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At the moment, it is vital that we are sensitive and kind. We don’t talk about the fantastic opportunities or upsides of the pandemic when so many people have suffered and died.

This is about starting to build a sense of shared purpose and common identity to make it less likely that people will return to their familiar habits and ways of working. It’s working together to build the kind of world (and kind world) we want.

Moving forward therefore is built on connecting to the past; the conditions before, created or revealed by the pandemic

This is also not the time to say everything we have done so far has been wrong all along; it is about building on the legacy before us, the generations before us that have helped develop and grow our understanding. It is being respectful of that past.

Moving forward therefore is built on connecting to the past; the conditions before, created or revealed by the pandemic.  Bringing that together with the present (how your ‘work is done’, what you and your team have achieved and can achieve and need to do now) and the future (possible changes that matter to us all and are based on your experiences and situations and not ‘work as imagined’).

What have we learned?

On Thursday 28 April, Q’s Organisational Resilience & Safety-II group organised a special zoom session to explore how practice is changing in the light of our COVID-19 response. Instinctively we know that everyday work in the complexity of a healthcare environment requires us to modify what we do to meet the needs of our patients. The challenges and pressures healthcare professionals are facing now are well beyond the boundaries set in ‘normal’ operation. The focus of the session was to share the real adaptations that are being made by our community right now to allow others to capitalise on them and for us to explore how practice may change beyond the current crisis.

The shared purpose conversation that transpired was inspirational and insightful. 132 people attended, representing healthcare organisations throughout the UK but also from New Zealand, Canada, Germany, Norway, Ireland, Portugal and Singapore. Attendees came from a range of disciplines, including clinicians, policymakers, quality improvers, patient safety and human factors specialists, incident investigators and social workers.

Following scene-setting and time for reflection, the hosts, Suzette Woodward, Simon Gill and Paul Bretton, encouraged use of the chat function to elicit discussion and analysis around three critical questions:

  1. You are adapting and adjusting your actions and decisions all of the time – even if you are not aware of that – can you think of ways in which you have adapted your practice over the last few weeks that have made a beneficial difference to the care you provide?
  2. In thinking about the adaptions you have been making what are the emerging new possibilities you have seen or experienced over the last few weeks that you want to continue?
  3. What can you do differently now?

In the discussions that followed 26 adaptations were shared, predominantly at a team and organisational level. The highest number of adaptations related to staff well-being. Contributions included the use of collaborative work, de-brief/safety huddles for regular updates and responding to staff queries/concerns. However, they also related to the ability to share positives, e.g. the number of patients discharged home, and the use of “collective light touch goal setting for wellbeing and sense of achievement as well as getting things done and working collaboratively.” There was a recognition that systematic psychological support is a priority so the team; “feel that they are doing ok and that it is ok not to be ok” and to make sure support is available for anyone who is suffering from significant stress/ trauma.

The highest number of adaptations related to staff well-being

Three participants commented on the rapid increase in virtual consultations and the resultant good feedback from both staff and patients. The extensive adoption of virtual working using tools such as teleconferencing and WhatsApp. Trello was mentioned by four participants; resisted before COVID-19 but now embraced by both team members and their organisations. Both the increase in productivity and the alleviation of isolation were mentioned as benefits.

Clinical changes were highlighted, such as an adaption of the ECMO retrieval process and “paediatric therapy teams taking their games/learning through fun on to adult wards.” “Fluidity of roles” and “upskilling” were also recognised as being critical to the response.

Supporting these adaptations there were many threads relating to the change in management style, with the flattening of hierarchies and the simplification of approval processes leading to easier and quicker adoption of change. Participants recognised that they were trusted by senior leaders to make such changes (“trusting the frontline to deliver putting power back into the organisation. ‘l’ leadership at all levels of organisation”; “they are getting approval at daily command meetings”) with virtual governance arrangements allowing such change to be adopted rapidly without the normal committees (“support the change and defend our position should we need to – still avoiding knee jerk and things must be thought through, but the process isn’t a barrier”). However, there is also the observation of “(appropriate) steepened hierarchy” and “command and control has built a powerful shared purpose – then made space for innovations and behaviour change.” A pertinent warning regarding command and control was offered too, “we can do things better if we take more time and involve diversity of opinions.”

The flattening of hierarchies and the simplification of approval processes led to easier and quicker adoption of change

Almost half of the adaptations that participants thought should continue related to the retention of staff well-being and support for psychological safety (“the absolute focus on our staff wellbeing – physical, emotional and psychological needs being central/ fundamental to our work”; “Sustaining compassion, kindness, human connection”; “showing appreciation to our fellow colleagues”; “the level of trust placed in us as employees has been great”; “its almost as if its become OK to tell your colleagues you value them and appreciate them”). Also the recognition of all staff, regardless of hierarchy, was mentioned and the need for support for senior management and leaders was also recognised.

70% of the adaptations which should be retained were at an organisational level, including networks built, new skills acquired, “finding the best route to disseminate information” and “methods of communication from executive team.” Virtual working/ consultations should also be retained and “flexibility of daily schedules for those working from home, currently necessary to manage childcare etc at present, shows potential to allow for a better work-life balance as we are trusted to get the job done in the way that works for us.” Better use of resource resulting from minimising contact was mentioned, “focusing on who really needs to see a patient, previously a patient would see multiple members of staff, now we are much more cognizant of the importance of reducing multiple reviews/re-examination and having the most suitable person seeing the patient first time.” A significant thread related to a drop in incident reporting “but an increase in excellence reporting.” What we have collectively learnt was important “the new ways of working are sustainable as we now have an excellent foundation (model) to address how we respond to winter pressures in healthcare”; “staff have been given crash course in quality and change – QI on steroids – over a period of intense change – those skills should be used when ‘normal’ returns.”

Big issues that were raised

Some of the larger issues raised should become our challenge to resolve. One important thread relates to the very nature of adaptation:

  • “How do we identify and recognise the negative aspects of ‘ultra adaptation’?”
  • “The ongoing framing of the value of adaptability; the current level the crisis has demanded is taking a toll, so is there a risk that standardisation and a false sense of stability will actually feel more appealing to those exhausted.”
  • “Are we creating conditions for flexibility where we may before have deliberately created rules/processes that force compliance? And is it clear for staff where we need/expect adaptation and where they need to default to a standardised process?”
  • “Many (most?) improvement efforts seek to standardise and reduce variation and thereby shift towards protocolised safety (Safety I) and compliance. Training to create adaptive behaviours is very different, and design of that training itself needs a lot of attention.”

Other challenges identified:

  • “Need for ‘Just Culture’ to underpin Safety II.”
  • “Moving away from healthcare dissonance towards liberated healthcare with collaborative decision making.”
  •  “How we frame risk in the context of safety conversations – embracing certain risks and variance which are necessary to get work done.”
  • “We have a silo effect in healthcare where different units will have solved issues in various ways and collaboratively we could work to compare and contrast to really explore the best practice.”
  • “Cultivate an attitude of curiosity”; “a mindset of ‘curiosity without judgement’ is crucial.”
  • “So many of my colleagues are now so stretched with the quantity of the work that the other aspects are very much lower priorities – they have no headspace to reflect.”

Moving forward

The discussion was rich and lively, constructive challenge was evident and helpful references were shared (see below). The feedback was excellent and the overriding conclusion is that this should be the start of further conversations to address the current crisis but also to establish learning for the future. Many favoured more large meetings like this but others suggested that these could be in smaller groups focussed on locality, clinical themes or sectors. We will explore options and come back to you. Thank you once more for your participation and we look forward to meeting again.

To watch the recording of this Zoom session, visit the event page.

For more information and to join in the conversation, visit the Organisational Resilience and Safety-II Special Interest Group (all welcome to join).

Further links and resources

Resilience Engineering Assocation: Global community of practice of those who are leading research and developing practical applications in how to create resilience in complex systems.

Rethinking Patient Safety – Suzette Woodward
Outlines what we need to do differently to truly transform our approach to patient safety.

Implementing Patient Safety – Suzette Woodward
Full of ideas and examples for how the latest safety thinking can actually be achieved.

The Lilypond Model – Paul Stretton
New conceptual model to describe patient safety performance.

The Checklist Manifesto – Atul Gawande
Avoidable failures are common, and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it – correctly, safely or efficiently.

Invisible Women: Exposing Data Bias in a World Designed for Men – Caroline Criado Perez
Reveals how in a world built for and by men we are systematically ignoring half of the population, often with disastrous consequences.

Still Not Safe – Robert Wears and Kathleen Sutcliffe
The story of the rise of the patient-safety movement.

Safety-I and Safety-II – Erik Hollnagel
Detailed and tested arguments for a transformation from protective to productive safety management.

Just Culture – Sidney Dekker
How to restore trust and accountability in your organisation.

Compassionomics – Stephen Trzeciak
Uncovers the eye-opening data that compassion could be a wonder drug for the 21st century.

The Fearless Organization – Amy C. Edmondson
Practical guidance for teams and organizations who are serious about success in the modern economy.

Simply Complexity – Neil Johnson
A Guide to Complexity Theory.

Complexity and Management – Ralph D. Stacey
The impact of complexity on strategy, systems thinking, organization and management theory, and organizational change.

Out of This World – Paul Sean Hill
The principles of high performance and perfect decision making learned from leading at NASA.

Systems Thinking for Everyday Work – NHS Education for Scotland (NES)
Cards based on RE Safety-II principles

Thinking fast and slow – Daniel Kahneman
Book on the conscious and unconscious working of the mind and its effect on performance.

#ABCchat – Kaleidoscope Health and Care
Video discussion on varied topics at 11-1130 on Thursdays.

The Varieties of Human Work – Steven Shorrock
Understanding the difference between work-as-imagined and work-as-done.

Safer Healthcare – Charles Vincent, Rene Amalberti
Models of safety.

Schwartz Rounds – Point of Care Foundation
Development of a new version of Schwartz rounds that can be done in these times.

Huddles – Penny Pereria (Q)
And a national view from across the UK and Ireland, inc increased used of huddles as a fast way to connect and adapt.

Coordinated Response Protocol / Learning Review – Ivan Pupulidy
Redesigning how you investigate incidents. The work was done at the US Forest Service.

Learning from Excellence focussed on COVID-19 – Learning from Excellence

Team of teams – Stan McCrystal
How to combine the agility, adaptability, and cohesion of a small team with the power and resources of a giant organization.

Human Performance Contributions to Safety in Commercial Aviation – Dr. Jon Holbrook
Great research by NASA on human performance contributions to safety in commercial aviation.

Rebel Ideas – Matthew Syed
Great book on the importance of cognitive diversity.

Brave New Work
Lots of details on reinventing workplaces. There are Reinventing Work meet-ups spreading around the globe at the moment.

Practice – Do we really know why things go well? – Stephan Ore, Erik Hollnagel and Ivonne Herrera
Small pilot implementing Safety-II, perhaps you want to try?  RPET tool developed by Erik on diverse healthcare units in Oslo.

The structured communication tool – Raymond M, Harrison MC
SBAR (structured communication tool) can help you think about email – if you struggle with being succinct.

Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program – various authors

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience – various authors

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