On 24 January, I attended the learning event, 'Looking back and looking forward', held by NHS North Middlesex University Hospital Trust. This was one of a series of regular events to reflect on what has gone well and where the Trust can improve its service quality and patient safety.
I was delighted to attend the event, along with Patient Safety Learning's Associate Director of Patient Safety, Claire Cox. We also enjoyed the opportunity to share the reflections from our report, A Blueprint for Action, and to #share4safety.
We were really impressed. The event showed a genuine commitment and openness for learning, with a multi-disciplinary audience including frontline clinicians, patients, non execs, CCG commissioners, and more.
Challenges revealed through powerful personal stories
During the event, we were presented with stories from both clinicians and patients. One particularly powerful story was told by a consultant who, when he was a junior surgeon, didn't challenge an international leading expert, despite the concern that he was going to make a mistake and cause harm. His story revealed power gradients and the toxicity of hierarchy.
We also enjoyed hearing reflections on safety and care from patients and families. These weren’t always easy to hear. There was a positive response from delegates who want to address the challenges around culture which these stories identified. The event also had a strong emphasis on using data and insight to understand safety and performance challenges and to measure impact of improvement.
Views shared by Patient Safety Learning
These different elements were really encouraging to hear as they reinforced our own views here at Patient Safety Learning. We believe that focusing on six foundations of unsafe care - three of which include patient engagement, Just Culture, and data and insight - will help to create the patient-safe future.
This is precisely what we spoke about in our own session. In our talk, titled 'Practical action to achieve the six foundations for safer care', Claire shared our ambition and the impact that the hub is having in sharing learning for patient safety.
Learning that results in action
We were delighted to be at an event that focused on learning why things might be patient safety risks and challenges, and that this learning was supported by strong, reflective case studies from the clinicians directly involved.
But this learning must come with action. While at the event, it was less clear to me how some of the learning will be applied for improvement and how it is being shared more widely in the Trust. This is a huge issue for so many healthcare organisations. It reflects, I suspect, lack of organisational capacity and expertise, rather than a lack of commitment. I was pleased to hear after the event that the Trust uses most of the themes from the learning to feed into their quality priorities for 2020/21.
This passion for learning - and acting on what we learn - was the drive behind creating our shared learning platform, the hub. We want to encourage patients, clinicians and all of those working in, or with an interest in, patient safety, to sign up to the hub and share their learning so that, together, we can improve patient safety. Visit the hub and sign up at www.pslhub.org
Let's work together to share learning
Claire comments: "This is one hospital's learning event. Wouldn't it be great to widen it out? There are numerous neighbouring hospitals that could have benefitted from the learning we heard about on Friday. Perhaps in the future there could be a shared learning event for all NHS staff and stakeholders to drop in and see what is going on 'next door'? Patient safety leads could form a network and even host at each other's trusts. Lets not keep this valuable learning to ourselves. Let's #share4safety."
