Rapid learning: driving up patients’ safety across out-of-hours services
Released: 29/11/2011
A process for rapid learning: sharing experience when things go wrong in out of hours services, a paper that reviews the collaborative work of 10 out-of-hours providers over the past year, has been published today by the NHS Alliance.
This work has been developed in direct response to the Ubani case, in which the death of David Gray was ruled by the coroner as an ‘unlawful killing’.
Over the past year, the NHS Alliance, which includes the membership of most out-of-hours providers across England within its urgent care network, has been working with the support of a wide range of national partners to develop a new anonymised system for rapid sharing and learning between out-of-hours providers. The IT system, which has played a crucial part creating the right mechanism for information gathering and sharing, was developed and supported by East Lancashire Medical Services (ELMS).
Rick Stern, Urgent Care Lead for the NHS Alliance said: “There is too often a fear that reporting errors will lead to individuals being blamed rather than trying to learn everything we can from mistakes. Through this initiative we have brought together key players in this field to explore how we can share the learning across organisations and the whole urgent care system. Creating a system that allows people to learn from their mistakes and share the learning with others, rather than being only blamed by what went wrong, is key if we are to improve patients’ safety and out-of-hours services.”
He added: “Following the Ubani case, there was a major review from the Department of Health and an enquiry by the Care Quality Commission, resulting in a series of recommendations, especially for how we commission out-of-hours services. However, new rules and guidance are not enough. One of the biggest failings is the culture of avoiding blame and the lack of good systems for sharing what has been learnt.”
A medical director, who has been part of the pilot, commented “it is the new culture of sharing and acknowledgement of error that is crucial … if sustained and developed it will evolve into something deeper and more important than we ever envisaged at the outset”.
The paper highlights the benefits of rapid learning and some of the key issues around how providers learn and share information within organisations and across the wider out-of-hours system. According to the paper, some of the benefits from rapid sharing of learning are:
- * The outputs from the clinical panel, or ‘consensus statements’, have the potential to create a shared approach across the sector, driving up patient safety across out of hours care;
- * It begins to shift the way providers think about incidents giving them “cultural permission to admit that occasionally we mess up”;
- * It is a valuable educational material for clinicians who can work from live cases;
- * It offers a link to a wider organisational risk register, joining up clinical and corporate governance;
- * It highlights the importance of clinical leadership from the top of the organisation on patient safety and the quality of clinical care.
Although this initiative focuses on out-of-hours services, in hours general practice faces similar issues, such as the blame culture and lack of a system that allows people to share information. Therefore, its outputs could be useful across the health care system.
In her input to the paper, Dr Kathy Ryan, chair of the clinical panel, wrote: “The 66 incidents on the website so far cover a huge range of episodes. Once the number started to grow, we realised we needed more than just a list, and ‘tags’ or themes were created. Examples of tags include clinical assessment, prescribing, communication, safeguarding and so on. Any given incident can carry more than one tag, and it was quickly evident that certain areas kept coming up, for example, end-of-life.”
“The clinical panels have provided an opportunity for clinical leaders to debate these issues - and discus a rich vein of shared experience and intelligence. This aspect of the teleconferences, and indeed the whole project, the sharing in the Rapid Sharing of Learning, has been powerful.”
A process for rapid learning: sharing experience when things go wrong in out of hours services will be launched at the 2011 NHS Alliance Conference in Manchester on the 1st December at a workshop on Leadership and culture in urgent care – how can we rapidly share learning when things go wrong? The workshop will include presentations from Rick Stern, Urgent Care Lead, NHS Alliance and Dr Kathy Ryan, Clinical Director - Unplanned Care, Wirral Community Trust and will be chaired by Diane Ridgway, Chief Executive of East Lancashire Medical Services.
Full report attached.
Ends.
Notes to editors:
1. NHS Alliance brings together GP consortia, PCTs, clinicians and managers as the leading organisation in primary care. We are an independent non-political membership organisation proud to be at the forefront of clinically-led commissioning. Its leaders are all dedicated professionals, who represent the Alliance’s diverse membership, working ceaselessly to meet the challenges facing the NHS today. Find out more at www.nhsalliance.org.
2. The Urgent Care Network within the NHS Alliance includes most of the out-of-hours providers across England. It also has an elected leadership group of chief executives and medical directors from across the sector.
3. For more information, please email pressoffice@nhsalliance.org or call 07772756674.