Learning from Excellence - Implementation for Growth
Exploring the journey from inception to implementation and growth of ideas, with a focus on safety and resilience. Key points include clear philosophy, seeking buy-in, starting small, and emphasizing what goes right over what goes wrong. Encourages creating a community around successes and promoting a positive outlook on improvement.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
Learning from Excellence Inception to implementation to growth Adrian Plunkett, Birmingham UK April 2017 @adrianplunkett
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
Source: Eurocontrol. From Safety 1 to Safety 2. A white paper www.eurocontrol.int
Trying to understand safety by only looking at incidents is like trying to understand sharks by only looking at shark attacks Attributed to Bob Wears
...it is both easier and more effective to increase safety by improving the number of things that go right, than by reducing the number of things that go wrong. Eric Hollnagel, Resilience Engineering in Practice
1 + 1 = 2 2 + 2 = 4 3 + 3 = 7 4 + 4 = 8 5 + 5 = 10
Rieger at en.wikipedia derivative work: JohnKiat (talk) derivative work: JohnKiat [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or GFDL], via Wikimedia Commons
Negativity culture: Adverse events Error Risk IR1 / Datix SIRI / SUI Never event
Second victim effect Third victim? Fourth victim?
Source: Eurocontrol. From Safety 1 to Safety 2. A white paper www.eurocontrol.int
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
What do people report? No one has reported themselves Reports focus on what was DONE Many themes
took her own initiative to design a bespoke care plan on ventilation weaning on a patient with complex needs that is clear for both her colleagues and parents to understand. This meant that everyone involved in this patient's care had a shared mental model
Great innovation and organisation of the ward-round with a new structure trialled that was more efficient and more enjoyable for the team
...during a busy shift ... took the time to communicate with family ... compassion and kindness... the family was comforted and reassured... Empathy, kindness, extremely supportive towards the whole family.
...was looking after a patient on PICU. During the morning ward round not only had he spotted a ten fold drug dose error which he flagged for our attention, he also challenged very appropriately and constructively about why a child with a viral infection was on antibiotics.
Despite her fear of needles, agreed to have the flu vaccine in order to protect herself and others.
After making a human error, was the only member of staff who spoke to me personally, explained the situation and listened to what I had to say. He made me feel positive about the learning aspect, he supported me with the care of the child. came in at 7am and instead of speaking with his colleagues he came to speak to me directly and heard my story and comforted me in the situation. I don t think he realised the difference his support made. Thank you .
What do we do with reports? Planned output 1 Individual feedback only 2 Staff bulletin 3 Educational tool for training / simulation 4 Mini / rapid - AI 5 Roundtable / IRIS
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
LfE Impact Staff survey 67% response rate (>200 PIC staff) 87% perceived LfE can contribute to improved patient care 87% believe that studying good practice is = reflecting on own mistakes 93% believe LfE can improve morale 87% belieive LfE can improve motivation
Your thoughts? Won t people report themselves or each other? That was unexpected and very nice. Thanks. Who decides what is excellent? What a lovely thing to do ...you ve brought tears to my eyes. Thank you so much. I wasn t sure if I should fill in a form in about How do you know this makes a difference? Next to excellence, comes the appreciation of it. William M Thackery
Inception The idea Clear philosophy Sense-check Get buy-in Implementation Start small Stick to underpinning philosophy Make it valuable Growth Seek backing Gather data Focus on the idea win hearts and minds Create a community and point of contact
... The two most powerful words in the English language are well done Sir Alex Ferguson
