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Turn Up The Volume! Listening for safer care – graffiti walls

November 3, 2015 By Steve Turner

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On 16th October we held a unique learning event, bringing together whistelblowers and health leaders from all quarters (staff, public, patients, carers, relatives)  to speak out for safer care.

We collected (and continue to collect) a large amount or information, in the speaker videos , graffiti walls, question and answer sessions, feedback forms, emails, twitter (under #turnupbristol).


To help keep the conversation going here are the graffiti walls:

CLICK ON THE IMAGES TO ENLARGE THEM

CONCERNS:

Concerns (2)

POSITIVE THINGS:

PostitveThings (2)

PLEDGES:

My pledge is (2)

OUTSTANDING QUESTIONS:

Oustanding Questions (2)

MOST IMPORTANT THING I LEARNED TODAY:

The most important thing I learned today was... (2)

I NEED TO LEARN MORE ABOUT:

(Nothing put on this wall)


CLICK HERE FOR THE EVENT VIDEO SUMMARY (less than 3 minutes)

CLICK HERE FOR THE RESOURCE PAGE


Page updated: 11/3/15

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Filed Under: Care Homes, Care Right Now, CIC, Elderly care, NHS, Organisational Culture, Transparency, whistleblowing

Why I set up Turn Up The Volume! (3)

October 18, 2015 By Steve Turner

Now the event is complete three things stood out for me:

  1. That this is a  movement not just a  conference

  2. That between us we have the answers if we work together

  3. The need for truth and reconciliation

 

Click here for the resource pages.

 

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Filed Under: Care Right Now, Human Factors, Leadership in Health, Organisational Culture, Transparency, Uncategorized, whistleblowing, Workshops

Why I set Up Turn Up the Volume! (2)

October 9, 2015 By Steve Turner

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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.

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Filed Under: Care Right Now, Human Factors, Leadership in Health, Organisational Culture, Transparency, whistleblowing, Workshops

Steve Turner on ‘Why I set up the Turn Up The Volume! event’ – ‘Reflections on the ‘dark side’

September 19, 2015 By Steve Turner

The Turn Up The Volume Conference aims to promote best practice in patient safety:

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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:

CLICK HERE FOR THE TALK

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

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Filed Under: Care Right Now, Leadership in Health, Organisational Culture, Transparency, whistleblowing

Children’s medicines – how listening to parents led to safer care

August 22, 2015 By Steve Turner

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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 incidents 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.

Click here for the poster.

Last updated: 06.12.2021

CRNAnimationTestFor more information contact: info@carerightnow.co.uk

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Filed Under: Care Right Now, Children Health, Leadership in Health, Medicines, Medicines Optimisation, NHS, Organisational Culture, Prescribing, Transparency, Uncategorized, Workshops

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