“Dr Adrian Plunkett is a consultant in the NHS (in paediatric intensive care). He has a passion and desire to improve patient care through learning from excellence.” – Gareth Presch
“Excellence is never an accident”: Aristotle
Five years ago I was unlucky enough to develop a bad case of pneumonia, and spent a week as an inpatient in hospital. The care I received during that week was very good, but I was really struck by one or two episodes of excellent care. In particular, I remember a junior doctor and a nurse practitioner, both of whom demonstrated excellent competence and compassion. During my recovery I wondered if we could capture this ‘excellence’, in order to study it and learn from it. What would happen if we had a formal system for capturing and investigating excellence?
Currently, the most common approach to safety and quality improvement in healthcare is to focus on preventing error. This approach reflects our innate negativity bias: the human brain is very good at spotting error and anomalies. My concern is that we have become preoccupied with correcting and avoiding error, and we are missing learning opportunities from excellent practice. I don’t dispute that it is necessary and useful to learn from mistakes, but our inquiry into error in healthcare comes at a cost. In particular, there are significant costs for the individuals who have made the ‘error’. The process of being investigated compounds the already adverse experience. The phenomenon of the second victim is very well described.
I also have concerns that the incident reporting approach to safety can sometimes turn into an exercise in retribution and can even become vindictive. The terms for incident reporting are morphing from verb to noun: I’ve heard “I’m going to Datix this”; “That needs to be Datix’d”; or worst of all: “I’m going to Datix you.”
So, what can we do about this?
A good first step would be to move away from the industrial model of management. The NHS workforce comprises humans, not machines. Humans can feel and think and innovate and create. We can be altruistic, creative, empathic, kind and compassionate. These traits, or human factors, could be studied; we could try to capture them and learn how to replicate them or maximise and amplify them. We could move away from the stick and carrot approach, and to use appreciation, sincere praise and gratitude.
I believe we can apply this approach to quality improvement and safety in healthcare. Let us focus the lens on the really good practice and attempt to understand that, as well as the other end of the spectrum. Let’s not ignore the bad stuff completely but let us accept that error will always happen. We want systems that can tolerate error; this is resilience. I think we can go a long way to building these systems by studying and replicating excellence.
Learning from Excellence:
In 2014, we launched ‘Learning from Excellence’. The initiative is a formal reporting system for capturing excellence. We have taken our existing incident reporting system and created a new form – an online, simplified incident reporting form – to report excellence. We don’t provide a definition of excellence – we let our staff decide what is excellent. We have between 20-60 reports per month, and the rates are steadily rising. Individuals who have been reported receive a formal citation from the Trust Governance department in the exact words in which the report was written.
But this is more than just feedback to individuals. We study the reports, and categorise them into themes. We have invited ourselves to the safety meetings, and started to identify areas of practice with adverse safety themes, which are also represented in the excellence reports. We identify reports with high learning value, and carry out ‘reverse SIRIs’ to better understand why this episode of excellence was able to take place. We have started using excellence reports as a quality improvement tool, and we have already demonstrated some tangible improvements, such as improved prescribing practice.
Our initiative is now spreading outside our department, and several other centres are starting similar initiatives. Our hope is that this new approach will improve quality of healthcare delivery and staff morale – and both will increase in a virtuous cycle.
For more information, please see our website: www.learningfromexcellence.com, or follow us on twitter: @adrianplunkett
*The opinions expressed are the bloggers own and do not necessarily reflect the views of the World Health Innovation Summit.