The HSRN Spring meeting was an opportunity to hear from some of the researchers funded by the NIHR HS&DR Programme in 2009 on patient safety and to also hear from Dr Carl Macrae and Rick Iedema on their reflections in the field. Around 50 people took part, with lively discussion on interpretation of emerging findings, methods and implications for practice and future directions for patient safety. Tara Lamont, Scientific Advisor to the HS&DR Programme, opened the meeting and noted the particular focus was on organisational-level influences on patient safety and understanding some of the implications for change.
Professor Charles Vincent, Health Foundation Professorial Fellow at the University of Oxford, reflected on the shift in emphasis over the last 15-20 years to the enormous role of wider systematic factors and highlighted his interest in hearing more about some of the topics to be explored during the meeting, including the role of boards and open disclosure policy.
Handovers in care occur at many points along the patient journey such as when a patient moves from A&E to a ward, from a ward to community care or their home. We heard from two researchers exploring the handover process to understand opportunities for improving patient care. View the presentations at the bottom of this page.
Our first speaker, Professor Justin Waring, explored the threats to safe hospital discharge drawing on observational field methods in two different organisations. He reflected on the key learning points from his study, including the importance of a dedicated discharge coordinator, how opportunities for functional proximity lead to informal knowledge sharing between staff, the need to move away from seeing discharge as an end point, using fit-for-purpose single health records rather than multiple software packages and finally, the importance of distributed leadership so frontline staff can take ownership over the process.
Dr Mark-Alexander Sujan’s work, published in the Health Services and Delivery Research journal, looked at handovers in emergency care and he opened his talk with the story of Frank, a hit and run patient brought into A&E by ambulance and then placed 7th in line to be assessed by the triage nurse. Frank’s condition declines while he is waiting to be assessed, yet the paramedics need to leave him without the opportunity for a handover because of the focus on targets in the system. Frank’s story ends well but his experience is a helpful reminder of the tensions in the system. Dr Sujan introduces the notion of “being worried” explaining how practitioners make trade-offs in different situations and the secret second handover.
Moving on to the role of hospital boards, Professor Russell Mannion’s starting point was the research gap in the UK on what boards do and how they function to promote a patient safety culture. His project is still in progress, yet the emerging findings present a fascinating account of a disconnect between how members of the board respond to surveys on the importance of patient safety yet with contradictory observations from fieldwork. Other emerging findings include the continued use and reliance on hard data rather than the softer forms of intelligence gathering such as walk-arounds and engagement with staff.
Research funded by the NIHR HS&DR Programme in the patient safety portfolio is also making a contribution to theory development as illustrated by the work presented by Professor Martin Kitchener. His research project proposes a realist analysis model to identify and analyse the contextual mechanisms that interact with organisational factors to generate the outcomes of hospital patient safety interventions. The final report presenting the full set of intervention-context, mechanism, outcome configurations (I-CMO) from this work is under review.
Professor Yvonne Birks’ research on open disclosure explored the Being Open Framework in the UK context – how is it being used and what is the evidence to underpin its use. Her findings highlighted a number of important implications, including:
- The Being Open Framework has 10 key principles yet 3 of these are often not discussed, nor reflected in the literature. These are confidentially, risk management and clinical governance.
- Who defines harm and error matters, yet, patients are typically not involved in this process and they expressed frustration with the inconsistencies.
- Junior members of staff are not usually involved in disclosing harm, yet, interventions to improve open disclosure are targeted at this staff group.
Carl Macrae, a social psychologist and Health Foundation Improvement Science Fellow, asked the question: what’s the point of safety incident reporting? Offering reflections from his work in the aviation industry, he noted how in health we look at file cabinets of incident reporting data and not social infrastructure to understand error and the invisible infrastructure of improvement.
Rick Iedema, now at the Agency for Clinical Innovation (NSW Ministry of Health) in Australia as well as a Professor of Healthcare Innovation at the University of Tasmania, reflected on the afternoon’s presentations offering a number of concluding thoughts:
· The issue of complexity came up in all the presentations and the importance of this for how we understand and communicate the emerging research in the field.
· Using the concept of everyone having a ‘Understandascope’ through which they see the messy everyday reality, Rick found all the projects to be embedded in the context and environment in which they are trying to understand and improve.
· The importance of taking our research back to practice and opening up discussion with those in the frontline.
In closing, several speakers emphasised the radical and perhaps, not fully exploited, potential of patients and carers as agents to improve care and identify system weaknesses. Tara Lamont asked delegates to consider other future research directions in the field of patient safety to close the meeting.
Thank you to all our speakers and delegates for making the HSRN Spring Meeting a success.
View the presentations:
Yvonne Birks - Birks.pdf
Justin Waring - Waring.pdf
Alexander Sujan -Sujan.pdf