{"id":2791,"date":"2013-02-15T21:30:31","date_gmt":"2013-02-15T21:30:31","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=2791"},"modified":"2013-02-15T21:30:31","modified_gmt":"2013-02-15T21:30:31","slug":"what-can-i-do-to-help","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=2791","title":{"rendered":"What Can I Do To Help?"},"content":{"rendered":"

\"stick_figures_moving_net_150_wht_8609\"<\/a>The growing debate about\u00a0the safety of our health care systems is gaining momentum.<\/p>\n

This is not just a UK phenomenon.<\/p>\n

The\u00a0same\u00a0question was being asked 10 years ago across the pond by many people – perhaps the most familiar name is Don Berwick<\/a>.<\/p>\n

The term Improvement Science has been buzzing around for a long time. This is a global – not\u00a0just a local\u00a0challenge.<\/p>\n

Seeing the shameful reality in black-and-white [the Francis Report<\/a>] is a nasty shock to everyone. There are no winners here.\u00a0Our blissful ignorance is gone. Painful awareness<\/strong> has arrived.<\/p>\n

The\u00a0usual emotional reaction\u00a0to\u00a0being\u00a0shoved from blissful ignorance into\u00a0painful awareness is characteristic;\u00a0\u00a0and it does not matter if it is discovering horse in your beef pie or\u00a0hearing of 1200 avoidable deaths in a UK hospital<\/a>.<\/p>\n

Our\u00a0emotional reaction\u00a0is a predictable sequence that goes something like:<\/p>\n

Shock => Denial => Anger =>Bargaining =>Depression =>Acceptance<\/p>\n

=> Resolution.<\/p>\n

It is the psychological healing process\u00a0that is called the grief reaction<\/strong> and it is a normal part of the human psyche. We all do it. And we do it both individually and collectively. I remember well the global grief reactions that followed the sudden explosion of Challenger; the sudden death of Princess Diana; and the sudden collapse of the\u00a0Twin Towers.<\/p>\n

Fortunately such avoidable tragedies are uncommon.<\/p>\n

The\u00a0same chain-reaction happens to a lesser degree in any sudden change. We grieve the loss of our old\u00a0way of thinking –\u00a0we mourn the\u00a0passing away\u00a0our\u00a0comfortable rhetoric that\u00a0has been\u00a0rudely and suddenly disproved by harsh reality. This is the Nerve Curve<\/a>.\u00a0\u00a0And learning to ride it safely is a\u00a0critical-to-survival life skill.\u00a0\u00a0Especially in turbulent times.<\/p>\n

The UK population has\u00a0suffered two psychological shocks in recent weeks –\u00a0the discovery of horse in the beef pie and the\u00a0fuller public disclosure of the story behind the 1000’s of avoidable deaths in\u00a0one of our\u00a0Trust hospitals. Both are now escalating and the finger of blame is pointing squarely at a common cause: the money-tail-wagging-the-safety-dog<\/em>.<\/p>\n

So what will happen next?\u00a0 The Wall of Denial has been\u00a0dynamited with hard evidence. We are now into the Collective Anger<\/strong> phase.<\/p>\n

First there will be widespread righteous indignation<\/em> and a strong desire to blame, to hunt down the evil ones, and to crucify the responsible and accountable.\u00a0Partly as punishment, partly as a lesson to others, and partly\u00a0to prevent them doing\u00a0harm again.\u00a0 Uncontrolled anger is dangerous especially when there is a lethal weapon to hand. The more controlled, action-oriented\u00a0and future-focused will want to do something about it. Now! There will be rallies,\u00a0and soap-boxes, and megaphones.\u00a0The We-Told-You-So<\/em> brigade will get shoved aside and trampled in the rush to do something –\u00a0ANYTHING. Conferences will be hastily arranged and those most fearful for their reputations and jobs will cough up the\u00a0cash and clear their diaries. They will be expected to be there. They will be.\u00a0Desperately looking for answers. Anxiously\u00a0seeking credible leaders. And the snake-oil salesmen will have a bonanza! The calmer, more reflective, phlegmatic, academic types\u00a0will call for more money for more research so that we can\u00a0fully analyse and fully understand the problem before we do anything.<\/p>\n

And while the noisy bargaining for more cash keeps everyone busy the harm will continue to happen.<\/p>\n

Eventually\u00a0the message\u00a0will sink in as\u00a0the majority accept that there is no way to change the past; that we cannot cling to what is out-of-date thinking; and that all of our\u00a0new-reality-avoiding tactics are fruitless. And we are forced to accept that there is no more cash. Now we are in danger of becoming helpless and hopeless, slipping into depression, and then into despair. We are at risk of giving up and letting ourselves wallow and drown in self-pity.\u00a0This is a dangerous phase.\u00a0Depression is understandable but it is avoidable because there is always<\/strong> something than can be done. We can always<\/strong> ask the elephant-in-the-room questions.\u00a0Inside we usually know the answers.<\/p>\n

We accept\u00a0the new reality; we accept that we cannot change the past,\u00a0we accept that we have some learning to do; we accept that we have to adjust; and we accept that all of us can do something<\/span>.<\/p>\n

Now we have reached the most important stage – resolution. This is the test of our resolve. Are we all-talk or can we convert talk-to-walk?<\/p>\n

\"stick_figure_help_button_150_wht_9911\"<\/a>We can all ask ourselves\u00a0one question:\u00a0“What can I\u00a0do to help?”<\/strong><\/p>\n

I have asked myself that question and my first answer was “As a system designer I can help by looking at this challenge as a design assignment and describe what I see<\/em>\u00a0“.<\/p>\n

Design starts with the intended outcome, the vision, the goal, the objective, the specification, the target.<\/p>\n

The design goal is: Significant reduction in avoidable harm in the NHS, quickly, and at no extra cost<\/em>.<\/p>\n

[Please note that\u00a0a design goal is\u00a0a “what we get” not a “what we do”. It is a purpose and not just a process.]<\/p>\n

Now we can\u00a0invite, gather, dream-up, brain-storm any number of design options and then we can consider logically and rationally\u00a0how well\u00a0they\u00a0might meet\u00a0our design\u00a0goal.<\/p>\n

What are some of the design options on the table?<\/p>\n

Design Option 1.<\/strong> Create a cadre of hospital inspectors.<\/p>\n

Nope – that will take time and money and inspection alone does not guarantee\u00a0better outcomes. We have enough evidence of that.<\/em><\/p>\n

Design Option\u00a02.<\/strong> Get\u00a0lots\u00a0more PhDs funded, do high quality academic research,\u00a0write papers,\u00a0publish them and hope the evidence is put into practice.<\/p>\n

Nope – that will take time and money too and publication alone does not guarantee adoption of the lessons and delivery of better outcomes. We have enough evidence of that too. What is proven to be efficacious in a\u00a0research trial is not necessarily effective, practical\u00a0or affordable \u00a0in reality.\u00a0\u00a0<\/em><\/p>\n

Design Option 3.<\/strong>\u00a0Put together\u00a0conferences and courses to teach\/train a new\u00a0generation of competent healthcare improvement practitioners.<\/p>\n

Maybe –\u00a0it has the potential to deliver the\u00a0outcome but it too will take time and money. We have been doing conferences and courses for decades – they are not very cost-effective. The Internet may have changed things though.\u00a0<\/em><\/p>\n

Design Option 4<\/strong>. All of the above<\/span>\u00a0plus<\/strong> broadcast\u00a0via the Internet\u00a0the current pragmatic know-how of the basics of safe system design to everyone in the NHS so that they\u00a0know what is possible and they know\u00a0how to get started.<\/p>\n

Promising – it has the greatest potential to deliver the required outcome, a broadcast will cost nothing and it can start working\u00a0immediately.<\/em><\/p>\n

OK – Option 4 it is –\u00a0here we go …<\/p>\n

The Basics of How To Design a Safe System<\/strong><\/p>\n

Definition 1<\/strong>: Safe means free of risk of harm.<\/em><\/p>\n

Definition 2<\/strong>:\u00a0Harm is the result of hazards combining with risks.<\/em><\/p>\n

There are two components to safe system design –\u00a0the people stuff and the process stuff.<\/p>\n

For example a\u00a0busy main road is designed to facilitate the transport of\u00a0stuff from A to B. It also represents a hazard<\/strong>\u00a0– the potential for harm.\u00a0If the vehicles bump into each other or other things then\u00a0harm<\/strong> will result. So a lot of the design of the vehicles and the roads is about reducing the risk<\/strong> of bumps or mitigating the effects (e.g. seat-belts).<\/p>\n

The risk<\/strong> is multi-factorial. If you drive at\u00a0high speed, under the influence of\u00a0recreational drugs, at night, on an\u00a0icy road then the\u00a0probability of having a bump is\u00a0high.\u00a0 If you\u00a0step into a busy road without looking then the\u00a0risk of getting bumped into is high too.<\/p>\n

So the\u00a0path to better safety is to eliminate\u00a0as many hazards as possible\u00a0and to reduce the risks as much as possible. And we have to do that without\u00a0unintentionally creating more hazards, higher\u00a0risks, excessive delays and higher costs.<\/p>\n

So how is this done\u00a0outside<\/span> healthcare?<\/p>\n

One tried-and-tested method for designing safer\u00a0processes is called FMEA\u00a0– Failure Modes and Effects Analysis<\/em>.<\/p>\n

Now that sounds really nerdy and it is.\u00a0 It is an attention-to-detail exercise that will make your brain ache and your eyes bleed. But it works – so it is worthwhile learning the\u00a0basic principles.<\/p>\n

For the people part there is the whole body of Human Factors Research<\/em> to access. This is also a bit nerdy for us hands-on oily-rag pragmatists so if you want something more practical immediately then have a go with The 4N Chart<\/a> and the\u00a0Niggle-o-Gram (which is a form of emotional\u00a0FMEA). This short summary is also free to download, read, print, copy, share, discuss and use.<\/p>\n

OK\u00a0– I am off to design and build something else – an online\u00a0course for teaching safety-by-design.<\/p>\n

What are you<\/span> going to\u00a0do to help improve safety in the NHS?<\/p>\n","protected":false},"excerpt":{"rendered":"

The growing debate about\u00a0the safety of our health care systems is gaining momentum. This is not just a UK phenomenon. The\u00a0same\u00a0question was being asked 10 years ago across the pond by many people – perhaps the most familiar name is Don Berwick. The term Improvement Science has been buzzing around for a long time. This … <\/p>\n

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