Changing the Narrative of Safety Reviews in Healthcare Healthcare Improvement Scotland Scottish Mortality and Morbidity Programme. Could this Work Across Health and Social Care? Manoj Kumar Manoj_K_Kumar Brian Robson

“How Safe Is Our Care?”

TRAINING Patient Safety DoC TIME MONEY/RESOURCE MEDICO LEGAL Joy in Work Realistic Medicine QI MONEY/RESOURCE Mortality /Case Note Reviews Human Factors/Ergonomics COMPLAINTS National Audits Patient Safety Fatal Accident Inquiry Adverse Event DoC MEDICO LEGAL WMTY . TIME PERSONAL REFLECTION TRAINING TEAM REFLECTION

- WORK AS IMAGINED WORK AS DONE

Courtesy: Neil Patel

Courtesy: Neil Patel

>50% Learning - Infrequent/ Rare/ Never SMMP National Survey 88.1% M&M or similar peer review meeting >50% Learning - Infrequent/ Rare/ Never Significant variation Output ?Culture ? £££

EFFECTIVE REVIEWS SYSTEMS THINKING SHARED LEARNING IMPROVEMENT THROUGH COLLABORATION EFFECTIVE GOVERNANCE

System/ IT/ Logistics Knowledge/ Training Shared Learning Scottish M&M Program System/ IT/ Logistics Designing effective systems to support the process Human Factors Quality Improvement Knowledge/ Training Shared Learning Embedding skill set Learning for Improvement

care and compassion dignity and respect openness, honesty and responsibility quality and teamwork

Guidance/ Tools/ Framework SMMP Workshop

Undergraduate Professional Practice Block A new generation of NHS Scotland workforce Safety reviews Human Factors QI

Poor Design Poor Engagement Poor Outcome Responsive User friendly ‘Memory’ Links to simulation/ training Supports Learning & Improvement

Systems- Based Framework for Safety Review (M&M) Analysis   Seek multiple perspectives Consider Work Conditions Analyse Interactions and Work Flow Understand Why Decisions Make Sense at the Time Learning Value of Case HF/E Safety 2 QI Just Culture Psychological Safety

“You can’t change the culture” M&M Meetings – ‘Toxic’ “The M&M Process can be non-judgemental, fair and a genuine learning and improvement process” (Trainee) “…. positive effect on trainees/ trainers..”. “....process has allowed trainees/ staff to to confidently raise concerns ...feel reassured that they will be addressed in a learning environment.” ... .We have had some fantastic learning opportunities so here's hoping the process can go from strength to strength. (Senior Charge Nurse) “We feel that the overt linkage between Datix and the QI (M&M) meetings is a particular strength"  (Scottish Deanery)

“Doctors/ Staff do not engage/ poor at reporting” ?

Improve reporting by improving available systems Integrated Incident Reporting System with M&M meetings

Coming together is a beginning Staying together is progress and working together is success Henry Ford