In the meantime the event resources are here.
We’ll be updating these resources after the event to ensure it lives on and achieves real change.
Steve Turner on ‘Why I set up the Turn Up The Volume! event’ – ‘Reflections on the ‘dark side’
The Turn Up The Volume Conference aims to promote best practice in patient safety:
Why did I set it up?
I’m not in the conference business so why did I take the risk of setting up, promoting and delivering a national event? I’ll attempt to explain.
There are plenty of reports, reviews and consultations on the need for an open culture and an end to bullying in healthcare organisations. In fact if you start with the Francis Review into Mid Staffordshire, by my calculation we are now on to the eighth. That’s a lot of talking and precious little action.
They all refer to the same thing, best expressed by Sir Robert Francis who agreed that the treatment of whistleblowers in the NHS has been abysmal.
In fact, The Freedom to speak up review report contains damning information on what happens when staff are not valued and listened to, leading to the statement that ‘The effect of the experiences has in some cases been truly shocking’. The report makes disturbing reading and links the culture of ‘fear, blame, defensiveness and scapegoating’ directly to patient safety.
This fires me up because I’ve had an unusual career and seen things from many angles. I’ve been a senior manager, management consultant and specialist clinician. I’ve worked for the NHS and for a US healthcare firm. So you could say I’ve been to the ‘dark side’ and back, depending on your views as to where the ‘dark side’ is.
Many of the jobs I’ve had involved, and continue to involve, working across several NHS trusts and organisations. Here I’ve seen, and continue to see, the best and worst of care and the best and worst of cultures. This variability which exists even today is alarming. Critically within a single organization cultures can vary massively, and patient safety is affected accordingly.
So what do we need to do?
In my view there is no organisation, professional group or body that represents a ‘dark side’ it’s about how we behave individually and together and how we treat each other.
Times are tough and people get pressured but there is no excuse for being uncivil or not listening. When this type of behavior gets copied it works like a toxin in organisations.
If you want to see a better explanation of this I recommend this talk on Developing Cultures of High Quality Care by Michael West:
So now’s the time to act together to break down barriers and tribalism, and cut across hierarchies for safer care. We will all benefit and services will be safer.
Useful resources:
Turn Up The Volume Conference Resource page
Steve’s blog on culture and leadership in healthcare
Steve’ blog on bullying and accountability
Personal views of the author: Steve Turner
Last updated: 18/10/2016
Children’s medicines – how listening to parents led to safer care
Case Study:
Background:
From 2008 to 2014 my company ran education sessions on managing medicines in a mental health trust. In common with some other mental health trusts the provider also looked after paediatric community services. This is not a mental health service. It covers children with complex health needs including enteral feeding tubes, ventilation; epilepsy and rapidly changing medicines. Children under the care of this service may be taking in excess of 15 different medicines per day, have complex titration regimes, emergency drugs with associated care plans, plus numerous ‘as required’ (prn) medicines.
It is not unusual for children with complex conditions to be under the care of up to five different providers, and to move between three different providers in one day. For example, from a Home Care Service to the Special School, to a Short Break House, maybe also being seen in an Outpatient Clinic on the same day too. As a result parents frequently have to repeat the information on their child’s medicines every time they move to another service, or a new person is involved.
Where to start?
The idea for change came about because of concerns that the staff in Children’s Short Break Houses were not learning what they needed about children’s medicines, as the learning was geared to the majority of staff who worked in mental health. So a new learning package for children’s staff was commissioned.
Part of the work to design the learning package included a baseline assessment which was conducted with parents and staff. This soon revealed that training alone was not the answer. It showed delays in medicines information reaching GPs, workarounds for obtaining information in order to administer medicines in the houses and a general lack of confidence in the whole process.
As a result we looked at the whole system starting with the area where most concerns had been raised, which was having an up to date complete list of a child’s medicines available at all times (medicines reconciliation). The system in place for Short Break Houses involved paying a local GP (not usually from the child’s GP Practice) to write up a medicines chart for each child. The process was fraught with difficulties and delays and widely disliked by everyone directly involved.
So we set about looking for a new way to manage the lists of medicines with more training and more input for the staff in the services involved. We came up with a new (and much more robust) process for medicines reconciliation in the Short Break Houses. This was fully documented in a new policy, and involved cross checking by both the staff and the parents.
Just before this went live, we asked the parents to review and comment on it and they said
‘If you’re producing an accurate and up-to-date list of my child’s medicines, why keep it the Short Break House, can’t it go with my child?’
So the My Medicines chart, which travels with the child, was born.
What was involved?
The My Medicines process led to the design and production of a new chart which has to be signed and checked by the parents.
It resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go.
Benefits:
The new process, which continues to evolve, means that the child’s GP is now directly involved in day to day medicines reconciliation (they weren’t before); the parents are always asked to check and sign the charts (they weren’t before); verbal messages about medicines are never taken, and incomplete (or missing) directions are rapidly rectified (never worked around).
Some specific benefits of the new process include:
• It has reduced the risks of error, by providing full and accurate information on children’s medicine across their entire pathway.
• It cuts out the need for parents to keep having to repeat what medicines their child is taking to different professionals and care agencies.
• It frees up medical and clinical time which was previously spent chasing missing information.
• It has reduced the number of third part handovers and transcribing of prescription information.
Looking back it’s hard to believe that the old ways of working, which caused so many difficulties (especially for front line staff), were carried out for so long. These risky practices, or similar, are believed to still be commonplace in England.
Revealing hidden incidents and near misses:
In the first month of the project we raised 17 medicines or near misses. Of these 11 related to problems with communication of information across the child’s pathway.
Resolving these has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further. Previously many of these incidents were not logged or tracked across organisations. In some cases it was only due to the vigilance of the staff and parents that they were spotted and errors avoided.
Accepting the changes:
The project was well received by parents and staff, and resulted in improved communication and engagement between different clinical groups and providers. This included the Consultant Paediatricians (working for the secondary care provider), who were initially sceptical.
The project was less well received by the relevant medicines and prescribing committees, who were understandably concerned about who owned the My Medicines chart and had agreed its content. Explaining this was made more difficult because it is hard to get across the complexity of the arrangements, due to the critical nature of the children’s illnesses, in a committee setting.
I make no apologies for ensuring from the outset that it was the parents who owned the charts, which were designed by the project team (not a committee) to meet all best practice standards. It always worries me that when it comes to cross- organisational working the formal committees and systems in place can inadvertently act as a barrier to safety rather than promoting it. There is no doubt we had designed a safer process and my company was happy to take accountability for any associated risks.
As a legacy of the project, a Community Paediatric Pharmacist was appointed specifically to work with this group of children. So whatever evolves will now be based on inter-disciplinary thinking and working and will have clear safety parameters. I am grateful to the enlightened thinking of the leaders who commissioned this work and supported this novel approach.
Steve Turner
Managing Director Care Right Now (CIC)
This example is incuded in the NICE Shared Learning resource and was highly commended in 2015.
Last updated: 15.08.2019
For more information contact: info@carerightnow.co.uk
Pushing the boundaries
Pushing the boundaries
At Care Right Now we love pushing the boundaries. If someone, especially someone in ‘authority’, tells us it’s not possible it just makes us more determined.
For info there the latest on our work with people with long term conditions:
http://www.carerightnow.co.uk/condition-management/
…what do attendees on our course say?
‘You should listen to those guys. You will learn something’ April Attendee 2015.
It’s the power of patients and the public which will drive forward safer and more cost effective care, and this doesn’t need complex jargon or rules, or to be stage managed by existing bodies.
Here’s another example of a successful project which pushed the boundaries:
http://www.carerightnow.co.uk/parent-held-medicine-records/
Author: Steve Turner 11/5/15
The right to speak up……..Guest blog from Dr Kim Holt
‘The right to speak up……..
Whistleblowing laws were brought in following tragedies such as the Herald of Free enterprise disaster. The legislation was intended to prevent workers raising concerns from being dismissed. This has failed abysmally as Sir Robert Francis stated in the Speaking up review, at best the law (Public Interest Discrimination Act) has limited effectiveness.
At least that gap is now acknowledged. It’s been accepted. So whilst the law remains ineffectual workers remain unsafe. That’s the least of our problems.
Patients First has grown organically from a handful of campaigners to a large and growing network of health professionals who have fought against a system that has been cruel and vindictive in too many cases. The stories of breakdown and loss have been heart breaking to hear. Personally I have listened to maybe thirty or forty similar heart wrenching stories of severe bullying, ignoring of the concerns and failing health and well being. Sir Robert Francis detailed similar in his report published last week.
Patients First contributed by submitting a summary of 70 cases in a thematic review. The patterns used to try and make the individual the focus rather than the issue are remarkable.
Attending a rally last week an eloquent doctor asked how listening to these stories Sir Robert could bear to leave these individuals unresolved. He has. There needs to be some process of reconciliation for the historic cases, as well as most importantly learning from them.
My own journey of whistleblowing took me through all the layers of internal management to the regulators and eventually the media. Until I received support from my MP and the media investigating the ~Peter Connelley story, I didn’t feel that my concerns were being listened to or taken seriously. Colleagues of mine who tried at the same time to speak up, resigned out of frustration, but also felt used by a system that didn’t really care to hear our views. NHS London who investigated my concerns in 2009, treated them as an employment matter rather than a patient safety issue, completely missing the point. The Health Select committee agreed that employment tribunals are not the place for patient safety matters to be heard. Yet this still goes on.
Now its clear that bullying is a major problem and can be linked to raising concerns. The leadership of the NHS will now have to start addressing that by training and more robust support for staff. Unions need to rethink their response to requests for help when staff report bullying, and much earlier intervention generally, and better psychological support is essential. I proposed an early intervention scheme which has been in principle accepted by NHS employers as a good way forward and currently sits with the Department of Health.
This would allow an external scrutiny early one where clinicians or managers are raising concerns about patient safety. The focus would be the patient safety, not the individual.
Whistleblowing externally to regulators and politicians also needs to have a better system in place, and we need to see an end to the post code lottery that currently exists. Some people receive brilliant support from their MP, others have been ignored.
Campaigners have achieved a lot in having these issues heard and now accepted, now we look to government and politicians to ensure that there is fairness for all and no more turning away from difficult issues.
These are my own personal views.
I founded the Patients First network in 2011, contact them at patientspfirst@aol.com
@PatientsFirstUK
Dr Kim Holt’
Click here for the link to the Patients First web site
This article first appeared in the Shaping Our Lives Newsletter Spring 2015 – Issue 23
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