together for Better Births in the South West
  12. 12. SWMCN – Working together for Better Births in the South West • Shared learning across networks and Local Maternity Systems • Themes aligned to the Five Clinical Drivers • Open to all working in maternity and neonatal services • Involve women and families, Maternity Voice Partnerships • Quality Improvement • Four events per year
  13. 13. SWMCN – Working together for Better Births in the South West • A forum for local improvement to thrive • An opportunity for all network partners to work collaboratively • Effective collaboration between local partners • Opportunities for system level improvement • An opportunity for increasing local improvement capability • A sustainable solution for maternal and neonatal improvement
  14. 14. SWMCN – Working together for Better Births in the South West MNHSC Local Coordinating Group Patient Safety Collaborative Local Maternity Systems Maternity Clinical Network Neonatal ODN NHS Improvement Public Health
  15. 15. SWMCN – Working together for Better Births in the South West Local Learning Systems Local Maternity Systems and Networks Services in Trusts and community Mothers and families
  16. 16. www.weahsn.net/matneoqi
  17. 17. Steps and timing • Form two circles with the inner facing out. • Standing across from another person respond to the open ended sentence that follows : 1 min • Question 1 x 1 min • Switch roles – stay curious & dig deep : 1 min • Inner circle take a step to the right • Respond to the next question Keep up the pace!
  18. 18. What first inspired me to work in maternal and neonatal care is…
  19. 19. What I hope can happen for us in this work is…
  20. 20. If we do nothing, the worst thing that can happen for us is…
  21. 21. A question that is emerging for me is…
  22. 22. When all is said and done, I want to…
  23. 23. Rethinking Safety
  24. 24. Rethinking patient safety Dr Suzette Woodward National Clinical Director Sign up to Safety Team
  25. 25. Last night I had a vision Of people asking questions Instead of talking without listening And admitting that the news was new Take a breath, try these for size: I don’t know I changed my mind Between life and death we’ll find the time To get it right Last night I had a vision Of people being congratulated Instead of ridiculed and hated For admitting that they’d made mistakes If everybody’s ready for some changes to make Let’s try and get it right Frank Turner Lyrics
  26. 26. 3 things we need to do now 1. Create a balanced approach to safety – Safety I with safety II 2. Urgently tackle the blame culture – Negativity, incivility and bullying 3. Care for the people who care – Bringing joy to our work
  27. 27. 1 Create a balanced approach to safety
  28. 28. Safety I Failure Success
  29. 29. Safety I myths 10% of people will be harmed by healthcare We will find the root cause Zero harm is possible Increased reports equal better safety culture Incidents will surface the truth
  30. 30. Problems will be solved with: A few more resources A little more effort Another set of recommendations Better data Further regulation
  31. 31. Why only look at what goes wrong? 10 / 90
  32. 32. Normal day to day performance Exceptional performance Never events Significant and Serious incidents Learning from deaths Incidents Complaints Claims Safety I Safety II and Learning from Excellence
  33. 33. Refocus Failure Success
  34. 34. • Unexpected and emergent • People adjust and adapt • Create order out of disorder • Inevitable and necessary performance variability – study and celebrate this
  35. 35. • Help people succeed under varying conditions • Understand the everyday in order to replicate and optimise what we do • Understand ‘work as done’ in order to prevent things from going wrong Erik Hollnagel
  36. 36. work as done versus work as imagined work as prescribed work as disclosed
  37. 37. Change the language Change the mindset Patient Safety Working Safely Zero harm Improvement Human Error Performance variability Natural variation Strengthen Violations Adjustments
  38. 38. Learning from excellence highlights success in an environment where the prevailing approach to learning is to highlight failure Dr Adrian Plunkett
  39. 39. Safety II Failure Success &
  40. 40. In summary People make countless adjustments during their work Most of these lead to success Some lead to failure This is just work Take the blame out of failure Adapted from Adrian Plunkett
  41. 41. 2 Urgently tackle the blame culture
  42. 42. Range of blame
  43. 43. Minor incivility can lead to.. • an immediate loss of cognitive capacity • reduction in the quality and time of people’s work • potentially knock on impact on service users • an impacts on onlookers civilitysaveslives.com @civilitysaves
  44. 44. Defined by one bad day • When something has gone wrong .. – it is probably true to say it has gone right many times before .. – and that it will go right many times in the future – and yet people are judged by one error or incident for the rest of their careers
  45. 45. How many of us would survive the microscopic scrutiny of our actions? There is almost no human action or decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight
  46. 46. Intentional v unintentional
  47. 47. Restorative Just Culture • People are not the problem and usually the solution – when something goes wrong ask…. –Who was hurt? –What do they need? –Whose obligation is it to meet the need? Sidney Dekker
  48. 48. Restorative Just Culture Sidney Dekker
  49. 49. Creating a restorative learning culture 20 min film via: http://sidneydekker.com/just-culture/ The story of Mersey Care
  50. 50. 3
  51. 51. Kindness Gratitude Joy Wellbeing
  52. 52. Gratitude • Lowers blood pressure and boosts immune systems • Increases happiness and fights depression • More likely to be kinder to others • A person who feels appreciated will always do more than expected • Feeling appreciated keeps people going when it is tough
  53. 53. • People are 43% more productive when they feel valued • Close working friendships increase employee satisfaction by 50% • People with a close friend at work are 7 times more likely to engage fully in their work
  54. 54. Kindness is ‘helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped’ Aristotle
  55. 55. Be kind People see kindness as weakness, but it’s the most unbelievable strength if you use it in the right way
  56. 56. Clear is kind – unclear is unkind • An act of kindness can be.. – helping someone find a new role if their skills don’t fit for the one they are currently in – helping someone improve their abilities or performance – Helping people address their weaknesses rather than leave them to flounder and struggle
  57. 57. Kindness, emotions and human relationships • Unwin’s report champions the need for greater understanding, intelligence and acceptance of kindness as a vital part of the way we work and not just an add-on Julia Unwin, Carnegie fellow
  58. 58. Given all these benefits of kindness and gratitude and joy it seems surprising that very little attention is paid to this in both healthcare and in helping people work safely
  59. 59. The opposite of wellbeing • Fatigue • Hunger • Memory loss • Distractions • Shame and grief
  60. 60. The business case is clear; the best places to work have the best retention. What matters to people is when they feel appreciated and supported, when they feel part of a shared endeavour, knowing what the purpose is Sarah Jane Marsh
  61. 61. What has it got to do with patient safety?
  62. 62. The big challenges facing patient safety is about we behave towards one another
  63. 63. Safety II Learning from excellence Just culture GratitudeJoy Kindness Wellbeing
  64. 64. Creating healthy and supportive workplaces is no longer a nice thing to have – it’s a must do
  65. 65. A few easy things you can do to bring this to life
  66. 66. Notice the everyday
  67. 67. Keep a gratitude diary
  68. 68. Golden moments and golden days
  69. 69. Create a positive workplace • Say thank you • Laugh and have fun • Eat together • Learn new things • Support flexibility and trust
  70. 70. Never forget how powerful it is to simply say thank you www.signuptosafety.org.uk www.suzettewoodward.org.uk @suzettewoodward @signuptosafety
  71. 71. Rethinking Safety
  72. 72. Great Western Hospitals Swindon (Wave 2) Kathryn Owen, Christina Rattigan What we wish we knew this time last year…
  73. 73. Pre-wave SCORE survey 20 February West of England Local Learning System 3 25 March National Sharing Day, London April Introductory visits to Wave 3 Trusts May 8 – 10 May National Learning Set Wave 3.1 22 May West of England Local Learning System 4 July 17 – 19 July National Learning Set Wave 3.2 September 25 September West of England Local Learning System 5 November 13 – 15 November National Learning Set Wave 3.3
  74. 74. Nathalie Delaney Creating the conditions for a culture of safety and continuous improvement
  75. 75. https://vimeo.com/166819236
  76. 76. What matters to you? • What makes for a good day for you? • What makes you proud to work where you do? • When we are at our best, what does that look like?
  77. 77. (with thanks to Matt Hill and Jo Pendray from South West AHSN)
  78. 78. (with thanks to Matt Hill and Jo Pendray from South West AHSN) Preparation – engage the team, communicate
  79. 79. (with thanks to Matt Hill and Jo Pendray from South West AHSN) Preparation – engage the team, communicate Engagement– send out reminders
  80. 80. (with thanks to Matt Hill and Jo Pendray from South West AHSN) Preparation – engage the team, communicate Engagement– send out reminders Analyse and report– don’t disseminate before debriefing, familiarise yourself with the charts
  81. 81. (with thanks to Matt Hill and Jo Pendray from South West AHSN) Preparation – engage the team, communicate Engagement– send out reminders Analyse and report– don’t disseminate before debriefing, familiarise yourself with the charts Debriefing– get together and dig in
  82. 82. • What gets in the way of a good day is… • What frustrates me in my day is…
  83. 83. https://soniasparkles.coSoniam/2017/09/24/joy-in-work-pictorial/
  84. 84. Avedis Donabedian
  85. 85. HEE workforce Workshops for Maternity
  86. 86. What have we offered – Workshops (Glos and BSW LMS) which provide an opportunity for staff across a Maternity system to get together and: • Identify main workforce issues • Agree ways in which these can be addressed • Action plan on key priorities • The workshops delivers: • A Workforce Action Plan • A starting point in discussion across LMS on workforce, which needs to be owned and built on.
  87. 87. What we have found • Great work and strong foundations in all Trusts/LMS’s we have engaged with • Need for better use of all staff – Midwives, MSW’s and Medical staff • Some service changes are needed – Community Hubs for HV and Midwives • Frustrations with IT • Midwifery Consultant – seems popular • Releasing clinical staff time to make change happen
  88. 88. Next steps • More work on analysing what the workforce looks like in Maternity across the system – HEE and local Trust staff • Reconciling a Workforce Strategy for all LMS’s and the South West? • Developing practical Workforce Plans for LMS’s and supporting plans on OD, Learning and Development, Recruitment and Retention etc. as required
  89. 89. Contact • Marc Lyall – Workforce Transformation and Education Development lead • Mobile – 07585 999539 • Email – Marc.Lyall@hee.nhs.uk
  90. 90. Ann Remmers Safety at a system level
  91. 91. Primary Drivers Secondary Drivers Creating the conditions for a culture of safety and continuous improvement Improve the experience of mothers, families and staff Improve the detection and management of diabetes in pregnancy Improve the early recognition and management of deterioration during labour & early post partum period Improve the detection and management of neonatal hypoglycaemia Improve the optimisation and stabilisation of the very preterm infant Develop safe and highly reliable systems, processes and pathways of care Aim To improve outcomes and reduce unwarranted variation by providing a safe, high quality healthcare experience for all women, babies and families across maternity care settings in England. Reduce the rate of stillbirths, neonatal death and brain injuries occurring during or soon after birth by 20% by 2020 Improve the proportion of smoke free pregnancies Learn from excellence and harm Improving the quality and safety of care through Clinical Excellence
  92. 92. Improve the proportion of smoke free pregnancies Improve the optimisation and stabilisation of the very preterm infant Improve the detection and management of diabetes in pregnancy Improve the detection and management of neonatal hypoglycaemia Improve the early recognition and management of deterioration during labour and early post partum period We are…. Mark where you think your organisation is on the improvement journey for the Big 5 topics Don’t know Solved it!Getting started
  93. 93. Improve the proportion of smoke free pregnancies Improve the optimisation and stabilisation of the very preterm infant Improve the detection and management of diabetes in pregnancy Improve the detection and management of neonatal hypoglycaemia Improve the early detection and management of deterioration during labour and early post-partum period SwindonBathBSWGlosBNSSGSomersetPlymouthCornwall Don’t know Getting started Solved it! Median
  94. 94. Where are you now? What are your plans? What are your challenges? Improve the proportion of smoke free pregnancies Improve the optimisation and stabilisation of the very preterm infant Improve the detection and management of diabetes in pregnancy Improve the detection and management of neonatal hypoglycaemia
  95. 95. Where are you now? What are your plans? What are your challenges? Change Ideas Which change ideas are you planning to test from the national driver diagram? Why have you selected them? How have you assigned the testing of change ideas? What has gone well in relation to change ideas? What change ideas will you test next? What’s difficult about selecting and testing change ideas? How might you overcome these barriers? PDSA Which PDSAs have you tested? Have you learnt anything from testing? How did you record your PDSA? Who has been involved in your testing? Have you had to teach the MDT about using PDSA? Have you used measurement to inform your PDSAs? How do you share your learning/outcomes from PDSA? What has been good about doing PDSA? What PDSAs are you planning to do? Who will test for you? Where will the tests happen? What’s been challenging about PDSA? How might you overcome these barriers? Measurement What measures from your measurement plan are you using at project level? Consider; Outcome, Process, Balancing, Qualitative. How do you collect your measures? How are you presenting and sharing your measures? What is your data telling you so far? What has been positive about using measures? What are your plans related to measurement? What has been challenging about measurement? How might you overcome these barriers? Involving women How have you involved women and families in your project? What strategies/approaches have you used? What have you learnt from involving women and families? How will you be evaluating women and family experience? What are your plans for involving women and families in the future? What has been challenging about involving women and families? How might you overcome these barriers?
  96. 96. Ann Remmers Summary and Next Steps
  97. 97. • Check out www.weahsn.net/matneoqi • Next event Wednesday 22 May 2019 at Holiday Inn Filton Bristol Book your place here: https://matneoqi_west_22may19.eventbrite.co.uk • Save the date: Wednesday 25 September 2019 at Holiday Inn Filton Bristol https://matneoqi_west_25sep19.eventbrite.co.uk

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