Patient Safety Journal Edition 2 - May 2020 by munglani

Volume 1, Issue 2, ISSN 2632-363X

May 2020

PATIENT SAFETY JOURNAL

for better, safer care

> Safer care for mothers and babies > Learning from suicide-related claims

> Improving weekend safety > Effective communication in teams

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BRISTOL

PATIENT SAFETY CONFERENCE 2021

16th June 2021 In our eighth year, this is our second online conference www.bristolpatientsafety.com

National Patient Safety and Quality Improvement Poster Competition 2021 Judges will be looking for examples of innovation, joint working and a clear focus on quality improvement including evidence of PDSA cycles, learning and changes made.

Open for applications 1 December 2020 Entry Deadline 9th April 2021 www.bristolpatientsafety.com

PATIENT SAFETY JOURNAL

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for better, safer care

Patient Safety Journal This a record of the proceedings and learning shared at the Bristol Patient Safety Conference. The purpose of the journal is to improve safety and care through: • sharing approaches to improvement at all levels in a healthcare setting including system-wide change • accelerating the sharing of ideas and tools that have been successfully put into practice •

c elebrating practitioners’ quality improvement work and barriers overcome

Contents Sharing learning on safer care for mothers and babies Ann Remmers, Nathalie Delaney et al. 5-13 Learning from suicide-related claims A thematic review of NHS Resolution Data Dr Alice Oates

14-19

Strengthening the weak-end handover: improving weekend safety at a district general hospital Dr Ann Archer BM BCh, Dr Rachael Goddard, Mr Paul Faulkner 20-26 Editor-in-Chief Dr Tricia Woodhead

Time to ‘Meet & Greet’ Gemma Ashton-Cleary, Ella Leuzzi, Jay Over, Dr Clare Fox, Dr Rachel Chiumento 27-34

Senior Editors Miss Anne Pullyblank Dr Mark Juniper Professor Wai Tse Assistant Editor Dr Laura Munglani Publisher Katherine Dougherty, KJD Communications Copy Editor Ravi Munglani Designer Lesley Lee Design Website www.patientsafetyjournal.com 33

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Introduction from the assistant editor

Dr Laura Munglani

Working as a junior doctor in the South West and South Wales I’ve had a close relationship with the Bristol Patient Safety Conference (BPSC) in recent years. Having first attended BPSC in 2016 I found it a fantastic forum for sharing the excellent patient safety and quality improvement (QI) work taking place across the UK. Following success in one of my projects collaborating on the establishment of a treatment escalation plan document in Weston General Hospital, aimed at reducing complaints around end of life care, I was invited to speak at BPSC in 2017. I was able to share the tools that made it a success, the lessons learnt to inspire other junior doctors, and the keys to achieving sustainability in quality improvement. With QI now an essential part of all junior doctors’ curriculums, it is even more important that platforms like the BPSC exist to enable the proliferation of approaches and tools that have been successful to make a sustained change within local departments. A focus on QI is needed now more than ever as we are adjusting to life and work in the NHS during the COVID-19 pandemic. Systems have been shaken up at every level, presenting a great challenge, but also the opportunity to focus even more on patient safety while the NHS gets back up and running. In this issue of the Bristol Patient Safety Journal, Ann Remmers and colleagues present findings from the national Maternal and Neonatal Health Safety Collaborative (MNHSC) in ‘On Sharing learning on safer care for mothers and babies’ (pg. 5). Their first two years of data collected from 134 maternal and neonatal units in England, highlights specific QI projects from Swindon, Plymouth, and Taunton. Their work focuses on reducing unwanted variation nationwide through simultaneous and networked local changes in the culture of mother and baby care to achieve successful and sustainable improvement.

Dr Alice Oates discusses ‘Learning from suicide-related claims. A thematic review of NHS resolution data’ (pg. 14): a review of clinical negligence claims around suicide. She presents the common problems encountered by individuals affected in both clinical and non-clinical care, highlighting issues such as family involvement in only 20% of suicide-related claims. She then goes on to discuss NHS Resolution’s nine recommendations based on this analysis, with the aim to improve patient safety. In ‘Strengthening the weak-end handover: improving weekend safety at a district general hospital’ (pg. 20) Dr Ann Archer and colleagues discuss their QIP utilising a handover smartphone application to improve the quality, reliability, and accessibility of the handover document, having been inspired by a clinical incident at Weston General Hospital. The increasing use of technology was a common theme in BPSC 2019 and innovations can often be easily disseminated between hospitals and NHS trusts. Finally, in ‘Time to ‘Meet & Greet’’ (pg. 27) Gemma Ashton-Cleary and colleagues discuss the cardiac arrest team handover at the Royal Cornwall Hospital NHS Trust. Their article focuses on improving resuscitation team communication by allocating specific responsibility and leadership roles during team handover. A common theme amongst these articles and the talks at BPSC 2019 is teamwork. It has become clear that an effective team is absolutely key to producing sustainable quality improvement work. By sharing ideas, approaches and lessons learned at all levels, in the NHS and beyond, we can empower healthcare professionals and their teams to improve the quality of patient care. This journal embodies the celebration of QI work and some of the key points from Bristol Patient Safety Conference 2019 and we hope to see you at the next conference on 16th June 2021.

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Sharing learning on safer care for mothers and babies Ann Remmers1, Nathalie Delaney1, Heather Pritchard2, Sally Hedge3, Shomais Amedick1, Julie Edwards4, Dr Anita Sinha4, Anne Baxter4, Kathryn Owen4, Dr K Girish Gowda4, Christina Rattigan4, Charlotte Wallen4, Karin Jones4, Donna Johnson4, Julie Herring4, Dr Smita Sinha5, Sue Fulker5, Nicky Van-Eerde5, Dr Nicola Johnson5, Lucy Duncombe5, Tracey Sargent6

Abstract or Summary Maternal and neonatal services operate in a complex and demanding environment, and leaders at all levels should ensure the safety of both staff and the women and babies being cared for. It is everyoneâ&#x20AC;&#x2122;s responsibility to contribute to developing and nurturing a culture that avoids harm, promotes learning whether the outcomes are good or bad, and enables staff to speak up about concerns in order to drive improvement in quality. The national Maternal and Neonatal Health Safety Collaborative (MNHSC) was launched in February 2017 and is a three-year programme led by the NHS Improvementâ&#x20AC;&#x2122;s National Patient Safety team. The MNHSC aims to: Improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide high quality healthcare experience for all women, babies, and families across England. The collaborative is structured into three waves, each running April to March. During a 12-month wave there are three phases: diagnosis, testing, and refining and scale up. Trusts receive support from a named NHS Improvement Manager, as well as a safety culture assessment, and three national learning sets (3 days each). There is a national sharing day at the end of each wave. Local units in Wave 2 have shared their learning from quality improvement projects aligned to the national driver diagram, and demonstrated positive impact for mothers, babies and staff across the region. Nationally, results from the culture surveys have been collated to identify themes and actions for improvement in safety culture. Using a structured quality improvement approach has enabled staff working in the maternal and neonatal setting to work together to improve care aligned with the national clinical drivers. Culture will only improve if everyone supports the changes required, and when quality improvement was linked to improvements in safety culture, both the quality of care and culture improved.

1 2 3

West of England Academic Health Science Network, NHS England & NHS Improvement, South West Academic Health Science Network,

4 5 6

Great Western Hospitals NHS Foundation Trust, Taunton and Somerset NHS Foundation Trust University Hospitals Plymouth.

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Introduction The Maternal and Neonatal Health Safety Collaborative is a three-year programme, launched in February 2017. The collaborative is led by NHS Improvement’s Patient Safety team and covers all maternity and neonatal services across England. The collaborative

contributes to the national ambition, set out in Better Births1 of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020, and the new strategy sets out the ambition for 50% by 2025.

Figure 1 – System wide safety programme for Maternal and Neonatal Health

Methods The Collaborative programme involves all 134 maternal and neonatal units in England. Each unit will participate in one of the three “waves”. Whilst in a wave, units undergo a structured quality improvement process, aligned to the national driver diagram along with a safety culture survey. Nominated improvement leads from each unit build their knowledge of improvement theory by attending nine days of learning sessions during the wave. The driver diagrams and change packages are a resource that maternal and neonatal

healthcare staff can use as part of a systematic improvement approach to improve services for women and babies. The change packages relate to the five clinical priorities outlined in the national driver diagram and set out change ideas, concepts and interventions that can be tested to accomplish the stated project aim. These five drivers are underpinned by a strong focus on safety culture, systems and processes, engaging with staff, women and families, and learning from both error and excellence.

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Figure 2 – National driver diagram

A network of local learning systems across the country, that brings all providers and network partners together, to work on system level/wide quality improvement has been established. At a local level, units are part of the Local Learning System (LLS). The local learning systems are ‘improvement forums’ where individuals, across different professions and from different organisations, come together to share and learn about the improvement approaches and outcomes. The idea is to create learning systems to encourage the sharing and adoption of good practice. Local Learning Systems provide a further layer of support for organisations to focus on quality improvement, collaboration and an opportunity to reduce variation (and hence inequality) within local

geographies, thus enabling maternity and neonatal systems to flourish. Some improvement work, such as smoking cessation, benefit from a system level approach in order to deliver a sustainable solution. In the South West and West of England, the Local Learning Systems are supported by a faculty, Local Coordinating Group (LCG). Members of the LCG provide coordination of the support and activities across the three waves, including developing the LLS. Members include local maternity system (LMS) leads/ Board representation, the maternity clinical network, neonatal operational delivery network, Patient Safety Collaborative and NHS Improvement.

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Examples of Quality Improvement projects in the West and South West of England Swindon Great Western Hospitals NHS Foundation Trust completed two projects, one focussed on improving the detection and management of diabetes in pregnancy, and the other at reducing neonatal hypoglycaemia. Both projects were presented at the national

learning and sharing day in March 2019. The projects used a quality improvement approach, including PDSA testing ramps, a driver diagram and measurement for improvement.

Figure 3 – Great Western Hospital NHS Foundation Trust roadmap for diabetes project

The neonatal hypoglycaemia project reduced heel tests per baby, and reduced neonatal admission (as seen in run chart above). Staff knowledge and patient satisfaction were measured and results were good. For balancing measures, the readmission rate was nil. Having a clear, structured and easy to understand pathway in place was key learning for the project, along with the

paramount importance of patient participation. The positive impact of team working, networking and linking into the national programme resulted in the words of the project lead: “happy babies equals happy mums, equals happy staff.”

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Figure 4 – Great Western Hospital NHS Foundation Trust results for neonatal hypoglycaemia

Plymouth University Hospital Plymouth (UHP) was a pilot site for carbon monoxide (CO) monitoring in 2011, where CO screening was introduced at booking for all pregnancies, but despite this intervention there was no noticeable improvement in smoking at time of delivery (SATOD) rates, with the local performance data regularly recording 16 – 20% of women smoking. The UHP smoking in pregnancy rate has remained high (14 – 18%) due to social health demographics, leaving UHP as an outlier in the south west. UHP commenced Wave 2 of the Maternal and Neonatal Health Safety Collaborative in March 2018 and were keen to be part of the nationwide programme to improve safety, reliability and the healthcare experience, and to reduce variation in outcomes for women and families.

Their change ideas began with understanding the current position and verifying the data recorded in the organisation. The team had a suspicion that the smoking at time of delivery (SATOD) data was not a true reflection, but were confident that all women were being offered CO screening at booking. Some quick audits demonstrated a degree of non-compliance and the limitations in IT data recording systems where the performance (dashboard) data is collated. This information was shared with the wider teams and addressed, where possible, with the education of staff inputting the information and this consequently improved in a short space of time.

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Figure 5 – University Hospital Plymouth CO monitoring at booking rate

The team implemented an increase in antenatal touchpoints offering CO screening, including on unplanned admission to Triage. The Saving Babies Lives compliance audit illustrated they were not recording the minimum standard of 36/40 smoking status, so the implementation of increased touchpoints began to address this measure, whilst providing a tool for the midwives and obstetricians to have the difficult conversations with women who continued to smoke during their pregnancy. The service did not receive any additional complaints during this time, which was a valid concern from some of the staff.

UHP is fortunate to have a close link with Livewell Southwest (an independent social enterprise providing integrated health and social care service for people across Plymouth, South Hams and West Devon), who provide the “Brief Intervention” training to staff which has been in place since 2011 and has provided additional ad hoc training to staff working solely in the acute setting, such as band 7 Delivery Suite Coordinators and Maternity Care Assistants, expanding the knowledge and skills of frontline staff where we were introducing additional CO screening.

The team reported that: “The three sets of “away days” created the perfect opportunity for us to learn about improvement and the QI methodology, to give us the confidence to just get started, the opportunity to network and share our successes and pitfalls, and to seek help and support where we had encountered challenges. We had met some fantastic and innovative individuals along the way and benefited from engagement with the quarterly Local Learning Sets. Our involvement with the MatNeo collaborative has already contributed to a reduction in the smoking at time of delivery (SATOD) rate to 12%.”

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Figure 6 – University Hospital Plymouth Smoking at time of delivery rate

Taunton Taunton and Somerset NHS Foundation Trust focused on the SCORE survey as their improvement project. SCORE: Safety – Communication – Operational Reliability – Resilience – Engagement is an internationally recognised way of measuring and understanding culture in organisations and teams based on the IHI Framework for Safe, Reliable and Effective Care.2 The team designed trust specific communications and had good engagement to achieve a response rate of 71%. Debriefs were held with teams (with support from HR) across the weekdays

including early and late times to capture both day and night staff. As a result the team co-designed a driver diagram with an action plan based on the results of the survey with feedback. Suggestions came from all teams, including staffing review, further survey around shift patterns, and celebration of success events, monthly staff meetings, and improved feedback post-incidents. A national publication has been published collating the results from the 87 trusts participating in Waves 1 and 2. 3

Figure 7 – National culture survey results

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Discussion Challenges raised by the teams included ‘that time was precious’ in the busy clinical environment and that it could be a challenge to “take time to step back and look at what you are doing when doing the day job”. Involvement from all stakeholders and support from senior leaders helped. The study days were valuable to step outside the workplace and see new innovations and ideas as well as sharing, and to get reassurance that other units had similar challenges and they were not alone. The key insights from the national culture survey were that how culture is perceived

varied widely in maternal and neonatal work settings and roles, reflecting the variable nature of culture. To date this has included insights from over 24,000 staff from a range of disciplines and clinical settings. Leadership was identified as key to involving culture, and leaders need to understand the culture of their organisation to be effective in facilitating improvement. The cultural insights are being used to inform local improvement plans which are being linked directly to quality improvement projects, the summary report identified themes and key actions to support units in improving their culture.

Conclusions Maternal and neonatal services operate in a complex and demanding environment, and leaders at all levels should ensure the safety of both staff and the women and babies being cared for. It is everyone’s responsibility to contribute to developing and nurturing a culture that avoids harm, promotes learning from successes and from errors, and enables staff to speak up about concerns and drive improvement in quality. The NHS Patient Safety Strategy Safer culture, safer systems, safer patients4 sets out the need to significantly improve the way we learn,

treat staff and involve patients. We have found that using a structured quality improvement approach has enabled staff working in the maternal and neonatal setting to work together to improve care aligned with the national clinical drivers. Culture will only improve if everyone supports the changes required, and when quality improvement is linked to improvements in safety culture, both the quality of care and culture are improved.

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Figure 8 â&#x20AC;&#x201C; Sign Up to Safety infographic5

To find out more and get involved in the work of the collaborative in the region, visit www.weahsn.net/matneoqi Acknowledgements The authors would like to acknowledge the support of the national improvement team at NHS Improvement and the fantastic engagement from participants across units in the West and South West in taking part in the collaborative and local learning systems.

Conflict of interest disclosures Disclaimers and conflict of interest policies are found at: http://bit.ly/1wqiOcl

Article submission and acceptance

Contacts/correspondence Nathalie Delaney, West of England Academic Health Science Network, nathalie.delaney@weahsn.net

Intellectual property & copyright statement We as the authors of this article retain intellectual property right on the content of this article. We as the authors of this article assert and retain legal responsibility for this article. We fully absolve the editors and company of Patient Safety Journal (PSJ) of any legal responsibility from the publication of our article on their website. Copyright 2020. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Date of Receipt: 09.08.2019 Date of Acceptance: 20.10.2019

References 1

NHS England (2016) Better Births. https://www.england.nhs.uk/mat-transformation/

Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. (Available on ihi.org)

NHS Improvement (2019) Measuring safety culture in maternal and neonatal services: using safety culture insight to support quality improvement. Available at https://improvement.nhs.uk/documents/5039/Measuring_safety_culture_in_matneo_services_qi_1apr.pdf

NHS England (2019) NHS Patient Safety Strategy https://improvement.nhs.uk/resources/patient-safety-strategy/

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Learning from suicide-related claims A thematic review of NHS Resolution Data Dr Alice Oates BMedSci (Hons) MBChB MRCPsych PG Cert (Hons)1

Abstract or Summary This thematic review presents a detailed analysis of clinical negligence claims made after an individual has attempted to take or has taken their life. Claims relating to completed and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery. The full report can be found at: https://resolution.nhs.uk/resources/learning-from-suicide-related-claims/

Keywords Suicide, suicide prevention, clinical negligence claim, learning, good practice

Introduction Suicide has a devastating, lifelong impact on the family, carers and staff bereaved when a person takes their life. While compensation claims relating to suicide are a small, highly specific group of incidents that may involve potentially avoidable harm, this may not reflect the entirety of care across the NHS. This review looks at cases both where liability has been admitted – which by definition means that there were errors that should have been prevented – and where liability was denied, as in both instances claims will contain learning that should be shared. This thematic review analyses in-depth the data held by NHS Resolution on compensation claims that relate to suicide between 2015 and 2017. The claims that are reviewed are those where member organisations received funding to provide legal representation at inquest via NHS Resolution’s inquest scheme. In addition, there is a review of non-fatal suicide attempts following which a claim was pursued. The purpose of this review is to identify the clinical and non-clinical issues in care that arose in those claims, share this learning with 1

South London and Maudsley NHS Foundation Trust, London, UK

the wider system to act as a driver for improvement, and make recommendations to reduce further harm.

Methods NHS Resolution’s claim management system (CMS) was searched for all claims relating to suicide that were accepted for funding under NHS Resolution’s inquest scheme between 2015 and 2017. The CMS holds a wealth of information, which can include the original hospital serious incident (SI) investigation, statements from clinicians, expert reports, and records of inquest, among other documents. An in-depth review of the documents was conducted using thematic analysis methodology.

Results The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports.

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Part one identifies recurring clinical themes and areas for improvement. Five areas where there were common issues in clinical care are discussed in depth: • Substance misuse • Communication, particularly failures in intra-agency working • Risk assessment • Observations • Prison healthcare. Part two identifies four main areas of concern, where: • There was a lack of family involvement and staff support through the investigation and inquest process. • The quality of root cause analysis undertaken as part of the Serious Incident (SI) investigation was generally poor and did not focus on systemic issues. • Due to the poor SI report quality, the recommendations arising from SI investigations were unlikely to reduce the incidence of future harm. • Reports to prevent future deaths (PFDs) were issued to trusts by the coroner with little consistency and there were poor mechanisms to ensure that changes in response to the PFDs had been made or addressed the issues highlighted. Key findings • There were 101 claims between 2015 and 2017 suitable for review. Admissions of liability were made in 46% of the claims reviewed. • There were examples of excellent practice, which are important to share. A number of trusts had a proactive approach to engaging families, staff and patients in improvement work.

However: • Those with an active diagnosis of substance misuse were referred to specialist services less than 10% of the time. • Risk assessments were often inaccurate, poorly documented and not updated regularly enough. There was little account taken of historical risk. • Observation processes were inconsistent and heavily influenced by organisational pressures. • Communication with families was poor. • There was evidence of poor quality SI investigations at a local level: - The family were involved in only 20% of investigations. - Only 2% of investigations had an external reviewer and 32% of incidents were investigated by a single investigator. - The recommendations were unlikely to stop similar events happening in the future.

Discussion Although this review analyses a small number of specific claims, the findings resonate with other reports with similar findings.1,2 This review, especially when making recommendations, has taken into account the work currently on-going within the wider system. This includes implementation of The Five Year Forward View for Mental Health3, NHS England’s Learning from Deaths4 guidance and the forthcoming review of the serious incident framework by NHS Improvement due later this year. Trusts should consider the findings of this report and will need to work with commissioners who will have an important role in implementing many of the recommendations within this review. National support from the organisations responsible for oversight, safety, training and

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improvement will also be required to ensure changes are embedded and sustained. Recommendations NHS Resolution developed recommendations to address many of the issues in care highlighted by the report. Where these recommendations explicitly reference actions to be undertaken by bodies external to NHS Resolution, we have worked in partnership with them to agree the relevant recommendation and are grateful for their support and commitment to action them. The nine recommendations are below: 1) A referral to specialist substance misuse services should be considered for all individuals presenting to either mental health or acute services with an active diagnosis of substance misuse. If the physicians decide against this the reasons should be documented clearly. 2) There needs to be a systemic and systematic approach to communication, which ensures that important information regarding an individual is shared with appropriate parties in order to best support that individual. Trust boards should consider how to best enable communication within their existing systems and prepare to adapt to new models of care, which should include working models to facilitate communication across services. 3) Risk assessment should not occur in isolation – it should always occur as part of a wider needs assessment of individual wellbeing. Risk assessment training should enable high quality clinical assessments, which include input from the individual being assessed, the wider multi-disciplinary team and any involved families or carers. While acknowledging that risk can be considered as ‘high’, trusts should move away from stratifying risk assessments into crude ‘cut offs’ of risk and encourage more 16

descriptive formulations. In order to ensure that professionals are performing to a high level, this training should be repeated every three years and risk assessment should be reviewed regularly during clinical supervision. 4) The head of nursing in every mental health trust should ensure that all staff including: • mental health nursing staff (including bank staff and student nurses who may be attached to the ward); • health care assistants who may be required to complete observations; and • medical staff who may ‘prescribe’ observation levels undergo specific training in therapeutic observation* when they are inducted into a trust or changing wards. Staff should not be assigned the job of conducting observations on a ward or as an escort until they have been assessed on that ward as being competent. Agency staff should not be expected to complete observations unless they have completed this training. *including principles around positive engagement with patients, when to increase or decrease observation levels and the necessary multi-disciplinary team discussions that should occur relating to this and actions to take if the patent absconds

5) NHS Resolution should continue to support both local and national strategies for learning from deaths in custody. In particular, there should be ongoing learning from litigation in cases involving prison healthcare, which will continue to inform the prison safety programme and National Partnership agreement action plan. External bodies such as Her Majesty’s Inspectorate for Prisons (HMIP) and the Care Quality Commission (CQC) have a role to play in sharing good practice nationally and will ensure that these programmes are effective in delivering their objectives.

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6) The Department of Health and Social Care should discuss work with the Healthcare Safety Investigation Branch (HSIB), NHS Improvement, Health Education England and others to consider creating a standardised and accredited training programme for all staff conducting SI investigations. This should focus on improving the competency of investigators and reduce variation in how investigations are conducted. 7) Family members and carers offer invaluable insight into the care their loved ones have received. Commissioners should take responsibility for ensuring that this is included in all SI investigations by not ‘closing’ any SI investigations unless the family or carers have been actively involved throughout the investigation process. 8) Trust boards should ensure that those involved in arranging inquests for staff have an awareness of the impact inquests and investigations can have on individuals and teams. Every trust should provide written information to staff at the outset of an investigation following a death, including information about the inquest process. In addition we recommend that the following mechanisms to support staff are considered: • The SI investigator should keep staff members up to date with the SI process, and the trust legal team should inform them of whether they will be called to coroner’s court as soon as this information is known. • There should be formal follow-up points to ‘check in’ with staff that have been involved in an SI. For example, there could be a follow-up meeting with managers three months, six months, and one year after the SI to ensure staff are supported both throughout the process and when it has finished.

• Introduce a system for monitoring and alerting managers when staff have been involved in more than one SI in close succession. 9) NHS Resolution supports the stated wish of the Chief Coroner to address the inconsistencies of the PFD process nationally. We recommend that this should include training for all coroners around the PFD process. Monitoring of the PFDs given, both in terms of number and content, should lie with both the CQC, and other external bodies, with this information being shared nationally to drive improvement in health care systems.

Summary This review identified 101 claims where inquests were funded between April 2015 and November 2017 for those that had taken their lives. It also reviewed a selection of claims related to non-fatal suicide attempts. The costs to families, carers and staff involved are, and will always be, immeasurable. The potential litigation costs are difficult to establish and will not include the potential future costs to the NHS of on-going treatment, revision surgeries or psychiatric follow-up for suicide attempt survivors or those impacted by the events. When reviewing the clinical and non-clinical themes five main areas were identified: the support available for those with active substance misuse; risk assessment; observation processes; communication spanning a range of environments; and the care provided to those in prison. This review has looked at the quality of trusts’ serious incident investigation reports, and the clinical and non-clinical features demonstrated in these claims. Areas of good practice nationally have been highlighted as examples of how trusts can begin to tackle some of these issues.

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The review of SI reports revealed that family involvement in the SI process was often limited, and the RCA process frequently failed to determine why the incident occurred, leading to recommendations that were unlikely to prevent recurrence of the same issue in similar circumstances. The role of trusts in supporting staff was also explored, with recommendations made to improve this process. This review also provides supporting evidence from other studies and reports that demonstrate similar findings, suggesting that the improvements required are neither straightforward nor simple. The recommendations of this review take into account this wider evidence, outlining not only what should be done, but who has responsibility for this and in what timescale improvements should be expected. The limitations of this review have been discussed. Although a small proportion of the total number of suicides has been reviewed, the similarities within our data to larger national data sets allows us to be confident that our sample is reasonably representative and that the recommendations are likely to be applicable across the wider system. Overall, care for those with mental health problems in England is very safe. This report demonstrates that there is much room for improvement, however, both in the way that we deliver care and in the way that we investigate incidents when things do go wrong. By highlighting common failings in care, while at the same time sharing some of the excellent practice from around the country, it is hoped that this review will improve the safety of services for patients and in doing so reduce the incidence of harm in the future.

Acknowledgements This report would not have been possible without the kind support and help of many individuals and organisations. The author would like to extend their sincere thanks to all of them. • The families and carers that have so generously shared their experiences of loss to suicide and reflections on the investigation, inquest and claims processes. • Members of staff in trusts from each region of the country who have contributed openly and honestly about the challenges they face, and approaches they have adopted to meet these challenges. • NHS Resolution panel firms who contributed to the

thematic review of the data and offered additional insights into the inquest and claims process. Additional thanks to those who facilitated focus groups with members, without which this report would have much less to share. Particular thanks go to Daryl Norvock of Accumension who offered support with data collection and quantitive analysis.

• Denise Chaffer, Director of Safety and Learning, NHS Resolution • Justine Sharpe, Safety and Learning Lead and Mental Health Lead, NHS Resolution. National organisations including: • The Care Quality Commission • The ‘Learning from Deaths’ group at NHS England • The Royal College of Psychiatrists, in particular Dr Elena Baker-Glen for her review and insight • The National Confidential Inquiry into Suicide and Homicide team in Manchester • NHS Improvement • Her Majesty’s Inspectorate for Prisons policy team • The Health and Justice team at NHS England • AvMA • Chief Coroner’s Office

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Conflict of interest disclosures

Intellectual property & copyright statement

None to declare.

We as the authors of this article retain intellectual property right on the content of this article. We as the authors of this article assert and retain legal responsibility for this article. We fully absolve the editors and company of Patient Safety Journal (PSJ) of any legal responsibility from the publication of our article on their website. Copyright 2020. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Article submission and acceptance Date of Receipt: 20.09.2019 Date of Acceptance: 10.10.2020

Contacts/correspondence Dr Alice Oates c/o Safety and Learning Team, NHS Resolution, 151 Buckingham Palace Road, London, SW1W 9SZ draliceoates@gmail.com

References 1

Care Quality Commission. The state of care in mental health services in the UK 2014â&#x20AC;&#x201C;2017. s.l. : Care Quality Commission, 2017.

T he National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. s.l. : University of Manchester, October 2017.

Independant Mental Health Taskforce. The Five Year Forward View for Mental Health. s.l. : The Mental Health Taskforce, 2016.

NHS England National Quality Board. Learning from Deaths. s.l. : National Quality Board, 2017.

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Strengthening the weak-end handover: improving weekend safety at a district general hospital Dr Ann Archer BM BCh, Dr Rachael Goddard Mb BCh1, Mr Paul Faulkner1

Summary Weekend handover of medical patients at Weston General Hospital was dependent on a computer system considered to be unreliable. Following a clinical incident, we sought to introduce a new handover app to improve the reliability, safety and accessibility of the handover system. In addition, we developed a weekend handover paper tool to sit within the patientsâ&#x20AC;&#x2122; clinical notes to enable better communication between ward doctors, nursing staff and the weekend medical team.

Keywords Weekend handover, electronic handover, patient safety, information technology, health informatics

Background Patient safety during the weekend is a contentious issue in many hospitals due to limited staffing and increasingly complex patients for on-call doctors to manage. In 2018, Weston General Hospital used a spreadsheet-based medical weekend handover system that was located on a shared, secure, computer drive. This was vulnerable to technical errors and could not be accessed if the user had not been given the correct permissions. As a result, it could be unreliable and difficult to access, particularly by new members of staff or those working on a temporary basis. Prior to the project starting, a malfunction of the existing system had led to a significant patient safety event, highlighting the urgent need for change. In addition, nursing staff felt that they did not have a robust system for knowing which patients required planned reviews over a weekend and were often unsure of the parameters for nurse-led discharges. We sought to address the problem with a reliable and sustainable solution that also empowered nurses to take a more active role 20

in the management of patients over the weekends.

Aims We set out to increase the safety of patients who require medical review while inpatient over weekends and bank holidays. The team sought to improve the reliability of clinical computer systems, the accessibility of the handover systems and the communication lines between doctors and other ward staff.

Methods The Model for Improvement framework2 was used to structure the initial stages of this quality improvement (QI) project. What are we trying to accomplish?

How will we know that change is an improvement?

What change can we make that will result in an improvement?

Act

Plan

Study

Figure 1 â&#x20AC;&#x201C; The model for improvement

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We aimed to improve the reliability of the computer system used to hand over patients for review over the weekend. Both outcome measures and balancing measures were used to analyse whether changes were actually an improvement. The Datix reporting system was used to gather data on frequency of handover-related clinical incidents. A reduction in the number of events relating to weekend handover was considered a positive outcome measure and as a balancing measure any increase in clinical incidents following an intervention would be monitored. In addition, qualitative feedback was gathered from the staff groups who were interacting with the new computer system. The SurveyMonkey website was used to facilitate data collection. Positive feedback was considered as an outcome measure while negative feedback and increased workload were considered as balancing measures. As part of the qualitative feedback process, we asked staff for suggestions to help enhance safety practices; these were used by the team when designing the changes. Following the establishment of the initial aims and measures using Model for Improvement, the project was divided into two phases and changes were tested using rapid Plan-DoStudy-Act (PDSA) cycles to enable focused and efficient improvements.

Interventions Phase One: Reliability and Accessibility A baseline audit revealed that the perceived reliability and safety of the existing handover system was poor. A new handover system was developed and tested over six PDSA cycles to address this issue. PDSA Cycles one to four: • Handover system drafted based on staff comments and the Royal College of Physicians’ Acute Care Toolkit recommendations for safe handover3 • Health informatics development of handover secure web application using Trust’s web development platform • Pilot of Handover App piloted in a test environment (figure 2) • Based on live feedback: addition of filter functionality, development of simplified ‘removal’ function and simplification of access rights applied PDSA Cycle five: • Education of relevant staff groups at organised teaching and Grand Round • Communication of planned change with relevant staff groups using WhatsApp and email • Rollout of the new Weekend Handover App to the whole Trust

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Figure 2 – Weekend Handover App, front page

PDSA Cycle six: • Ongoing live feedback leads to the optimisation of patient handover for Bank Holidays and the development of a standard operation procedure Phase Two: Improving communication between staff The baseline audit identified that nurses felt that they did not have a good awareness of the intended weekend plans for their patients. In Weston General Hospital a paper-based notes system was in place; a weekend handover tool was created to standardise the written handover from doctor to nurse prior to the weekend.

PDSA Cycles one to four: • Pilot handover tool drafted in conjunction with nursing and medical teams • Tool piloted on small patient samples; live feedback leads to the addition of a nurse-led discharge criteria box and treatment escalation details PDSA Cycle five: • Following study of balancing measures, handover tool merged with existing ward round tool to reduce duplication of work (figure 3) • Piloting on a larger scale PDSA Cycle six: • Wider roll-out of optimised handover tool

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Figure 3 â&#x20AC;&#x201C; the Weekend Handover Tool

Results In the twelve months prior to our interventions, two clinical incident reports were submitted relating to failure in electronic communication and medical handover at the weekends. In the nine months since the implementation of the Weekend Handover App and the introduction of the Weekend Handover Tool, there have been no clinical incidents reported relating to the handover of patients at the weekends. Feature

Further qualitative data was achieved by analysing the results of pre- and postintervention surveys, looking at staff membersâ&#x20AC;&#x2122; opinions on the safety and reliability of the handover system. A scale of 1 (least favourable) to 10 (most favourable) was used to assess different features, and how perceptions changed following the interventions made as part of the QI project (table 1).

Baseline Audit (n=18)

Reliability of the Handover 3.3 / 10 System

Post-Completion Audit (n=13) 7.5 / 10

Safety of Handover System

4.3 / 10

6.9 / 10

2.5 / 10

7.6 / 10

Overall improvement

8.6 / 10

Nursing staff awareness of weekend plan

Table 1 - Audit of perceived features of the weekend handover system pre- and post-implementation

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The results demonstrate a favourable outcome following the interventions, with the surveyed

staff members acknowledging a safer, more reliable handover system (figures 4-6).

Most safe

Most reliable

Least

Least reliable

Figure 4 – perceived safety of the weekend handover system

Figure 5 – perceived reliability of the weekend handover system

Completely aware

Completely unaware Figure 6 – perceived awareness of nursing staff of a patient’s weekend plan

Analysis of qualitative comments gathered at survey demonstrated a positive shift in staff’s perception of the weekend handover system

following intervention, and also contributed to ongoing development of the system (Table 2).

Baseline Audit (n=18)

Post-Completion Audit (n=13)

“The spreadsheet never seems to be working”

“[The new system is] much clearer to read and easier to access”

“Over the bank holiday it was difficult to ensure sick patients were reviewed”

“Good system, [I] enjoy the filter”

“It would be useful if nurses were aware of who was for routine review”

“Great change that provides greater safety and reliability”

“The computer system needs to be more reliable”

“Excellent addition of specific bank holiday lists”

“It would be good if the jobs for one ward could be in once place”

“Very useful to have a nurse-led discharge section”

Table 2 – Selection of open comments pre-and post-implementation

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Discussion The project team set out to design a system that was both reliable and sustainable. By using simple quality improvement methodology, we have demonstrated a marked improvement in the reliability of the weekend handover system, as evidenced by both qualitative and quantitative data. The majority of the data used in this project is based on subjective feedback, which is a significant limitation. However, this has been provided by clinicians who initially raised the safety concerns, are using the system regularly to handover patients and are providing weekend care. As such, we feel that this staff group is best placed to appraise it. A further limitation was the small size of the survey samples used. Including additional qualitative data was therefore important to capture information and maintain a balanced perspective whilst implementing change. One of the key intentions of the project was to ensure sustainability. An advantage of using a clinical incident reporting system, such as Datix, to provide outcome and balancing measures is that it serves as an ongoing source of feedback and is embedded in the governance structure of the organisation. This is therefore well-positioned to trigger further change should patient safety concerns relating to weekend handover processes arise. The previous handover system was created by a team of doctors (who have since moved on from the hospital) with only limited input from the Health Informatics team. A key factor in ensuring sustainability of the new system is that it is owned and maintained by the Health Informatics team themselves, using software that is regularly updated and widely used for similar purposes in the Trust. In addition, the system is introduced as part of the induction programme for new doctors joining the trust.

Currently at Weston General Hospital various medical specialties employ their own ward round tools; developing a weekend handover tool that is compatible with each teamâ&#x20AC;&#x2122;s own needs has been challenging. Therefore, despite the positive feedback it has been difficult to truly embed the paper ward round and weekend handover tool within the working practices of medical staff directorate-wide. However, the multidisciplinary team have highlighted the extent to which the tool can enhance practice and improve patient safety, and as such are engaged to pave the way for Trust-wide uptake of a standardised paper handover tool.

Other developments The health informatics team has developed a system of electronic bed boards using the same software that was used to create the Weekend Handover App. Ultimately, the intention is for these to link together, thus enhancing the available information about patients and reducing some of the duplication of work teams currently experience when handing their patients over for a weekend. The Trust is still using a paper-based system for the majority of clinical documentation but is aiming to move to work with our partner trust to develop a digital roadmap that achieves a paper light/paperless solution. It is hoped that the work entailed in this QI project can be incorporated into the final product, continuing to enhance patient safety practices over the weekends through clearer documentation, and the continued facilitation of safe nurse-led discharges.

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Conflict of interest disclosures

Intellectual property & copyright statement

Disclaimers and conflict of interest policies are found at:

We as the authors of this article retain intellectual property right on the content of this article. We as the authors of this article assert and retain legal responsibility for this article. We fully absolve the editors and company of Patient Safefy Journal (PSJ) of any legal responsibility from the publication of our article on their website. Copyright 2020. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

http://bit.ly/1wqiOcl

Article submission and acceptance Date of Receipt: 24.09.2019 Date of Acceptance: 10.11.2019

Contacts/correspondence Annarcher1@nhs.net Rachael.goddard@nhs.net

References 1

Weston Area Health Trust

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009

The Royal College of Physicians (2011). Acute Care Toolkit 1, Handover. Available at: https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-1-handover (accessed 18 July 2019).

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Time to ‘Meet & Greet’ Gemma Ashton-Cleary BSc Hons, RGN, PG Cert1, Ella Leuzzi BSc Hons, RGN, PG Cert2, Jay Over MA, RGN, PG Cert3, Dr Clare Fox, MBBS, BSc4, Dr Rachel Chiumento BSc Hons, MBChB Hons, MRCPCH, PG Cert Clin Ed5

Abstract An obligation of all healthcare establishments is successful delivery of a high-quality resuscitation service led by a cardiac arrest team1. The foundation of a safe and high-functioning team is effective communication2. At the Royal Cornwall Hospital NHS Trust (RCHT), a large district general hospital, we introduced a formal cardiac arrest team ‘Meet and Greet’ meeting as a component of the medical handover meeting at the start of the day and night shifts. The purpose of this meeting was to enhance the communication of the cardiac arrest teams, identify gaps in skills and reduce avoidable challenges, with the primary aim of achieving 95% attendance from all team members. We gathered quantitative and qualitative data through team meeting registers and staff surveys, which demonstrate a continual improvement in attendance to 93% at the point of publication. We hope to achieve a sustained attendance of at least 95% for all the team members. Similarly, we have seen an improvement in all five of the secondary aims. Keywords Cardiac arrest, human factors, team meet, brief, communication, skills.

Background The foundation of a highly functioning team is effective communication, underpinned by clear leadership. Simulation studies have shown that in-hospital resuscitation teams are more likely to function well and perform good quality cardiopulmonary resuscitation in an appropriate timeframe when leadership is effective and tasks are clearly allocated3. The Resuscitation Council (UK) highlight the importance of non-technical skills within teams citing good communication, strong leadership, situational awareness and task management4. They propose that team working is one of the most important human factors that can affect the quality of care when managing a patient in cardiopulmonary arrest, and therefore recommend a team meeting at the beginning of each duty period 5. Resuscitation Officer, Royal Cornwall Hospitals NHS Trust Resuscitation Officer, Royal Cornwall Hospitals NHS Trust 3 Resuscitation Officer, Cornwall Partnerships NHS Trust

A team who meet for the first time at the scene of a cardiopulmonary arrest are unaware of each other’s seniority, skillsets and competencies which can lead to suboptimal performance6. This is a common situation in cardiac arrest teams, as doctors are frequently changing roles and moving to different departments or new hospitals as part of their training programmes. At RCHT the cardiac arrest team is made up of a pool of specialties, with team members often changing on a daily basis. Establishing regular ‘Meet and Greet’ meetings allows introductions, recognition of specific skills (e.g. airway management, vascular access) and designating leadership roles or specific responsibilities. This fulfills key domains of effective team development7.

Speciality Doctor, University Hospitals Bristol Paediatric Registrar, Royal Cornwall Hospitals NHS Trust

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Aims The purpose of a ‘Meet and Greet’ meeting for the cardiac arrest team was to improve name and facial recognition, pre-allocate roles, identify skills or possible skill gaps and reduce avoidable challenges prior to potential cardiac arrest calls. This could also build camaraderie, breaking down communication barriers between team members, thereby improving non-technical skills and team working. For the purposes of measuring improvement our primary aim was to achieve 95% attendance at the ‘Meet and Greet’ meetings. The five secondary aims were to evaluate whether there was an improvement in the arrest teams’: • Awareness of names • Awareness of roles • Awareness of skill level • Perception of good communication • Perception of good group cohesion

What did we do? In July 2015, the project team based at RCHT introduced a formal arrest team meeting. This was scheduled to occur as a part of the standard shift handovers of the acute medical admissions team.

A proforma was developed to describe the meeting structure that was used at each ‘Meet and Greet’ (Figure 1). The elements of this structure were designed to facilitate name and facial recognition, raise awareness of abilities or skill deficiencies, while also allowing the team to pre-allocate tasks and roles.

The ‘Meet and Greet’ meetings The meetings are held at 9am (day) and 9.15pm (night) at the point of shift changeovers seven days a week. The meetings last approximately five minutes and follow the ‘Meet and Greet’ proforma. The 9am meeting is held in the Acute Medical Unit (AMU) office whilst the 9.15pm meeting takes place in the site managers office which forms part of the hospital at night handover. The team consists of: • Medical Registrar • Intensive Treatment Unit (ITU) Trainee • Coronary Care Unit SHO • Foundation Year 1 (F1) Doctor • Critical Care Outreach (CCO) Nurse • Resuscitation Officer (RO) Figure 1 – Meeting Pro-forma

Resus Team (Meet & Greet) This should only take a few minutes. Please discuss and agree on the following: 1. Introduce yourselves: name & grade 2. 3.

Confirm resus team roles for the shift and assign if gaps: a. Team leader b. Airway c. Vascular access (EZIO skills) d. ECHO skills (FEEL) e. Anything else the team feels is important

Any important information that would be useful to know for example: a. Is the ITU bleep holder comfortable intubating? b. Is it the registrars first day? c. Are you handing over your bleep to someone else for part of the shift? d. Any other useful skills? e. Ward moves, new equipment, new clinical areas?

4. Confirm protocols (who to call for help) for difficult airway if applicable 28

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Interventions We used the Plan, Do, Study, Act (PDSA) cycle methodology to plan and implement our project, allowing for cyclical review of the changes made and evaluation of our progress (Figure 2). We used online staff surveys, ‘Meet and Greet’ attendance figures and face-to-face discussions with staff at the meetings to evaluate the project’s success. This in turn informed a number of adjustments as the PDSA cycles progressed.

Night Meeting – Initial focus was on establishing the morning meeting with Resuscitation Officer (RO) support. Once these were established efforts turned to utilising the Medical Registrar at night handover meetings. Test Bleep – This was also changed to occur at 9am to coincide with the start of the meeting. Originally switchboard performed a test bleep at some point during the morning, usually around 11am, but this time would fluctuate considerably dependent on workload for the switchboard team. As each bleep holder was expected to reply confirming their name and which bleep they were carrying it made sense for one member at the meeting to list those present. It also served as a reminder to those late for the ‘Meet and Greet’ meeting. Formal Register – Initially the Resuscitation Officers (ROs) kept a register of attendees but as their work rota did not include weeknights and weekends, it did not allow for consistent completion. A more formal register was produced for the morning meetings in April 2018 (Dec 2018 for evening meetings), requiring the team to print and sign their names against respective roles.

Figure 2: Pareto identifying components missing in incomplete Modified Centor Criteria scores

These changes included: Changing Morning Meeting Time – Originally 11am instead of 9am; the earliest time we could get agreement from all specialties to release trainees. It was clear from feedback from the majority of the team members that this was inconvenient because it was too late in the day. At 11am the working day had already started and the medical staff members found it disruptive to be called away from ward rounds, admitting new patients and other clinical duties.

Designated Lead for the ‘Meet and Greet’ – The Medical Registrar is now encouraged to lead the team brief meetings using the proforma. Reinforcing ‘Meet and Greet’ Meetings – The ‘Meet and Greet’ is highlighted during any resuscitation training delivered to medical staff, either at induction for new doctors or update training for existing doctors. It is also mentioned on all of the national resuscitation training courses delivered by the Trust. Senior and Resuscitation Committee Endorsement –The Medical Director and Resuscitation Committee have played a key role in implementation by their support for the project and endorsement of the change within the hospital.

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Results Primary aim - results From February 2016 to March 2018 the highest team attendee on average was the F1 doctor (71%). Other teams during this period had lower initial attendances, but all vastly

improved since the formal sign in register & test bleep was introduced. The highest team attendances on average from April 2018 to June 2019 are the Medical Registrar and Critical Care Outreach (both 93%) (Table 1).

Table 1 â&#x20AC;&#x201C; Average Attendance (Pre introduction of formal register & Post introduction of formal register)

The number of 9.15 pm meetings documented varies, with the number attended increasing in April-June 2019. There was one month (February 2019) where the data was missing. The highest overall percentage attendance has been from the Medical Registrars. The Critical Care Outreach Team had 100% attendance for December 2018 when the

Dec-18 Jan-19

register was introduced, however only 12 out of the 31 potential meetings occurred in this month. The lowest attendance was the ITU Trainee with three of the months having 0% attendance. For accurate percentage attendance data to be collected the meetings need to occur every evening (Table 2).

No of documented meetings

% F1 attendance

% CCU SHO

%ITU

%Med Reg

% CC Outreach

58%

33%

75%

100%

13%

94%

38%

Feb-19

February register missing

Mar-19

40%

20%

100%

40%

Apr-19

61%

35%

78%

48%

May-19

57%

96%

71%

Jun-19

43%

18%

93%

79%

Table 2 â&#x20AC;&#x201C; 9.15pm attendance (since formal register commenced)

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Secondary aims – results We saw an improvement in all 5 of our secondary aims over staff surveys at four time points during the projects. The two most dramatic improvements were seen in staff awareness of each other’s names (26% to 83%), and skill level (25% to 79%). Awareness of roles according to respondents

improved but was reasonably high at the first survey (63% to 65%). Finally, already high in the first survey, but still improving were the respondent’s perception of good communication at arrest calls (83% to 95%) and the perception of good group cohesion (84% to 95%) (Tables 3 - 7).

Table 3 – Awareness of Names

Table 4 – Awareness of Roles

Table 5 –Awareness of Skill Level

Table 6 – Perception of Good Communication

Table 7 – Perception of Good Group Cohesion

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Discussion Achieving 95% attendance from all the team members has been a challenge. Participant engagement is crucial before introducing change to any system. Within the healthcare setting successful implementation of the ‘Meet and Greet’ meeting has been challenged by the complexity involved with trying to simultaneously reconcile the shift patterns, handover and ward round times for several different specialties and their medical staff. These are recognised as some of the reasons why change in the NHS may take many years to deliver8. Initially the Resuscitation Officers (RO) team members were identified as being in the best position to encourage the Medical Registrar to lead the meetings, remind attendees and chase up non-attendees. It was evident that this was beneficial as the weekend and evening meetings were less well attended when the RO wasn’t on duty. Early barriers were finding a time for the meeting which suited all members; initially the senior anaesthetic body and cardiologists did not want this to coincide with their daily 9am ward round. This necessitated a compromise solution of an 11am meeting to get the project off the ground. However, once established and following initial positive feedback, buy-in from attendees and finally Trust level support, this issue was gradually resolved, and agreement was gained from all parties to change the meeting to 9am. This time change also reduced the chances of team members meeting at a cardiac arrest call prior to the ‘Meet and Greet’ each shift. Historically within our Trust, cardiac arrest test bleeps had been carried out at around 11am. We also negotiated a change to 9am to coincide with the ‘Meet and Greet’ meeting. This also acted as a reminder for team members. Initially switchboard leads were resistant to this change as 9am is a particularly high workload time. It was agreed that one individual would telephone 32

switchboard to respond to the test bleeps on behalf of all attendees. This reduced the number of calls received by the switchboard operatives and saved time for the individual team members. There has been a clear shift in culture, with rapid uptake of the meeting as evidenced by an attendance of 93%. Table 1 demonstrates improvement in attendance across all team members after the introduction of the formal sign-in register in April 2018. Focus initially was on establishing the day meeting, therefore it is difficult to compare attendance between the day and night meetings prior to the later implementation of a formal register at night in December 2018. The majority of the cardiac arrest team members already attended a 9pm handover so this was used as a basis for the 9.15pm night ‘Meet and Greet’. Data (Table 2) indicates that the number of documented meetings vary considerably month to month. The highest attendance overall is the Medical Registrar. The lowest percentage attendance at night is from the ITU Trainee. This was discussed at the trust resuscitation committee meeting in May 2019 and agreement was gained to release the ITU trainee to attend. This has shown an increase in June 2019. The Coronary Care Unit Senior House Officer (CCU SHO) attends the least, partly due to competing duties at the time of the meeting which we are currently addressing. Medical Registrars (Med Reg) and Critical Care Outreach nurses (CCO) attend most frequently. During the time of this project the CCO team was formally extended to a 24-hour, seven-day service which would attribute to the increase in their attendance. The aim remains for a 95% attendance in all team members and it is apparent that there is more work to be done in improving attendance both with the day and night meetings.

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The survey results show an increase across all our secondary aims which is very encouraging. Perhaps most positive is the respondent’s perception of good communication and group cohesion amongst the team at cardiac arrests. These results are commensurate with the reasoning behind the recommendations from NHS Improvement; advocating the use of ‘safety huddles’ to support effective communication to improve patient safety9. Effective safety huddles involve agreed actions and provide the opportunity to reduce harm by: • enhancing teamwork through communication and co-operative problem-solving; • sharing understanding of the focus and priorities for the day; and, • improving situational awareness of safety concerns. Further evidence of improving patient safety through briefings have been corroborated by the World Health Organisation (WHO) who incorporate them in the surgical checklist10. With the changes that have already been made it is clear to see that there is an improving trend. The project has now been through several PSDA cycles, each time making small changes and continuously evaluating their effect. It is essential for team members to buy into the change and for a clear team to be driving the change for it to be successful and for momentum to continue11. The regular staff surveys have contributed to providing a voice to the project.

Further Study The project group have already started rolling out the ‘Meet and Greet’ meeting into the simulation environment. With the promotion of its use in training, highlighting the benefits to the team members and reinforcing its use in clinical practice.

The team would like to share this project with all trusts across the South West United Kingdom. An awareness of the barriers the project group faced in embedding the team brief should allow other Trusts to put strategies in place much earlier to overcome any resistance. This would lend itself to continuity throughout regional rotations making transitions to new hospital cardiac arrest teams more fluid. An additional benefit of the project was staff skill development opportunities. The team meetings can be used as part of an education tool to allow trainees to gain experience in the leadership role or take on new responsibilities within the arrest team in a supported environment. The team brief allows for a peer support process to be easily established. With other members of the team on hand with varying skill levels, it enables the team to automatically provide the support mechanisms required for the less experienced trainees to gain “protected” experience. This is an essential ingredient in psychomotor learning12, 13. This project can also build a foundation in debrief following cardiac arrest calls. Based upon the work of Couper et al, the Resuscitation Council (UK) encourage debrief opportunities for all the team members following an emergency event14, 15. Informally this process has become more natural and supportive with the team having already met that morning.

Ongoing challenges The project group acknowledges that its success is forever reliant on keeping up momentum and engagement with the clinical teams especially when there are trainee rotational moves every 3-4 months and the inevitable end of year staff moves.

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Conclusion

Conflict of interest disclosures

Whilst it is difficult to prove an increase in patient safety or a more positive outcome in patient survival from cardiac arrest from our project, the existing evidence supporting the benefits of an arrest team meeting prior to an event has been discussed. Data from our survey further corroborates this evidence.

There is no conflict of interest.

Attendance has consequently improved as these human factor benefits are recognised amongst the team members. The project has enabled additional educational opportunities, and this is especially important as pressures on the NHS workforce increase. The project team are fully committed to continuing the hard work required to achieve 95% attendance and ensure the ‘Meet and Greet’ continues to be part of the normal working day within our trust. Acknowledgements The authors particularly wish to thank Matthew Metherell for his extensive input in collating data, design of data collection forms and providing technical support and database administration.

Article submission and acceptance Date of Receipt: 29.10.2019 Date of Acceptance: 24.11.2020

Contacts/correspondence Ella Leuzzi & Gemma Ashton-Cleary, Resus Team, Dept of Postgraduate Education, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, TR1 3LJ. ella.leuzzi@nhs.net / gemma.ashton-cleary@nhs.net

References 1

Resuscitation Council (UK) https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/#team

James Pittman, Bernie Turner, David A. Gabbott Communication between members of the cardiac arrest team —a postal survey Resuscitation 49 (2001) 175–177

Marsch, Stephan C.U. et al. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004 Jan;60(1):51-6.

Resuscitation Council (UK). Advanced Life Support (7th Edition). London (2016). Chapter 2. 7-12.

Resuscitation Council (UK). Advanced Life Support (7th Edition). London (2016).12.

James Pittman, Bernie Turner, David A. Gabbott Communication between members of the cardiac arrest team —a postal survey Resuscitation 49 (2001) 175–177

Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. BMJ Quality & Safety 2004;13:i85-i90

https://www.england.nhs.uk/wp-content/uploads/2017/09/practical-guide-large-scale-change-april-2018-smll.pdf

https://improvement.nhs.uk/resources/safety-huddles/

10 11

https://www.who.int/patientsafety/topics/safe-surgery/checklist/en/

Taylor, M., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., Reed, J. (2014) ‘Systematic review of the application of the plan-do-study-act method to improve quality in healthcare’, BMJ Quality and Safety, 23(4), pp. 290–298. doi:10.1136/bmjqs-2013–001862.

Quinn FM. The principles and Practice of Nurse Education. 3rd Edition. Chapman & Hall, London 1995.

Bullock I, Davis M, Lockey A & Mackway-Jones K. Pocket Guide to Teaching for Medical Instructors. 2nd Edition. Blackwell Publishing, Oxford 2008.

Couper K, Kimani PK, Abella BS, et al. The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for InHospital Cardiac Arrest. Crit Care Med 2015:1

https://www.resus.org.uk/resuscitation-guidelines/in-hospital-resuscitation. Resuscitation Team chapter.

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