Enhancing Patient Safety; using systems and process thinking Learning from Listening

Session objectives To understand what a process is. To practice mapping a simple process. To understand how processes support systems. Recognise the points of risk in processes.

Systems Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems.

Processes Processes are the components of a system. A process is a series of connected steps or actions to achieve an outcome. They have purposes and functions of their own, but cannot work entirely by themselves.

Symbols to use = Action/Activity = Decision = Inputs/ Outcomes

Break into small groups and using the symbols map your journey into today’s session.

My Map Leave House Drive to Work Photocopy extras Set out room Review notes Commence day Start Car Get showered Get dressed Receive presentation Feed the dog Decide where to park Decide what to eat Get out Of Bed Agree what we are going to have for tea Decide What to wear

A system A system is a collection of parts or processes organised around a purpose. Each system is embedded in other systems. Each process is part of at least one system. Each system is part of a bigger system, which are in even bigger systems, which are in even bigger systems etc. etc. etc. Working in Systems, NHS Institute for Innovation & Improvement 2005

Exercise 1

Why is it important to understand the systems we work in?

Systems Within Systems

A short story about ‘expectations’ Why the NHS is concerned about improvement?

Exercise 2 What went wrong? What impact did it have? Can you relate this to a healthcare experience?

What does the story tell you about patient safety? Patients have expectations and failure to achieve these reduces trust Processes are linked but are sometimes working against each other Confidence is reduced by failure to be consistent Patient is not supported and this undermines their personal preparation The creation of uncertainty increases and perpetuates anxiety

Making Improvements within complex Systems Structures Processes Patterns Frijot Capra 2002

Organisational Boundaries Roles & Responsibilities Teams STRUCTURES Departmental Layout & Structures Staffing Models Facilities Equipment Boards & Committees Targets & Goals The NHS Plan Patient Choice Financial flows Performance targets Workforce reform National clinical guidance & standards Patient Choice

Patient processes cross many boundaries A Rehabilitation BC D E % of work doesn’t add value for patient up to 50% of process steps involve a “hand-off”, leading to error, duplication or delay no one is accountable for the patient’s “end to end” experience job roles tend to be narrow and fragmented organisational/departmental boundaries Acute episode Long term /self management

Looking at the whole journey PresentationHistoryExamination Diagnostic tests DiagnosisStaging Treatment planning Treatment Palliative care Death Follow upDischarge Points at which: failures in the service occur unnecessary waits and delays

Patterns Thinking, behaviours Relationships, Trust, Values Conversations, communications, learning Decision making, conflict, power. Often ignored, remain unchanged and unchallenged, despite changes to structures and processes

“For me it’s my world – for the staff I am one of thousands” Patient, Learning from Listening – York Hospitals NHS Trust

Exercise From the patients stories, identify a care process that a patient felt could be better. Is there a potential for improvement that you could influence? What interactions between the elements would you need to consider and manage if you were going to take this change forward?

In Summary In Healthcare we work in a Complex Adaptive System Complex – many and varied relationships among parts of the system, making detailed behaviour difficult to predict Adaptive – people who make up the systems can change and evolve in response to new conditions in the environment System – coordinated action towards some sense of purpose Plsek 2000

To change an organisation, the more people you can involve, and the faster you can help them understand how the system works and how to take responsibility for making it work better, the faster will be the change.” Marvin Weisbord Training and Development Journal