Better team working for a safer hospital

Every day, lives are saved by talented and committed clinicians working in hospitals. Despite this, there are still cases where patients die or are harmed unintentionally due to breakdowns in safety. One in ten patients admitted to hospitals in developed countries suffer harm as a result of medical errors. However, research evidence indicates that improved team working can reduce errors and save lives.

Team work is increasingly important because the delivery of patient care is becoming increasingly complex, requiring interactions involving staff, technology and medication. The opportunity for error to creep into the system is high and one of the most pressing challenges facing today’s hospitals is to prevent or mitigate such risk.

There is now widespread recognition that more needs to be done to improve patient safety. In England, the Chief Medical Officer has highlighted the need to pay serious attention to patient safety.

System-wide changes in hospitals are needed to improve safety but these alone will not bring about improvements. To make progress, safety initiatives need to be underpinned by measures to engage clinical teams.

All staff must learn to prioritise safety problems and act on them so that medical mistakes are less likely to happen. Part of this relies on strong hospital leadership – a leadership that can guide and develop teams of clinicians to work together in the most effective ways so that patient safety becomes everyone’s responsibility.

In 2004, The Health Foundation launched its four-year Safer Patients Initiative. Now working with 24 hospitals across the UK, its ambitious aim is to reduce the number of adverse events at each site by at least 30 per cent. Four hospital sites are already two-and-a-half years into the initiative: Conwy and Denbighshire NHS Trust (Wales), Down Lisburn Health and Social Services Trust3 (Northern Ireland), Luton and Dunstable Hospital NHS Trust (England), NHS Tayside (Scotland). Together, they have already halved the number of medical mistakes occurring in their hospitals and are saving patients’ lives through their safety work.

Working with experts from the US-based Institute for Healthcare Improvement (IHI), the initiative provides the hospitals with technical expertise in order to build their own resources to make system-wide improvements. The IHI has been improving safety in hospitals across the US since 1991. Each SPI hospital is testing out what works to improve patient safety in three settings: on the wards; before, during and after operations; and in critical care. In each of these settings, clinicians are working with The Health Foundation and IHI on ways to improve infection control, the management of medicines and communication between staff teams and patients. There is also an underpinning commitment from the senior leadership to prioritise patient safety.

Having successfully completed the first phase of the project, the teams from the first four hospital sites will spend the next two years sharing their results, learning and best practice within their own hospitals. Ultimately, they expect to act as exemplars to other hospitals in the UK.

Making safety everyone’s responsibility

As well as focusing on technical solutions to patient safety, each hospital has been examining and improving its clinical leadership commitment and safety culture. The Health Foundation has provided each hospital with 20 days of support from a leadership development consultant to field-test the concept of shared leadership.

Shared leadership is based on the well-established principle that the most effective teams are those that recognise and make full use of the expertise and talent of all team members. The team can draw on all its potential capacity. Moreover, evidence suggests that a team trained in shared leadership can continue to function in the absence of its regular leader. The Safer Patients Initiative has shown that the quality of care delivered to patients can be improved when contributions from all team members are valued and clinical teams take shared responsibility for performance outcomes. Leadership development can be used to improve team processes, project planning and communication. It can also equip individuals with more effective change management skills.

What are the results?

The following are some of the key results from the patient safety work done by the first four hospital sites:

• NHS Tayside has seen its adverse event rate reduce by nearly three quarters.
  
• Ward staff at NHS Tayside have reported a steady increase in hand hygiene compliance to 94 per cent. This is helping to reduce hospital-acquired infections.
  
• Improvements on getting the right medicine, in the right dose to the right patient, at the right time have been made at Down Lisburn. Ninety per cent of medicines are now documented correctly when a patient arrives and are correct on discharge from the hospital. The system is also linked to GP patient records and is helping to reduce mistakes in the primary care setting.
  
• Luton and Dunstable’s standardised mortality rate has improved from being 11 per cent worse than average (in 2005) to being 11 per cent better than average (last quarter 2006).
  
• By using a colour-coded early warning scorecard and a rapid response outreach team, Luton and Dunstable estimate they are saving one or two lives each week.
  
• Conwy and Denbighshire has successfully implemented ventilator, central line and sepsis bundles to streamline and improve the quality of care delivered to critically ill patients. Their average length of stay on the intensive care unit has fallen by 2.7 days, allowing an additional 343 patients to be treated. The trust has also made a saving in its pharmacy drugs bill of £78,000 because patients are receiving less sedation, are not requiring so many antibiotics and are coming off intravenous medications faster.

With around 14,000 staff, NHS Tayside provides a comprehensive range of primary, community-based and acute hospital services for the populations of Dundee City, Angus and Perth and Kinross in Scotland. Patient safety is literally at the top of the agenda at NHS Tayside. Rather than finance or performance management, safety is the first issue discussed at the executive team’s weekly meeting.

Pat O’Connor, Head of Safety, Governance and Risk at NHS Tayside, believes that this has speeded up the decision-making process. “We have team briefings on patient safety activity involving the executive team plus key frontline staff,” she says. “So we don’t have the linear decision-making process that most people identify with the NHS. This means decisions filter down much quicker and the organisation can be much more responsive in addressing a particular problem.”

The executive team’s role

Pat says that this high-level support for the patient safety programme has been integral to its success. “Certainly at times you do need a senior leader to lead from the front, particularly in the early days,” she explains. "But then at different times you need someone at the back encouraging people.

“We’ve been fortunate to have that support from the outset, but you will always get some resistance in large organisations such as ours,” she continues. “The Institute for Healthcare Improvement’s advice is to focus on the ‘early adopters’ who have the will to change and generate momentum that way. Perhaps before I would have concentrated first on the people who were less interested, but I know now that’s not necessarily the best way to implement change.”

Much of the leadership development work at Tayside is focused around coaching and building skills for individuals who are improving safety on the front line. Clinicians are encouraged to find solutions to problems themselves, rather than taking issues up the management chain. As well as ensuring that management time can be focused on other priorities, this approach helps staff better understand the system in which they are working. They also feel greater ownership of the solution as a result.

There are numerous events throughout the year when clinicians can profile their achievements and an informal open monthly meeting called ’Celebrating Success’. At these sessions, the monitoring data is reviewed and all staff have the opportunity to air their opinions on implemented changes. Each team raises two challenges they’ve faced that month and the group collectively helps resolve them.

Lessons in clinical leadership

Jean Balfour is a leadership development consultant who has been working closely with the patient safety team at NHS Tayside. She says that the concept of shared leadership is about ensuring that improvement skills are spread throughout an organisation, rather than remaining at the top.  

“If leadership is left to the few, particularly in a senior role, then it stops change, innovation and improvement being able to permeate through the organisation,” Jean explains. “Whereas if leadership is shared with clinicians throughout the organisation, it enables people to lead change and improve things at all levels. In the case of NHS Tayside, we’ve seen that by developing and enabling leaders throughout the organisation at all levels, we can actually help to speed up the improvement process.”

Jean was asked to help the team work together more effectively and engage others in their safety improvement work. “A lot of my role was helping them work out how they were going to work with people who weren’t so engaged. How they were going to influence them, get them on board, teach them and help them to change their own practice,” she says.

Although Jean gave the team some formal coaching, much of her work focused on the facilitation of discussions. For example, one clinician used Jean as a regular sounding board, particularly for advice on how to influence other doctors. They used Myers Briggs Type Indicators ® to understand how to deal with different personality types in the team. This in turn helped them to devise more effective influencing strategies.

On a practical level, Jean advises that a flexible approach is needed. “You can’t just pull people away from the wards, theatres and clinics at pre-defined times,” she says. “At Tayside, things started to work really well when clinicians came to me and said, ‘I’ve got half an hour free at this time,’ because you knew that if they suggested a convenient time, you would be more likely to get their full focus.”

In Jean’s view, the progress that NHS Tayside has made in patient safety has not just come about from improvements to systems and processes but also from a clear recognition that leaders need to be developed and empowered at all levels. This has enabled clinicians to test out their own solutions to problems, communicate the results and influence others to adopt them.

“By using problem solving action learning sessions, we got people to come together and explore issues such as how to spread hand washing compliance across the whole of the hospital,” Jean explains. “They then set about unravelling the problem together. As a leadership consultant, it’s rare for me to be so rooted in a clinical setting but it’s been so rewarding for me to see this work result in improved outcomes for patients.”

Holding the gains

Changing the culture of an organisation is a long-term objective. Once change has been implemented and improvements recorded, the challenge is to sustain those advances, while also identifying other areas for improvement. “We call this holding the gains,” Pat explains. “For us, this means embedding safety considerations in everyday practice.

“Senior leadership used to be expected to have all the answers. Now people are saying ‘This is my problem and I need to find a solution to it.’ Solving the problem then gives them confidence to share their experience with others,” Pat concludes.

Conwy and Denbighshire NHS Trust covers nine hospital sites in rural North Wales. It has approximately 900 beds and over 5,500 staff. Dr David Gozzard is medical director at the Trust. He believes that securing senior buy-in for safety improvement projects is vitally important and can determine the success or failure of a project. Conwy and Denbighshire have used safety walk rounds as a way of ensuring the executive team are on the wards discussing safety issues with clinicians on a regular basis.

Building clinical leadership

Effective team working relies on a strong group dynamic, a common sense of purpose and ownership and the selfawareness of individuals. Convincing others that a course of action will lead to improvements in working practices and better patient care is not always straightforward. The Safer Patients Initiative team in Conwy and Denbighshire has found engaging early adopters and identifying different people’s working styles and preferences can help. They have also found safety briefings, known as ‘huddles’, a useful tool for team development.

Sue O’Keeffe is Acting Head of Modernisation at the Trust and was formerly Practice Development Sister. Sue has played a lead role in devising and implementing ‘care bundles’ to streamline and improve the care of critically ill patients on the intensive care unit. Care bundles are a series of interventions that have a significantly better outcome when used together, rather than individually.

When Sue first tried to implement the care bundles, she met with some resistance. “One senior clinician told me he thought they were cook-book medicine and would not help staff to do their jobs,” she says. “I knew I had to work with our early adopters to make the bundles a success. By working with innovative and forward-thinking nurses who weren’t afraid to give me constructive criticism, we tested out our approach with one patient for one day and recorded the results.

“In two years, I’ve seen the culture in critical care transformed,” Sue continues. “Nurses feel empowered to tell doctors ‘this is how we do things here’ and the doctors don’t question the approach because they can see the tangible benefits. For me, better team working is all about finding people’s niches and comfort zones, and utilising their skills effectively.”

Sue has also found the Myers Briggs Type Indicator® exercise valuable. “We still all refer back to our Myers Briggs types,” she says. “My personal style is that I don’t like to do anything last minute but there are a couple on my team who do everything down to the wire. This used to get me really agitated and I would keep chasing them up. But now I understand them and myself better, I feel much more relaxed about working with them. It’s enhanced our team as we now trust each other more.”

Sustaining and spreading change

David believes that changing the patient safety culture in a hospital requires a long-term commitment. “Everyone has to sign up to one vision, pursue it passionately and cultivate the skills to get others to follow,” he explains. “Change won’t happen overnight because it’s not being imposed from on high or by diktat. We’re making safety everyone’s responsibility, so it will take longer to do, but the improvements we make will be widespread and sustained.”

“It’s also really important that the clinical leaders are on board as they have an understanding grounded in practice,” Sue adds. “As part of the initiative, we’re collecting and monitoring more data over time. Showing consultants their individualised data can be a powerful way to compel them to take action.”

Using their enhanced leadership skills and the methodology taught by the IHI, the Safer Patients Initiative team at Conwy and Denbighshire will now work across the entire Trust. They have set up a multi-disciplinary Quality Improvement Forum for 15 clinicians, which will convene once a month for a year. Here, they will be taught patient safety methodology and given ideas and advice on how to make improvements on the wards. They will then test out changes and report back. If the first forum proves a success, the plan is to then extend it to other members of staff.

The four hospitals involved in the first phase of the Safer Patients Initiative have shown that improvements in patient safety can be achieved through more effective team working. They have found that decisionmaking processes are accelerated by involving the right people at the right times. This has meant that positive changes have been introduced faster and more easily. The exact means of solving problems in patient safety is often influenced by local circumstances. However, the Safer Patients Initiative teams have identified the following common factors that have helped them to work more effectively to provide safer patient care:

Make patient safety everyone’s responsibility

Support from the senior management team is vital. However, if the culture of an organisation truly is to change, people at all levels of the organisation need to make patient safety a priority.

Create leadership that supports patient safety

Efforts to improve patient safety need to be coordinated across the hospital, trust and board. Senior teams need to emphasise the significance of patient safety in all they do. Clinical teams need to feel confident that they can report their concerns about patients’ safety.

Ensure senior teams know how safety is affecting care

In the Safer Patients Initiative hospitals, the senior executive teams pay attention to how the clinical teams’ work is contributing to improvements in patient safety and how they can be spread across the hospital. They have found it helpful to appoint a patient safety officer to help ensure that the senior team is informed about safety issues across the hospital.

Identify and focus on ‘early adopters’

Focus attention on those most willing at the outset. The hospitals involved in Safer Patients Initiative have worked with early adopters to create ‘patient safety champions’ – individuals who promote their safety improvement work and build impetus for change.

Value contributions from all members of the team

For safety to improve, all members of the multi-disciplinary team need to be actively involved. Each individual should be valued for the professional knowledge and expertise they contribute and safety solutions should be designed with this in mind.

Work on individual and group dynamics

Identifying individual strengths and preferred working styles can help team members understand how their own style of working affects others in the team. Understanding how others work and what compels them to take action can help build influencing skills so that it becomes easier to make improvements and bring about change more quickly.

Ensure leadership is not over dependent on one person

When a team leader is absent, the team should continue to function effectively. All team members should have adequate training and development to ensure that everyone plays a role in delivering safe and effective care to patients.

Use data to build the will for change

Collecting data that relate to everyday clinical practice can help get people involved in quality improvement. Tracking change over time shows improvements in the quality of care and makes the connection between clinical teams’ work and improved patient outcomes.

Talk patient safety

Good communication is vital to ensuring that patient safety remains a priority. As well as using safety briefings and patient safety champions to promote safety issues, other communications channels can help disseminate messages about improvement.