5/25/22 – Adrian Plunkett, MD - Learning from Excellence

May 26, 2022

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For CME Credit, please read the CME announcement for this lecture.

For Community Practitioners, please read the following CME announcement.

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00:00It's a couple minutes after
00:02welcome everybody to grand rounds
00:04and Department of Pediatrics.
00:07And as you as we continue our year long
00:12celebration of our 100th anniversary.
00:16Have a few announcements before
00:19our speaker is introduced.
00:21Next week we have Dana Dunn coming
00:24to talk about embracing feedback.
00:28Creating a culture of psychological safety.
00:30So this will be a great opportunity
00:33to to hear from from Dana
00:35on a very important topic.
00:37And then June 8th is the annual
00:40town gown clown quiz show,
00:42so our chief residents will be
00:44leading that annual event that
00:48you'll you won't want to miss so.
00:52That's coming up in 2 weeks.
00:57On Thursday, May 26th, as tomorrow at noon,
01:00there's going to be a town hall
01:03around pediatric education,
01:05so I encourage all of you that
01:06want to know more about what's
01:09happening in education in our
01:12department about training programs,
01:14things about your roles as educators.
01:18Please come out.
01:19It should be great to hear what's
01:22happening and what what's on the horizon.
01:27And also want to remind
01:29you next week, June 3rd.
01:33We are having our last symposium of
01:37three that celebrate our Centennial,
01:39and this one is in cardiology
01:42and congenital cardiac care.
01:44So if you haven't registered, please do so.
01:47You can use the QR reader on your
01:49phone to to use that QR code there.
01:52It'll take you to the link we
01:55this is going to be in person,
01:57so I encourage you to come out.
01:59It should be great to hear about the
02:02important role that Yale Pediatrics
02:04has played in the evolution of
02:08cardiac congenital cardiac care.
02:15There is no commercial support
02:17for this grand rounds and any
02:20disclosures have been reviewed.
02:25And of course, you'll always.
02:26As always, you'll get CME credit
02:30for participating the number to
02:31text is right there on the screen,
02:33and also it'll be put into the zoom
02:36chat at various intervals throughout
02:38the grand rounds to remind you.
02:40And then if you have questions for our
02:43speaker at the end of the presentation,
02:46please use the Q&amp;A section of the Zoom.
02:50And with that I'm going to
02:51turn it over to Sarah Kendall,
02:52who will introduce today's speaker.
02:56Thank you Cliff. Well thank you everyone
02:58for joining us today as part of our
03:01quality improvement grand rounds we
03:03have invited Doctor Adrian Plunkett
03:05to share his experience in quality
03:08improvement just so everyone knows.
03:11Doctor Plunkett is a consultant
03:13pediatric intensivist in Birmingham, UK.
03:15He founded the Learning from
03:17Excellence Initiative in 2014.
03:19The learning from Excellence initiative
03:21is a social movement in healthcare,
03:24which aims to learn from what is working.
03:26Well and to provide positive
03:28feedback to staff and colleagues.
03:30It is a community of practice that
03:33has developed around this entire
03:35initiative and learning from excellence.
03:37Host regular events and provides teaching
03:39and training in their methodology,
03:41particularly with respect
03:43to quality improvement.
03:44Doctor Punka has published several
03:46papers on this initiative,
03:47as well as the spectrum of others
03:49related to healthcare quality.
03:51He studied medicine at Cambridge University
03:53and Imperial College in London and underwent.
03:56Pediatric subspecialty training
03:58in Southampton,
03:59London and Melbourne.
04:00Before beginning a consultant post in Brigham
04:05Children's Hospital in the UK in 2009.
04:09Here he was the lead consultant for
04:11his department from 2017 to 2021 and
04:14is the honorary secretary for the
04:16British Pediatric Critical Care Society.
04:19His work focuses on the pursuit
04:22of patient safety and is a key
04:24component of the wider endeavor
04:26for improving quality healthcare
04:28across all delivery networks.
04:30And with that I'd like to
04:32welcome Doctor Adrian Plunkett to
04:34our as our speaker today.
04:35Thank you.
04:38Thank you, Sarah, and.
04:41I very much appreciate the opportunity
04:44to speak at your grand rounds,
04:46and it's a real privilege to be here.
04:49I've got some slides,
04:51so I'm going to load them up. Just now.
04:57So hopefully you can see these.
04:58I'll put the slideshow on.
05:01So yeah, so the presentation will be about
05:04this initiative learning from excellence,
05:07and I encourage you to think of questions,
05:10put them in the Q&amp;A or in the chat,
05:13because I think the best part of
05:16these presentations comes from the
05:19discourse discussion that follows.
05:20What I'll do is is explain what
05:23the background philosophy and
05:26rationale for this initiative is,
05:29but also some of the evidence we've gathered.
05:32And some practical ways of actually doing it.
05:35But yeah, I think the the main
05:38benefit learning from both
05:40parties is in the discussion.
05:43So that's my that's the name of the
05:45initiative you've heard who I am,
05:47and if you're into social media,
05:49Twitter in particular,
05:50that's the Twitter handle that I use,
05:52and I use that exclusively for.
05:57Conversations and messages
05:59around this initiative.
06:02So I work in intensive care so it is a.
06:05Safety critical environment and I
06:07think that is relevant actually.
06:08When I think about the origins
06:10and the background to learning
06:12from accents because it.
06:13I I have been working for many years
06:15and the environment is very safety
06:17oriented and and we have for years
06:20and years that back at what has failed
06:22and how we can learn from that and
06:24that has been highly successful as
06:26it has for the whole of healthcare
06:29and other safety critical industries.
06:31But it it came about as an idea to me
06:33and I must say right from the start.
06:35This is not an original idea.
06:37The idea I'll explain in more detail shortly,
06:40but in essence it's around learning
06:44from what's working.
06:45This is not a new idea,
06:46but it occurred to me as something
06:48that we're not doing enough of.
06:50When I was reflecting on my own
06:53experiences of being a patient.
06:55It was actually over 10 years ago.
06:57Now that I started the consultant post,
07:01which is the post I'm in now.
07:03In Birmingham and not long after I'd started,
07:07I became unwell with a couple of
07:09bouts of quite serious illness and
07:11actually spent some time in hospital
07:13and completely changed my perspective
07:15and many of you would have had
07:17the same or similar experience,
07:19or, you know,
07:21we encounter brushes with the other side
07:24of healthcare throughout our lives,
07:25either as patients or as loved
07:27ones of patients,
07:28and I'm sure your Lord testified.
07:30The fact that it does
07:31change one's perspective,
07:32and it's quite a valuable.
07:33Opportunity for reflecting on how
07:36healthcare works.
07:37And what I noticed was.
07:39Most of the cows receiving
07:41was good and effective.
07:43And some of it was really excellent
07:46and I started to characterize
07:48what excellent care was and I.
07:50I I didn't do it initially,
07:52sort of deliberately,
07:53but on reflection I realized what I
07:56was recognizing as excellent was it
07:58tends to be human behaviors or team
08:00behaviours and they tended to be
08:02balancing compassion on the one hand
08:04and competence on the other hand and
08:06and presenting them both together.
08:08And I started seeing this excellent
08:11everywhere and I got better recovered and
08:14wrote a letter to the hospital to say.
08:17This is what excellent care
08:19looked like for me when I was in
08:22your institution as a patient,
08:24and I named individuals in there and teams,
08:27but I also described what
08:28the excellent care was.
08:30There was.
08:31This was descriptive praise with
08:33a element of gratitude in it,
08:35and then some time passed.
08:38It's about two years past actually
08:40and I was back to work by then
08:42and I I met one of the individuals
08:44who had treated me as a doctor.
08:46And he was one of the people
08:48I'd mentioned in this letter,
08:49and and now we were peers in in the
08:52completely different environment
08:54as professionals.
08:55And we recognize each other
08:57and for some reason I
08:59asked him if he'd received my letter
09:01of thanks. There must have been
09:03an element of doubt in my mind,
09:04otherwise I wouldn't have asked
09:05the question, and indeed he had
09:07not received the letter and.
09:09It occurred to both of us.
09:10At this time. There's an
09:12opportunity here to do better here,
09:14and if I'd written a letter of complaint,
09:16there would have been a mandatory response.
09:19And there would have been some
09:20evidence that something would
09:22have changed in response to that.
09:23But here was a letter.
09:25Full of descriptive praise
09:27full of intelligence.
09:29Actually from a service
09:30user about what worked well.
09:32The idea behind that is that one
09:33could reflect on it and build on it,
09:35and perhaps create better systems based
09:37on the intelligence and this feedback,
09:39but it was disregarded clearly and the
09:41fact didn't even reach the people for him.
09:44It was intended so that that was one
09:46of the kind of trigger points for.
09:49Designing or coming up with the
09:50idea of a formal system through
09:52which we can capture this.
09:54Positive intelligence,
09:55and that's where learning
09:56from experts came from.
09:57And on top of that, I also,
10:00as I said at the start,
10:01working in a safety critical.
10:03Industry as Healthcare is but
10:04particularly in intensive care.
10:06We're very focused on and the
10:08high risk and trying to do better
10:11by recognizing what's failing.
10:13And I realized more and more our
10:15efforts to make things better in
10:17safety and quality improvement were
10:19focused on the things that were going wrong.
10:21And I will probably say
10:23that several times today,
10:25and I hope to get this message across.
10:27I'm not saying that we should
10:28stop doing that,
10:29learning from accents or learning
10:30from what's working well.
10:32However,
10:32you want to do it or whatever you want
10:34to call it should be complementary approach.
10:36That should build on the foundation.
10:39Of the prevailing approach to
10:40safety and quality improvement,
10:41which is which is trying to get rid
10:43of the things that don't work so
10:46well so the aims of learning from science,
10:47then it's just an idea.
10:49As I said,
10:50there's there's no intellectual
10:51property here.
10:52It's not an original idea,
10:53we've just given it a name,
10:54but other people have run with
10:56it and given it different names,
10:57but they all do the same thing.
10:58They also have these two aims,
11:00which is 1 to learn from what's working
11:02in a system where our typical approach
11:04is to learn from what's failing.
11:06And key is to provide positive feedback,
11:09and that's actually a fairly unique
11:11element to this, so we're not just.
11:13Looking at the spectrum of work
11:15where things are successful,
11:16we're actually also telling individuals
11:18of the teams that they have been
11:21successful because it's not always known,
11:24and we're telling them why it was successful.
11:26So that is positive feedback,
11:27and that's what leads to the learning aspect.
11:30Now,
11:31you've probably seen this before.
11:32You've certainly would have seen
11:33the Bell curve before,
11:34but this particular depiction of
11:36it is produced by Eric Hollnagel,
11:38who's one of the. Leading academics
11:40in the world of safety and he he,
11:42he came up with the term safety too.
11:47So he defines safety one as as our
11:49prevailing approach to safety,
11:51in which we focus all our attention
11:53to make things safer and to improve
11:54quality by looking at the far
11:56left of this probability curve.
11:58So these are events in the safety critical
12:00industry depicted in the normal distribution,
12:03and the very very far left of the curve is
12:05the tiny part of our everyday interactions.
12:08Tiny part of our system
12:09where things go wrong.
12:11And safety one is a condition
12:12where there's few things possible.
12:14Go wrong, that's the.
12:15That's the typical definition of safety.
12:18And that's the intuitive model of safety as
12:21the safety too is what *********** proposes.
12:24You can consider you can reframe that.
12:26You can consider safety.
12:28It's a condition where as many
12:29things as possible go right,
12:31and both of those are true to some extent,
12:33but they're actually,
12:34although they sound subtly different,
12:35they actually profoundly
12:37different when you think.
12:39What do I need to do in order to actually
12:42practically study and practice safety?
12:45So if you're practicing safety one,
12:47you're just going to be focusing on.
12:49Things are going wrong that we're
12:51using instant reports and other
12:52ways of capturing things that fail,
12:54and safety two you would need to
12:56look at everyday work all the
12:57time and try and understand why.
12:59For the vast majority of time it works.
13:01It's successful,
13:02and when you do that you'll find that
13:04people are making it adaptations to
13:06their work the whole time because we
13:08work in highly variable conditions
13:10and a lot of that is.
13:12Excellent work depending on how
13:14you define excellence.
13:16Now,
13:16this preoccupation with the very
13:18small left part of the system.
13:21Is is a potential flaw or something?
13:24Something we have to be aware of
13:26in the typical approach to safety?
13:27Because it is just a small part
13:29of the system.
13:30So Bob Weirs who who was another
13:32academic in the world of safety.
13:34I'm sure many of you will have
13:36heard of has this quote attributed
13:38to him trying to understand safety
13:40by only looking at incidents.
13:43So by only looking at that far left
13:44of the Bell curve is like trying to
13:47understand sharks by only looking
13:48at shark attacks.
13:50It's a great metaphor because the
13:52shark attack is deadly and it captures
13:54your attention that's important.
13:56But it doesn't tell you much
13:57about the Organism.
13:58Tells you a little bit,
13:59but there's an awful lot more about
14:02the Organism that you need to
14:03learn and you can't do it just by
14:05studying the things that go wrong.
14:07So we have this preoccupation with
14:10failure for very good reasons.
14:12It's served us very well evolutionarily,
14:14and then the development of safety
14:17critical industries.
14:18But with with probably partly
14:20oversensitive to it.
14:22And there there is,
14:23there is some psychological evidence.
14:25To suggest that we do have a bias
14:29towards negativity and attribute
14:31more value to it than we do to an
14:33equivalent amount of positivity.
14:35So for example,
14:36in this hopefully you can see this slide,
14:39but you can't stop yourself.
14:42Seeing the mistakes, the anomalies,
14:44they are automatically identified.
14:45They're in that if you're
14:47into cognitive theories,
14:48they're in that system 1 automatic
14:51thinking you can't turn it off,
14:53so we can't help spotting things
14:55that are wrong and that this slide
14:58illustrates how we attribute a lot
15:00of value to things that are wrong.
15:01More value in fact than
15:04to things that are right.
15:06So most people would say the
15:08most obvious thing here or or the
15:10most notable thing in this slide,
15:11is that one of these sums is incorrect.
15:14And whilst that's true for the sums
15:16are correct and that's a piece of
15:18information is 4 times more valuable,
15:20but it's not the most obvious
15:22thing that we think of.
15:24I had I I always shared this
15:26when I talk about.
15:27This issue because this is a personal
15:30experience of the negativity bias.
15:32When I gave a talk a few years ago on a
15:35clinical topic and you all have seen this,
15:38in fact,
15:38you may even be providing feedback at
15:40the end of this talk along similar.
15:44Means,
15:44so here you've probably since
15:464 you have a score,
15:48they they're participants
15:48or the delegates are in.
15:50In the presentation.
15:51Get to feedback to the speakers,
15:53give it a score.
15:55So this is my name at the bottom here
15:57and I got scores 5 being excellent,
16:003 being neutral and one being very poor,
16:02and the vast majority of the schools
16:03were good so I knew that the talk I'd
16:05given was helpful for the delegates,
16:07at least that scored it as such.
16:09But then I spent the rest of
16:11the day thinking who was this
16:12person and what what did they.
16:14Was what did they think was so poor?
16:17About presentation and there's clearly,
16:20I think,
16:20overthinking it and we are
16:22drawn to this shark attack.
16:24In this to use that metaphor again.
16:27But now it's not just the
16:28sort of laughing matter,
16:30because actually there is.
16:31A risk that you can over respond to
16:36things that go very badly wrong.
16:39And it's in the world of safety.
16:40We that's called risk migration,
16:42where you respond to something
16:45that's a rare shark attack event.
16:48By changing the system to prevent
16:49it happening again.
16:50You then potentially migrate
16:52risk across the system,
16:53because for the vast majority
16:55of the time system works well.
16:56So here in this example I may have
16:58found this individual and said what
17:00exactly was it that you thought was
17:02so very poor about my presentation,
17:03and then I may have made changes,
17:05which of course would have
17:06potentially disrupted the experience
17:08for the vast majority.
17:09You enjoyed that presentation.
17:12The negativity bias is borne
17:14out on the media,
17:15so this is.
17:16These are the top 10 BBC News
17:19headlines from today and there's
17:22a lot of bad news out there.
17:23But there's always a lot of
17:24bad news out there
17:25because that's what we're attracted to.
17:27So these are the most read stories,
17:28and that's what the editors choose,
17:30and that's what the journalists write,
17:31so they're they're negativity.
17:33Bias actually permeates the whole of society.
17:36When I gave this talk a few years ago,
17:38somebody came up to me at the end of the
17:41presentation and said that they'd been
17:43going through their six year olds homework.
17:46Their six year old daughter's homework,
17:47and she had written something and he,
17:51the father, corrected all her
17:53misspelled words and at the end of it,
17:56she said thank you, Daddy.
17:57But what about all the words I spelt right,
18:00which made me think?
18:02Oh goodness, I'm sure I did the same
18:04and that this was my six year old sons.
18:06Written the homework and, uh,
18:09he was describing our recent
18:11holiday in Norfolk,
18:13which is actually where I grew up in England.
18:17And we go there on holiday here
18:18describing how we stayed in the caravan.
18:20We had ice cream played in
18:22the arcades and I just.
18:24Found myself highlighting the
18:26words that he'd spelt wrong.
18:28You may not be able to see this clearly,
18:29but the red lines are underlining
18:32the words you spelt wrong.
18:34But the words you start right
18:36for someone learning green were
18:37far more in the majority,
18:39and actually it proves the point that
18:41a lot of a lot of systems in in which
18:44things are working well most of the
18:46time it's actually easier to identify
18:48and to capture things that are going well.
18:50So there's potentially
18:51more learning from that,
18:52certainly at least as much learning
18:54from things are going well as
18:55things that are failing,
18:57and we should try and learn
18:58from them both clearly.
19:01So to cut to counteract the.
19:04Negativity bias you do actually
19:06have to suspend some of the innate
19:08cognitive processes you do.
19:10You do actually have to.
19:12Manually turn on the part of
19:14the brain that's looking for
19:16things that are going well.
19:18Steven Pinker,
19:18you some of you I'm sure will
19:20have heard of if well known
19:22public intellectual who's early,
19:25outspoken on this and and he's
19:28making a case that in many domains of
19:30humanity we are in fact making progress,
19:33but we wouldn't know that
19:34if you read the news.
19:38So let's come back to safety.
19:40That's just some of the
19:41background I realized.
19:42I'm presenting a relatively biased view.
19:45Some people talk about the presence
19:47of a positivity bias as well,
19:50but there's undoubtedly well described,
19:53negativity biased.
19:55So I just want you to remember that and.
19:58And I'm saying it is possible to suspend it,
20:01but it does take work and in order
20:04to recognize what's working well,
20:06it sometimes takes a little
20:07bit of extra effort.
20:09You come back to safety then.
20:11The language that we use around
20:13safety and to an extent this is
20:15true for quality improvement.
20:16Is is necessarily negative
20:17because our prevailing approach
20:19is to look at the negative.
20:21So these are some of the words
20:22that we use in our institution,
20:24and they're fairly
20:26internationally recognized.
20:27Uh, and they're all negative.
20:30This is important for another
20:32reason and not just for the reason
20:35that we are losing out on some.
20:38Intelligence from what's working,
20:40but also because a unilateral approach.
20:43To safety and quality improvement,
20:45which is just on what's going wrong?
20:48Is not actually very good
20:50for us psychologically,
20:50so we people talk about the second
20:53victim phenomenon that the mentality
20:54of which is debated and has
20:56actually been challenged recently.
20:58But the concept is certainly
21:00well described and that is if I.
21:03Make the mistake or involved in
21:05a in an era or some kind of harm.
21:07Some kind of medical harm that happens,
21:09the patient.
21:10Then the patient obviously suffers,
21:12but actually so do I,
21:14and so do the other members
21:17of staff involved.
21:19And that is in fact has been
21:21shown to be exacerbated by some
21:23of the scrutiny that follows.
21:25And while some of that is,
21:27I guess, on the avoidable it does.
21:30Make one wonder if it's possible
21:32just to introduce a bit of bit more
21:34balanced for trying to make things safer.
21:36We could potentially just move
21:38the pendulum back slightly across
21:40that bell curve and say, well,
21:41let's include in some of our inquiries.
21:43What's going, well, what's what's successful?
21:45What's going really excellently?
21:49So of course a matter it
21:50is a matter of perception.
21:52This this idea I've introduced to
21:53the idea that we have an innate
21:55bias towards the negative was
21:56slightly more sensitive to it.
21:58But you can change.
21:59You can choose to change the
22:00way you look at the world,
22:02and you can temporarily suspend that.
22:05And perception does depend on.
22:08What's going on around you?
22:09So if you're working in an
22:10environment where we are all the time
22:12looking at things are going wrong,
22:13we will start to notice things
22:15go wrong all the time.
22:16Equally, if we work in an environment
22:17where we're where we're making an
22:19active effort to learn from success,
22:20then we'll start to see more success.
22:23So I like optical illusions
22:24because they illustrate the fact.
22:26The what you see, So what you perceive
22:29does depend on the prevailing conditions.
22:32Here A&amp;B.
22:32If you can see those two
22:34squares on the checkered board,
22:35are actually the same shade of Gray,
22:37you wouldn't believe it until you remove
22:39or change the prevailing conditions.
22:41But it's true they are.
22:42Here's another one, the famous one.
22:44You can either see the vase in the middle
22:47with the two faces on either side.
22:49And you and this.
22:50With this one, you can actually choose.
22:52You can actually make a choice to.
22:53I'm going to notice the faces on.
22:55Gonna notice the bars, so there is an option.
22:59Change what you're perceiving.
23:01Through active choice,
23:03and there's a book of recently come out by
23:05the and neuroscientist called Annual Seth.
23:08The book is called being you,
23:09and it's about consciousness.
23:11The study of consciousness and
23:12he talks in there about the fact
23:15that we can turn up the game.
23:16To various elements of our perception.
23:20So if we if we choose to turn up the
23:22gain for looking for our car keys
23:24or looking for a face in the crowd,
23:26we do that without really thinking about it.
23:29We can actively turn up the
23:31game for noticing success.
23:33We're noticing excellence in our practice,
23:35but it does take a little bit of effort.
23:38This is an important quote.
23:40It's worth sharing and I think for
23:42that any of us who are working in the.
23:44Domain of quality. Improvement of safety.
23:46It's worth just thinking about this
23:49just I'll just let this one hang.
23:52Umm? There was an expensive thing.
23:59So. What do we mean by safety?
24:02And you could ask the same question
24:04about quality and I know it's
24:05been asked a lot and there's
24:07lots in the literature about it.
24:08Just coming back to safety is,
24:10as I said, at the fairly near the start,
24:13hold our goals, description of
24:15safety one and Safety 2 where we
24:18consider safety and safety one being.
24:20As few things as possible going wrong so.
24:23The person on the street would
24:25say it's safety and its simplest
24:27definition is the absence of harm.
24:29The absence of stuff going wrong,
24:30the absence of danger.
24:34But if you're defining something like that,
24:36then what you're defining by is.
24:38It's an absence of something, which means
24:40actually the definition is incomplete.
24:42There are quite a lot of definitions in
24:44our language that do rely on defining
24:47something by an absence or something else,
24:49so they are all in complete
24:52definitions tonight.
24:53Kind of put it to you.
24:54That safety in in this definition is
24:56incomplete because once the harm is gone in
24:59the hypothetical state where harm is removed,
25:01then what is left?
25:02What is that positive state that is left
25:05and that is actually what safety is now?
25:07A language lets us down.
25:08It's actually almost ineffable
25:10to describe that state.
25:12We've had a few attempts
25:14within our workplace using.
25:15Some creative methods and what you end up
25:19coming up with this more words and they
25:22tend to be more positively associated.
25:24But if you can consider safety as the absence
25:26of harm then just try and imagine what?
25:29The absence of harm looks like and then
25:31that will help you start to see what's
25:34creating safety in your workplace.
25:40So that's some of the background to
25:41learning from action. So then we.
25:42So I thought when I created it,
25:45we started a little pilot in
25:46intensive care unit and then it's
25:48become as you heard introduction.
25:50It's become like a social
25:52movement in healthcare.
25:54And we we go around talking about it.
25:56We write papers about it with.
25:58To some degree of thought leadership
25:59and we have a community of practice.
26:02We have conferences, etcetera.
26:03But really we're we rely on people in
26:06their own institutions to set it up.
26:08And what we're asking people
26:09to do is create a system where
26:11you can capture excellence.
26:12How do you capture excellence if it's?
26:14Fairly hard to define.
26:15I said at the start took me a while to
26:18realize that the accents I was saying
26:20was a balance of compassion and competence.
26:22But actually when you think about it,
26:24you know it when you see it,
26:25and most people would say, yeah,
26:27they've seen excellence at some time,
26:29either at work or at home, or somewhere.
26:31Have seen it.
26:32They know it when they see it.
26:33So with that in mind,
26:34you should just be able to capture it.
26:36So we created a reporting system.
26:38It sits alongside.
26:40The adverse Incident reporting system.
26:42Because this is allied to safety.
26:46It's more than just safety,
26:47of course,
26:48because of the positive feedback element,
26:50but it's most closely aligned to that.
26:52And also we work in the very high reporting
26:54environment in the intensive care,
26:56so that's how we set it up.
26:57Just electronic form.
26:58And just ask a few simple questions.
27:02We also got an open reporting form
27:04if anybody wants to use that as on
27:07our website that's freely available.
27:09Quite a few people use that because
27:10they don't have access within
27:12their own institutions.
27:13But this it just asks some simple
27:15question who did something excellent.
27:16You can define that however you wish.
27:19There's the beholder's share of witnessing
27:21something like excellent so you,
27:22you see it, you know when you see it,
27:25so write it down and it's the main bit.
27:27Is that second question what happened?
27:28What did they do this?
27:30It's free narrative text and then we
27:32have an optional question at the end,
27:34which is what can we learn from this?
27:36And which is not always completed,
27:39actually,
27:39because some of the learning for the
27:41witnesses didn't necessarily apparent
27:42other than what is just described in the box.
27:44This is what good looks like.
27:46So this is what good looks like then.
27:48You need to be aware of this
27:49so you can do more of this.
27:50This part of your practice is good,
27:52and when you receive these reports.
27:54That alone in it causes a change.
27:57It causes a change in your behavior
28:00because you you've had feedback,
28:01but some of the learning actually does
28:03come out from that last box as well.
28:05People tend to report other people,
28:08so no one's we've had over
28:1010,000 reports an institution,
28:11and there's I think over 100 centres now in
28:14the National Health Service UK doing this.
28:17And as far as I know,
28:19there hasn't been a report saying
28:20I was excellent today.
28:21I'm I'm looking forward to the first one,
28:24but there hasn't been there.
28:25Always seem to be about somebody else.
28:27And of course they have.
28:29A descriptive positive feedback in them.
28:33And I put them.
28:33I've done a few.
28:36Inquiries into what is it?
28:38What are the themes that are being reported?
28:40And I'll show you two very brief
28:42summaries of the thematic analysis.
28:45The first was a very crude one.
28:46They did myself and I just arranged
28:48my inbox into categories until
28:50I ran out of new categories.
28:52That kind of data saturation,
28:54and this is just a snapshot from my
28:56inbox and I realized this was just
28:58a single person exercise because
29:00I was just curious and I realized
29:01that I was describing and capturing.
29:05Human factors for one of a better word.
29:08There is kind of human behaviors,
29:10soft skills.
29:11They're sometimes defined as.
29:14Not all of them.
29:14Some of them are quite high schools,
29:16but most of them are.
29:18In that there's a whole literature on
29:20soft skills and things like compassion,
29:21kindness, courage,
29:23empathy, trust, generosity,
29:25and then there's other ones like innovation.
29:28A perseverance preparedness.
29:31Technical skills comes up.
29:33So this was a fairly
29:35amateur thematic analysis,
29:37subsequently done a more
29:38in depth thematic analysis.
29:39This is just in review at
29:41the moment and in journal,
29:43so this is pre peer review and
29:45it's pre publication but just.
29:47I think it's worthwhile sharing
29:49so you can understand what sort
29:50of things people are reporting.
29:52They they fall into five large groups.
29:54There's the pro social behaviors,
29:56which are some of these?
29:57Compassion, kindness,
29:59generosity peer support type of
30:02skills there are expertise and
30:04technical skills clinical acumen.
30:06Good split technical procedures etcetera.
30:10Positive work ethic comes up
30:12a lot and this actually is an
30:14important theme because it can
30:15also indicate there's a problem.
30:17So if you have a lot of positive work ethic,
30:19people donating labor,
30:20staying late, filling in gaps,
30:22going out a role,
30:23it may imply the system to stretched.
30:25So there is some intelligence to
30:27be gained from this that is.
30:28Type side the excellence domain in
30:30my tell you more about your system
30:32than you didn't already know.
30:34Personalized patient care is the 4th
30:36category in that includes innovation,
30:38positive deviance.
30:39Sure,
30:39some of you have come across that concept.
30:41The idea of.
30:43Of changing or going outside the
30:45protocol or being different,
30:47being deviant within your care group,
30:49it's for good purposes with good outcome.
30:53And the teamwork and leadership often
30:55reported in the Excellence reports
30:57and we we put them in one theme
31:00because they're so closely linked.
31:02So what's the space for the
31:04publication in there?
31:05That is,
31:06yeah,
31:06all of the reports fall into
31:08one of those five categories.
31:11The kindness one is interesting
31:13in my many years ago when I
31:15had a different Twitter handle
31:17that I experimented by asking,
31:19the question,
31:20does showing kindness and appreciation
31:22to colleagues at work make the
31:24system safer or improve safety?
31:26And most people said yes,
31:28there's one person actually.
31:29That said, makes safety worse.
31:31And again, that's the shark attack.
31:33One wonders what would happen
31:34if I spoke to that individual,
31:36understood that, but the majority,
31:38yeah, are saying it makes safer,
31:39and it's not necessarily.
31:41Easy to draw the line between.
31:42I'm kind to my colleagues
31:44and they're kind to me and
31:46that makes the system safer,
31:48but there is clearly an A recognition
31:50that there is a link there.
31:54So if we call it learning from experience,
31:56what where's the learning that
31:57are quite often get that question,
31:59but I think actually it kind
32:01of answers itself because once
32:03you understand how it works,
32:05if what I write a report for some essence,
32:07I've seen that gets fed back to the
32:09individual and the team who are involved.
32:11So there was the feedback
32:12loop has just happened.
32:14And learning and its simplest form,
32:15the simplest definition.
32:16All the theories of learning would
32:18reference to this at some point.
32:20Learning is a change.
32:22In response to feedback,
32:23it's a change in cognition or knowledge
32:26or behavior in response to feedback,
32:28and the feedback can be positive or negative,
32:30and we learn from negative feedback.
32:31We learn indeed from positive feedback.
32:33Now here's an example,
32:35just not going to try and illustrate
32:37how you can learn from a report.
32:39This is.
32:40Busy full of text and I'm sharing
32:41it like this because this is a real
32:44report that came in a few weeks ago
32:46on my unit and and I've anonymized
32:48it so you can't see who the patient
32:51is or who the staff members were.
32:53But just to describe what happened
32:55that this intensive care patient
32:57deteriorated suddenly and the
32:59nurse asked for help and.
33:03People came quickly and this was a
33:05junior nurse who was quite nervous
33:07and it wasn't apparent actually
33:09that she was nervous for that
33:10comes out in this report and she
33:12was well supported by the team.
33:13Everybody did exactly.
33:14It was a textbook case.
33:16Everybody did well.
33:18The patient recovered quickly,
33:20but she's just described that won't
33:21go through in too much detail,
33:23but this is what some of the reports look
33:24planned. She's identified individuals.
33:26And what it was they did and why?
33:30Why that's why that was good.
33:33Now.
33:33Firstly it's worth just thinking
33:35about how often do we really get?
33:39I in the wild description of good practice.
33:43We often say this is what good looks
33:44like or this is what we're aiming for.
33:46This is the imagined work that
33:48that is perfect.
33:50This is the textbook case,
33:51but how often do we actually get that
33:53in the wild from the shop floor?
33:55This is actually what good
33:56practice looks like,
33:57and and this is an example of it.
33:59And actually you can read it.
34:01So firstly the people received
34:02the feedback they understood from
34:05the perspective of that nurse,
34:06who I must say was also speaking on
34:09behalf of the patient in this case.
34:11They they.
34:12Received the feedback and they became
34:15aware that what they did was good.
34:18Some of that is apparent at the time clearly,
34:20especially if you have a patiently
34:22recovers or that they turn
34:24around a bad situation.
34:25But some of it is not apparent.
34:27Yeah,
34:27you can go through your working
34:29life without actually getting this
34:31type of feedback and not knowing
34:32that some of your interventions
34:34have had had really major impact.
34:35In particular, as I said,
34:36this nurse was nervous and it comes
34:38through in the report that she needed
34:40reassurance and we provided that I was
34:42one of the practitioners in this case.
34:44So I'm speaking as someone
34:46who's received this report.
34:47And so you can highlight the elements
34:49that are described in good practice
34:50and you get to draw them out of the
34:52report and share them with stakeholder.
34:54We read some of these out
34:56our departmental meetings.
34:57We we a group of people,
35:00see each report.
35:01So intelligence is shared slightly more
35:03widely than just the people in the team,
35:05but I must hasten to add here,
35:07we don't put these on notice
35:08boards and we keep these private,
35:10so there's not a league tables
35:12going on for who got the most
35:14excellence reports this week.
35:15This is fed back for feedback.
35:17Like
35:20and so yeah, and so you can draw
35:21out the intelligence in these
35:22reports and and share summaries.
35:24This is what good practice looks like.
35:27Some of these reports are so good
35:29and interesting that we actually.
35:32Sit down and trying to root cause
35:33analysis on them and we started doing
35:35that and realized that was useful,
35:36but it's better to use something called
35:39appreciative inquiry that that seems to
35:41fit better and appreciative inquiry is
35:42based on the fact that you get you get
35:45answers to the questions that you ask.
35:46So if you ask in a root cause
35:48analysis what went wrong.
35:49What underpinned that?
35:50What were the? Why did that happen?
35:52The five wires approach?
35:53Then you will get answers,
35:54but you can also ask questions like.
35:57What were the conditions that
35:58allowed this success to happen?
36:00Or imagine a future where this
36:02happens much more frequently?
36:04What conditions would have had to
36:05change in order for that to happen?
36:07And so you ask more,
36:09you basically ask more forward
36:11looking positive questions,
36:13and that allows the people who are
36:15participating in those discussions
36:17to generate improvement ideas.
36:21People often say, well,
36:22we learn from failure and not from success.
36:26That's actually. Not true.
36:28We learned from failure and
36:29we learned from success.
36:30And if you go into the learning literature.
36:34There's actually.
36:34A fair bit of evidence now to say that
36:38positive feedback is superior to negative
36:41feedback for many aspects of learning,
36:42and I won't go through all the papers,
36:44but I'm willing to share references if
36:47anybody wants to contact me after this.
36:49But just a list of things in which
36:52positive feedback has been shown to
36:54be superior to negative feedback,
36:56particularly of relevance,
36:57I think is this.
37:00Effect it has a motivation to improve your
37:03intrinsic motivation and your self efficacy.
37:05Your belief that you are able to do the
37:07work that you're doing but also improves
37:10relationships except some moral tone.
37:13A whole bunch of other benefits.
37:15So success is instructed and this
37:17all fits in to positive psychology.
37:20So the idea this is from Lewis what
37:23Lewis said here was sort of logic
37:26model that how positive psychology
37:28can work in an organization to
37:30make an organization better.
37:31And the flow chart speaks for itself.
37:34Learning from excess ticks.
37:36Most of these boxes it's about recognising
37:38virtuous acts and positive deviance.
37:40Building a culture of abundance,
37:42and which then builds into
37:44positive emotions and to build on
37:46strengths rather than weaknesses,
37:48improve social capital.
37:50The first performances etcetera.
37:55So the the kind of take home is that
37:57learning From's highlights success in
37:59environment where our typical approach
38:01to learning is to highlight failure.
38:03But what I thought it would be useful
38:05to do is just to show a few more
38:08slides on some of the real evidence
38:10that we've gathered from our work,
38:12but also from work outside.
38:16Our industry.
38:18So just a few more slides on that.
38:19And then hopefully we can
38:21get some questions going.
38:22I see there's a couple
38:23of comments in the chat.
38:26That's about CME credit.
38:27Don't forget to claim your CME credit.
38:30Uh, OK. So we did a survey.
38:34We've done a few surveys actually,
38:35and people in our community have
38:37done a few surveys just a couple of.
38:39Snapshots from the survey we did a few years
38:42ago in intensive care unit where I work.
38:45Staff recognized that both reporting absence,
38:47they're improving patient care and
38:48they also recognise that by engaging in
38:51excellent supporting, they're boosting.
38:53Their motivation,
38:54and that's consistent with.
38:56And what I was briefly discussing there about
38:59how positive feedback improves motivation.
39:03Now, here's here's a study.
39:04This is a really small study from
39:06a completely different domain,
39:08but I think it's a good example of how.
39:11Of how positive feedback can affect
39:14our learning, and.
39:15And I hope this will stimulate,
39:18stimulate you to think about this.
39:20So that this is from sports science.
39:24And what the authors of this study did?
39:27Was they randomized some students
39:29into two groups?
39:31One group was received was given
39:33positive feedback for a task and
39:35the other group was given negative
39:37feedback for the same task and the
39:39task was a complex motor task.
39:41So what they had to do was
39:43to throw a ball in a hoop.
39:45But they're using their non dominant
39:46hand and they're a blindfold on,
39:48so it's a very very challenging task,
39:51which is why their accuracy on on
39:53the Y axis is very low at the start.
39:55And you you see and what they did
39:58was for the positive feedback group
40:00each each person through 10 times.
40:02And the positive feedback we received
40:04feedback for their best 3 throws.
40:07And the negative for their worst.
40:10And what they found is that
40:12overtime both groups improved,
40:13and that's what you would expect.
40:14So firstly, that's good news,
40:16because we know that positive feedback
40:18and negative feedback can improve.
40:19You can learn from both,
40:21so we should therefore use
40:22more positive feedback,
40:23because our typical approach is
40:25to constructive negative feedback.
40:27So that's a vote for both types of feedback.
40:30But what they found?
40:31And this has been borne out in other studies.
40:33I just like the the way it's
40:35illustrated in this one.
40:36What they found is when they came back
40:38the next day, they then repeated.
40:39The test with no feedback and just saw
40:42at the two groups which one performed better.
40:45So who had the better retention and
40:46the ones who had the positive feedback
40:48had better retention of skills.
40:53And we thought we would test
40:55this within our own environments.
40:57This is a paper we published which
40:59is a free Open Access text. And.
41:02We want to use positive feedback as
41:05a quality improvement intervention.
41:08So I'm happened to be interested
41:11in antimicrobial stewardship.
41:12And it occurred to me that's
41:15actually quite easy to measure,
41:17because we we can measure in
41:19intensive care and we can measure
41:22antimicrobial exposure and consumption.
41:24And we can also measure the processes
41:26and the behaviors that lead that are sort
41:30underpin and to mercurial stewardship so.
41:32Good prescribing antibiotic review
41:34D escalation of antimicrobials and
41:37and few other measures like that
41:39are actually fairly well described,
41:40so that's what we did.
41:41So we used the Qi methodology.
41:44We did a 12 month study which was
41:46three months pre intervention,
41:48six months of continuous intervention which
41:51is positive feedback for practitioners.
41:54And then three months at the end to
41:56see if there's any effects that are
41:58continuous and what we found is this
42:00is just one of the process measures,
42:01so we're using a prescription
42:04system where we defined what a gold
42:06standard prescription would be,
42:08so it had all the elements of
42:11good antimicrobial prescribing.
42:12And. At the start of the study,
42:14about 50% of prescriptions were gold
42:18standard. They were all good enough.
42:20They all there were no drug errors or
42:22extremely rare to have drug errors.
42:24But what we did find was if you
42:26really make a really strict gold
42:28standard definition,
42:28then actually that's not that common.
42:31So only about half of them are
42:33gold standard and then over the
42:35time during the intervention.
42:36The frequency or prevalence of
42:38gold standard improved and then it
42:40continues to improve or stayed high
42:43afterwards and and what we've found,
42:45the aim of this study should have said
42:47at the start was to reduce antimicrobial
42:50exposure by greater than 5% and we did that.
42:53We tried to 6% production but actually
42:54in the broad spectrum antibiotics
42:56it was the 30% reduction now.
42:59That aspect is obviously good,
43:03but I was really much more
43:05interested in the previous slide,
43:06which is the change in behaviors.
43:10And I consider this a kind of stake
43:12in the ground for how you could think
43:15about doing quality improvement.
43:17I'm not saying this is the
43:18only way to do things,
43:19but if this isn't available option that
43:21you can instead of thinking about the
43:23problem and how you're gonna mitigate it,
43:25you could think about the opportunity
43:27and how you're going to promote it.
43:28And that's an approach to Qi that I think.
43:31Needs to be explored more and just the last
43:35few points from from other literature.
43:38So the IBM organization do a survey
43:41intermittently called the Work Trend
43:44Survey and they did a survey in 2013.
43:47Fourteen about 16,000 workers from
43:50multiple different domains and
43:51they found us a clear association
43:54between recognition and engagement,
43:56so recognition and this definition
43:58is actually on this slide is
44:00I receive recognition.
44:01Gonna do a good job that is
44:03literally that is positive feedback.
44:05So people who receive positive feedback
44:07in the workplace are more engaged,
44:09significantly more engaged.
44:11And through standardized measurements of
44:15employee engagement and employee engagement,
44:18is related to performance,
44:20and that's been shown in the
44:22National Health Service in the UK.
44:24All the way down to financial
44:26performance of large healthcare trusts.
44:30So there's a fairly clear logic model between
44:34providing positive feedback for doing a
44:36good job and performance safety quality,
44:39financial performance,
44:40and Michael West,
44:41who wrote that last paper summarized
44:43it best by saying in general,
44:45the more positively experienced of the staff,
44:47the better the outcomes.
44:53So I will hopefully we'll have about 10-15
44:56minutes for some questions or conversation.
44:58I just leave this.
44:59As I said, there's there's no
45:02intellectual property here.
45:03We're doing this because we really
45:05believe in that there's a team of us now.
45:07We're working on this if you're
45:10interested in knowing more.
45:11There's a we have a website called
45:13learning from access.com and you can
45:15join the mailing list or follow us on
45:17Twitter and join the conversation that way.
45:19And as I say,
45:21we have conferences and.
45:22We actually now have a podcast which
45:25is obviously free to access as well.
45:27It's called being Better Together.
45:30And have some interesting interviews on that,
45:32all in related topics around
45:34workplace cultures well being.
45:36Safety and and and really interesting
45:40discussion on gratitude and
45:42positive feedback on the last one.
45:44So I should stop talking and I'm
45:47hoping there'll be some questions.
45:49Thank you for listening.
45:55Thank you Adrian.
45:56That was excellent.
45:57Very exciting to hear this.
46:01I'll let folks put questions in
46:03the in the chat box or the Q&amp;A,
46:06but maybe just to to start out.
46:09This is maybe more of a
46:11theoretical question you describe.
46:12Sort of the bell curve with
46:15on the right and the left.
46:17You know adverse events on the
46:19left and good events on the right.
46:21Do you think it's theoretically
46:22possible to really shift that
46:24curve and make it more right?
46:26Cited tailed so that you have
46:28a lot more positive rather
46:29than just the bell shape.
46:33Yeah, so yes, I think it I.
46:35I think it is and in fact I think that's
46:37kind of what I'm promoting with this
46:40approach to quality improvements to say.
46:42You know you you can make.
46:43You can put the average. That you can.
46:46You can move that mean line up by decreasing
46:49the stuff that's going wrong on the left.
46:51Or you could pull it up by increasing the
46:54prevalence of good practice on the right.
46:56We could clearly could do both
46:58at the same time would be ideal.
47:01I think the Bell curve is
47:04probably an oversimplification.
47:06It's diagrammatic, isn't it?
47:07I I don't know what the actual shape is.
47:11Other than to say that.
47:13Rare things going wrong is is a
47:16very small part of the system.
47:18But we tend to always try
47:20and push the mean up.
47:22By just working on that left hand side.
47:26So I think, yeah,
47:27I think you can work from both ends.
47:30What do you think?
47:30Do you think it's?
47:31I mean I'm sold on this idea
47:34and I've welcoming criticism
47:36and critique and challenge.
47:38Yeah, I mean I,
47:39I think in theory it is.
47:41I'm not sure which side it's
47:42easier to to push or pull from.
47:44Probably a little bit of
47:46both as as you suggest.
47:50Yeah, it's only easier for the
47:52reasons I think I specified,
47:54and I guess your own experience.
47:58I would have to bear witness to it,
48:01but the it's easier to recognise
48:03things are going wrong.
48:05And they just come, that's,
48:07you know, just it's automatic and
48:08it's in built in our education.
48:10In our society, our evolution.
48:12So it does take a bit of
48:14concentrated effort to.
48:16Recognize what was working.
48:19Some people find it easier.
48:23That all of us are technically you do have
48:25to suspend the negativity behind sliding.
48:27I don't think it's possible to go
48:29into a meeting, for example where
48:31you're doing an adverse safety review,
48:33as I'm sure you've done.
48:35I've done many of them.
48:36I don't think it's possible in that same
48:38meeting to really recognize good practice.
48:40There's often a very small part
48:41of an adverse safety report.
48:43What went well on this particular
48:45case is usually a.
48:46A short paragraph,
48:47but because I think you actually need
48:50to just suspend what you're normally
48:52doing and actually actively turn on
48:54the different part of your perception.
48:58No, I think that makes sense,
48:59and I think sometimes we see a
49:04little bit of the Oreo approach
49:05where there's positive feedback.
49:06But then in mixed in with
49:09that is the negative.
49:11So I think it's actually, as you said,
49:13sort of changing the way you
49:15think a little bit about it and.
49:17And focusing more on that.
49:23I guess one of the other questions
49:24I would ask is, have you noticed
49:27just a big change following
49:29things like the pandemic with the.
49:32You know, sort of population health
49:35being so much different than individual
49:37care and and how that has changed.
49:41I mean certainly.
49:43UM, doing during the pandemic.
49:46There's been no reduction in expense
49:51reporting, it's it's the types of
49:53themes they're coming through,
49:55have remained within those five big themes,
49:57but they tend to be a little
49:59bit more on that prosocial
50:00and helping each other out.
50:02And kind of flavour.
50:06But no, I I don't.
50:08I think they're so fundamental the
50:10the themes that come through are so.
50:12Fundamental around the majority
50:14around human behaviours.
50:16That actually whatever your work.
50:19Conditions are whatever the prevailing
50:21problem is that you're facing the same
50:25thing still seem to get being picked up.
50:27So yeah, I was whenever there's a big change,
50:30I always just worry slightly
50:31that people will tail off with
50:33the accent supporting because
50:35they've got other things to do.
50:36But it turns out they it just continued.
50:38In fact, it's continues to slowly grow.
50:50Just a reminder, if anyone has
50:52any other questions to put them
50:54in the Q&amp;A or the chat box.
50:59There I had a question which you
51:02actually emailed me back about.
51:04You know the question is.
51:07Obviously, Adrian and your team.
51:10It sounds like there's kind of
51:12a positive team or a team that
51:15responds to positive reports and one
51:17that responds to negative reports.
51:19So in developing such a culture does,
51:23do you think that it could
51:25be integrated in one team,
51:27or is changing perspectives like
51:29the face and the VAS to difficult?
51:32Or if one, we're going to initiate a program,
51:36it requires a separate. Team
51:40I, I don't think you need to
51:41go as far as a separate team.
51:43I think it's just a different as a.
51:47Specified time to.
51:50So this is what we're doing in this
51:52meeting we are doing the positive
51:54reporting or in this meeting we're
51:56looking at the adverse was I?
51:57I think the the Oreo approach
51:59trying to do both at once.
52:01Just doesn't work,
52:02and you've probably all seen it.
52:04We have a checklist in the huddle and
52:06at some point there's a question.
52:08What's working well today.
52:11It's very hard to slot that in to the other.
52:15The typical or prevailing context
52:17which is to report what's not working.
52:21I think that you you do need to.
52:23Do a separate time,
52:24but we're all capable of it.
52:26It's clearly some people
52:27find it easier than others,
52:28and and the same as two for recognising
52:30and learning from what's not working.
52:33And we will have our preferences,
52:34but I think anyone could do it.
52:35You just need to separate it out in time.
52:39That's difficult because we
52:41have we work in an environment
52:43where we're time pressured.
52:45So the challenge I guess to
52:47the organizational development
52:48to leadership is figuring out.
52:50Is this valuable enough?
52:51To create more time or to
52:54carve out more time.
52:55For doing this and in fact
52:57is there some activity that
52:58we're doing now that we could
53:00sacrifice in order to spend some
53:02time learning from success?
53:07That kind of leads into one of
53:09the questions from our audience.
53:10They were asking if you could comment
53:12on how this might look for trainees.
53:17I'm not saying that the.
53:19People coming through in training
53:22tend to embrace this more easily,
53:25so it may be a generational thing maybe.
53:28And that's just in my organization.
53:30I noticed that.
53:32So that's an observation.
53:34But it certainly fits into training in terms
53:38of the learning that you do on the job.
53:41For learning clinical skills, etcetera.
53:44And we have. We have now quite.
53:48A lot, in fact, I think all of
53:51our trainees now are presenting.
53:52Excellent supports in their
53:54portfolio of learning and that
53:56along with reflection and we have,
53:58we've provided ways that you can reflect
54:00on it using appreciative inquiry or
54:02you can just do your own reflection on
54:05positive feedback and it clearly has.
54:07Yeah, a huge learning potential so
54:09it's highly relevant for trainees.
54:16It might also be worth stating
54:18because it may not be obvious if you
54:20haven't seen the system in action,
54:21as that the reports go in all directions.
54:25So there may be a senior doctor
54:28reporting in junior nurse and vice versa,
54:30so that they it's sort of
54:34transcends traditional hierarchies.
54:36And most staff groups have
54:38participated in it.
54:47Hi Adrian, thanks so much.
54:51What have you? I'm sure not
54:52everybody has embraced this.
54:53What have you handled?
54:54The folks who are who are a little
54:57stodgy about this kind of stuff.
54:59Yeah, the so it's. It's voluntary and.
55:04It's there's an option if
55:05you want to embrace it,
55:06then that's fine, it's available.
55:09And we've met, yeah,
55:10we've met like you know the road,
55:12just diffusion, change diffusion curve.
55:14You have the earlier doctors.
55:16Innovators and another bell curve,
55:18isn't it on one side?
55:19And then you have the laggards
55:21on the other side.
55:22Who are skeptical,
55:24skeptical you need skeptics in any
55:26change to challenge it and shape it,
55:29but some of them of course,
55:30on the far side can be a bit cynical
55:33and can can actually block it.
55:37What I've found,
55:37and this may just indicate the
55:39environment I work in.
55:40That is, we have quite positive
55:42leadership who who recognizes innovation.
55:45So we had immediate buy in from the leader,
55:51the chief executive and medical
55:52director of our organization.
55:54Which actually made it very
55:56easy to spread and then we just
55:58didn't do any top down launch.
56:00We spread it from the grassroots so
56:02we just started writing the reports.
56:04Didn't even tell anyone about the system,
56:06just sort of using it and people
56:07became aware of it.
56:08So kind of spread organically
56:10and then along the way we'd meet
56:13the occasional cynic or deeply
56:15skeptical person who so they don't.
56:17I don't get it,
56:18and what I tend to do is just.
56:21It ignore it.
56:22Really sort of not in a rude way.
56:24It just sort of.
56:25Let that go and say that's fine,
56:28please don't.
56:29Take part in this.
56:30If you can't see value in it,
56:32but please don't block it because
56:34these people are finding it valuable.
56:36And then.
56:38There have been a couple of conversions so.
56:41That means that I can remember a very
56:43clear conversation with someone.
56:45Who, after she'd received a report,
56:46she came to me and said I didn't get this?
56:49And now I do,
56:51because someone's written down
56:52something I did and I had no
56:54idea how impactful that was.
56:56And then that person's quite
56:58active in the movement.
57:00That's what's supposed to happen.
57:02Have changed the fusion.
57:03Isn't there?
57:03The far side gets carried away
57:07once it becomes.
57:08Prevalent and certainly prevalent in
57:10our department in our organization now.
57:15I think we have one more
57:17question in the box from ADA.
57:19She wanted to know in Pediatrics this is
57:22probably somewhat easier to push forward,
57:24given that there's a lot of
57:27positive parenting approaches.
57:29What about in other specialties?
57:32Have you found acceptance
57:33across other subspecialist?
57:35Yeah, that's that's a really good point.
57:37I've also. I'm also a parent and I'd
57:40like to say I practice what I preach,
57:42but I've I've again negativity bias kicks in.
57:46It can be quite hard to.
57:48Always remember that people respond better
57:50to positive feedback and they do next,
57:53but yes, it is well embraced in
57:55Pediatrics for sure and other
57:57specialties that have bought into it.
58:00I've noticed have been anesthetics.
58:02Interestingly, in critical care.
58:04UM and obstetrics seem to
58:07have a lot of buy in.
58:10And then.
58:11Also, I've noticed within our
58:13community there are groups like
58:15organizational groups who bought into it,
58:17so there's a series of private hospitals
58:20in health in healthcare in the UK
58:23who've introduced it across the board,
58:25and I don't know how they've done it,
58:26but they've just got great buy and
58:28that's in multiple specialties,
58:29so I think it depends on it.
58:31Obviously organizational culture,
58:32as well as specialty culture.
58:36So we did do a small study where
58:39we we examined some of the reasons
58:41for a kind of qualitative study
58:44about why it's implemented,
58:46like what are the barriers and what
58:48are similar facilitative implementation
58:50and we found conflicting results.
58:52So,
58:52for example,
58:53having a low morale and a low well
58:56being in your organization can
58:58be a facilitator for this,
58:59because it's perceived as
59:00something that would improve that,
59:02but in other senses it can be a barrier
59:05because people have burned out and.
59:07They didn't don't want to engage
59:09in a deeply skeptical so.
59:11So I still don't know the answer to that.
59:16Well, I know we're at the top of the hour,
59:18so thank you very much.
59:20We really appreciate you joining
59:22us today from across the way.
59:25I think if other folks have other
59:27questions, feel free to reach out.
59:30Connect to welcome any.
59:33Questions I know people don't
59:35always want to ask on zoom and
59:37virtual meetings because it's a
59:39bit can be a bit self-conscious,
59:40so if anybody wants to contact me,
59:42just fire me a question that's fine.
59:45I'm sure you can be linked
59:46up with my email address,
59:48or you can just contact me on the website,
59:50but thank you for the invitation
59:51as the the light to speak to you.
59:54Thank you, thank you all for joining today.