Improvement. West Midlands. Patient Safety Collaborative. Reflections 17/18. Patient Safety Collaboratives

Transcription

1 Improvement West Midlands Patient Safety Collaborative Reflections 17/18 Patient Safety Collaboratives

2 CONTENT FOREWORD 3 OVERVIEW: LEARNING FROM EXCELLENCE 4 CASE STUDY: APPRECIATIVE INQUIRY 6 OVERVIEW: SPACE 8 CASE STUDY: CQC WALSALL REPORT 9 CASE STUDY: NEWLYN COURT KINGS FUND 10 OVERVIEW: SCRIPT 11 CASE STUDY: THE Q COMMUNITY 12 OVERVIEW: MATERNITY 14 CASE STUDY: TEAM STEPPS PRIMARY CARE 15

3 FOREWORD It is with pleasure that I introduce the Reflections booklet from the West Midlands Patient Safety Collaborative (WMPSC). This booklet is not intended as a detailed impact report but rather an overview of the safety work we have supported and some key learning and insights we have gained over the past few years. Hosted by the West Midlands Academic Health Science Network (WMAHSN), WMPSC supports organisations across the region to improve patient safety and continue to reduce avoidable harm by working together to develop, implement, share and spread innovative safety practices and interventions. We continue to nurture and support a regionwide network focused on the improvement of patient safety across care settings, enabling and sharing best practice and innovation in patient safety. Our approach consists of: Continuing to support and develop the wider West Midlands safety network Supporting communities of practice around specific areas of safety Building capacity in key safety techniques to improve safety culture Employing specific collaborative programmes to test safety improvements on the ground in care settings, evaluating their impact and sharing learning across the wider safety network WMPSC has supported a number of healthcare organisations in the West Midlands with key capability-building approaches: Supporting teams in the West Midlands who have introduced the Learning from Excellence (positive incident reporting) approach to further develop and embed the technique (through Appreciative Inquiry training) Leading the recruitment of colleagues from the West Midlands with quality improvement skills into the next wave of the UK-wide Q Community (a network of quality improvers supported by NHS Improvement and the Health Foundation) Supporting teams to use team performance and human factors/ergonomics insights to improve safety, taking a wider view of human factors including systems design Supporting care home improvement programmes being undertaken in the Midlands to strengthen safety culture and reduce the incidence of adverse safety events by upskilling care homes staff with basic quality improvement techniques Reflecting on the work of WMPSC, there have been many successes the Collaborative have supported and helped contribute to: the Learning from Excellence initiative winning the Education and Training Award at the 2017 HSJ Patient Safety Awards; over 100 Q members from the West Midlands have joined the national Q Community; and the Safer Provision and Caring Excellence (SPACE) care homes programme has delivered measurable impacts on harms in care homes. The SPACE programme in Walsall has also been sighted as a key contribution to Walsall Healthcare NHS Trust achieving an outstanding rating for its end of life community services by the CQC. Going into the new financial year, WMPSC along with the other fifteen regional Safety Collaboratives will be focusing increasingly on three new national NHS Improvement defined priorities: Safety Culture, Patient Deterioration and Maternity/Neonatal Safety. We are using the insights and learning from our local programmes to support these national priorities and further test and measure impact on patient safety. A huge well done to all our partners and collaborators. As well as the WMPSC team for working together to improve patient safety across the West Midlands and indeed nationally. We are well placed to build on the collaborative work we have supported and look forward to more success in the future. I hope that reading the stories about our programmes will demonstrate our progress and encourage you to get involved in our work. Peter Jeffries Patient Safety Programme Manager 3

4 OVERVIEW: LEARNING FROM EXCELLENCE One of the major programmes the West Midlands Patient Safety Collaborative supports is Learning from Excellence (LfE). The Learning from Excellence idea originated with Adrian Plunkett, Consultant Intensivist and Emma Plunkett, Consultant Anaesthetist at University Hospitals Birmingham NHS Foundation Trust. Traditionally safety in healthcare has focused on avoiding harm by learning from error, but this approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. Staff at Birmingham Children s Hospital NHS Foundation Trust (BCH) felt that this approach overlooked opportunities to share good practice. Over 100 organisations have registered with Learning from Excellence and as a result of the WMPSC supporting the LfE programme, one of the initiatives that was launched is PRAISe (Positive Reporting and Appreciative Inquiry in Sepsis) at BCH. The project has led to many positive outcomes for patients including the median time for antibiotic administration for children with sepsis reduced from 60 minutes to 30 minutes (see the chart on the following page). Conclusions from the project found that 'Learning from Excellence' can have a positive impact on clinician behaviour leading to improvement in selected metrics (linking positive reporting, Appreciative Inquiry into cycles of quality improvement activity). The study aimed to improve early sepsis management and antimicrobial stewardship in paediatric intensive care patients. It involved using two novel interventions to influence the behaviour of clinicians managing new cases of sepsis in the hospital's paediatric intensive care unit. The first intervention is positive reporting, which identifies and reports good practice via a recently developed 'excellence reporting' system. This provides direct, formal, positive feedback to the individual (or team) involved in good practice, acting as a form of positive reinforcement and promoting further good practice. The second intervention is a modified form of Appreciative Inquiry an established, positive approach to bring about change. Adrian said: We believe that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale. The initiative has been adopted not just locally, but nationally and internationally. Adrian adds: There seems to be quite a lot of interest in the initiative, certainly within certain sectors within healthcare, and I think that s just because it s the right time for it. Morale is slipping in the NHS in general and one of the advantages of this initiative is that it has the potential to lift that. We use social media quite a lot, and the West Midlands Patient Safety Collaborative have helped with that as well. Over 60 organisations (local and international) were represented at November 2017 s Learning from Excellence Conference with 300 people attending. And the Learning from Excellence initiative won the Education and Training Award at the 2017 HSJ Patient Safety Awards. The judges felt that the entry was a truly innovative approach that has the ability to transform the way we improve patient safety. This should be considered for national rollout both from patient safety and staff morale. IMAGES: PRAISe study and LfE conference - November

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6 CASE STUDY: APPRECIATIVE INQUIRY Since August 2016, Appreciating People (AP) have been working alongside the West Midlands Patient Safety Collaborative, running a series of fully booked introductory talks on Learning from Excellence and Appreciative Inquiry (AI) training courses. The Collaborative have funded AI training courses to be rolled out across the West Midlands. The purpose of AI training is to introduce staff to a highly practical strength-based way of working - combining AI and positive psychology philosophies and techniques. The training covers the wellknown organisational development applications of AI, including how this approach supports engagement, staff wellbeing and resilience. The future aims for WMPSC on AI training is to create a cohort of trainers across the region and for them to take AI back to their organisation and disseminate. Within the West Midlands region there are 20 advanced AI practitioners. Moving forwards the aim is to increase the number of AI practitioners with a cohort from the East Midlands in a joint collaborative approach. As a result of adopting AI into their workplace, Elizabeth Torrance, Therapy Clinical Team Leader and Lead for the Acute and Community Respiratory team at Solihull Hospital, said: Since implementing AI into our everyday work, we have been able to adapt patient personal plans and encourage staff to use their personal skills to bring the best out of patients. Patients are being seen more often and we are now able to help patients using a holistic approach. Appreciative Inquiry is now fully embodied amongst the team, everyone is buoyant and wants to be part of the team. I m proud to work for a fabulous clinical team. One Walsall care home who were able to turn around their fortunes thanks to the use of AI was Ash Grange Nursing Home. The care home was rated as inadequate following a visit by the Care Quality Commission (CQC) in August 2017 but is now out of special measures. Ash Grange Nursing Home has seen improvements in all five of the CQC s questions (Safe, Effective, Caring, Responsive and Well-led) and is no longer rated as inadequate overall or in any of the key questions. The home is now rated as good in both the Safe and Effective categories. Elaine Proud, Area Quality Director at HC-One*, said: "I was called in October last year to come and help out at the home that safe to say had some safety concerns after the CQC inspection back in August At the time of meeting the team initially, they were pretty despondent and embarrassed by the outcome of the inspection. Caroline Maries-Tillott, Quality Improvement Lead at Walsall Healthcare Trust, suggested the team at Ash Grange to go onto Appreciative Inquiry training to help with adopting positive psychology and to improve staff wellbeing/resilience. It was definitely after this training there was something they came back with that gave them a sense of hope that they can turn things round with the right resources, leadership and guidance. In such a short amount of time, something great has been instilled at the home which has resulted in progress. Kindness and integrity is the start of any good quality care and Ash Grange have certainly shown that in abundance to help turn things around." *HC-One offer professional residential, nursing and specialist dementia care for older people in over 300 care homes in the UK. IMAGES: AI training - Walsall 6

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8 OVERVIEW: SPACE The Safer Provision and Caring Excellence (SPACE) programme is a large-scale two-year care home improvement programme being undertaken in care homes in Walsall and Wolverhampton which aims to strengthen safety culture and reduce the incidence of adverse safety events. There are two main delivery elements to the SPACE programme: Training events and workshops, held to help care home staff and managers develop leadership skills and enhance their understanding of safety-related service improvement. Training explores clinical and human risk factors related to safety, alongside techniques for designing and implementing service improvements Facilitated sessions delivered in participating care homes supporting staff to implement changes to practice relating to specific safety concerns such as falls prevention and pressure ulcer management The WMPSC commissioned the National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands (NIHR CLAHRC) to undertake a full evaluation of the SPACE programme. In addition the NIHR CLAHRC have generated a Mid-Year Report which has now been published. Some of the findings and quotes to come out of the report include: "There has been strong engagement from care homes in their uptake of risk monitoring tools such as safety crosses, and positive signs that the generic tools are being adapted by managers and staff to monitor specific areas of safety within their own care home." "There has also been positive engagement with PDSA (Plan, Do, Study, Act) techniques and with approaches to assessing safety that move away from assigning blame when an adverse event occurs, towards celebrating success, as evidenced by the widespread acceptance of the philosophy of Appreciative Inquiry introduced by programme facilitators in both Walsall and Wolverhampton." "There were also reports of improvements to teamwork, communication and sharing of best practice both within individual care homes and across the wider network of care homes participating in SPACE." Caroline Maries-Tillott & Tracie Wilson The aims of the SPACE project are to: Reduce avoidable harm such as pressure injury, falls and community acquired infections i.e. UTI s and chest infections Reduce avoidable hospital admissions from care homes Improve safety culture in Walsall and Wolverhampton Nursing homes Leadership and Safety Culture: There is increasing evidence of improved safety culture in nursing homes across Walsall and Wolverhampton. Homes are engaging with improvement projects and developing innovative solutions to common problems. Homes have hosted events which contribute to a positive safety culture with increased uptake of staff recognition schemes and visitor engagement in reducing avoidable harm. Communication and Handover: There have been a range of improvements to handover processes including: Inclusion of different staff groups Introduction of a handover template Introduction of a mid morning safety huddle Introduction of safety boards with symbols on key risks/residents needs Use of SBAR to escalate concerns Quality Improvement: Working in partnership to help make our nursing homes a safer haven Measurement for improvement and results so far: More than 80% of nursing homes have introduced safety crosses to measure harm-free care. Improvements in harm free care and safety culture has been observed across nursing homes in both boroughs. A range of nursing home staff including carers, managers, kitchen and activity staff have been trained in Quality Improvement techniques. Workforce Development: Staff have been involved in hydration, dementia awareness, falls and pressure injury prevention training. As a result they have initiated many interventions including hydration activities, walking aid and footwear checks, medication reviews and post-fall debriefs. Others are trialling the potential calming effects of lavender on residents with challenging behaviour. Orchard House Nursing Home in Wolverhampton has seen a 50% reduction in falls at since December 2016 (down from 8.75 average falls per month to 3.6 average). Harrison Unit at Parklands Court Nursing Home in Walsall has had ZERO care home acquired pressure injuries from January to August days PI free. For more information: caroline.maries-tillott@walsallhealthcare.nhs.uk tracie. wilson1@nhs.net 8

9 CASE STUDY: CQC WALSALL REPORT In December 2017, a Care Quality Commission (CQC) inspection report praised the input of the West Midlands Patient Safety Collaborative in Walsall s community health services for adults gaining a good rating. The CQC paid its visits on 31 May and June 2017, and while the report shows progress in each service area, a rating of outstanding was given to Walsall s end of life community services, while community health services for adults were rated as good. This makes Walsall Healthcare NHS Trust one of only a handful of community services in the country with this rating. The Trust is the only provider of NHS acute care in the Walsall borough, providing inpatient and outpatient services at the Manor Hospital as well as adult, children and young people and end of life care services in the community and serving a population of approximately 270,000 people. The CQC report acknowledges the input of the West Midlands Patient Safety Collaborative in contributing to the success of the service, particularly the Safer Provision and Caring Excellence (SPACE) programme and related improvements. The report said: From January 2017, the team secured a two year fixed term funded contract for a quality lead nurse, to support with embedding the model to improve the quality of care in private nursing homes. In addition, funding was in place for a 12 month contract for education to reduce avoidable harms in residential care. The West Midlands Patient Safety Collaborative had funded both posts. "Patients living in nursing homes were both vulnerable and dependent. The Trust had a team working across the Walsall borough which provided support and advice to the independent care home sector. A member of the team undertakes fragility assessments and a weekly visit to review patients. The private nursing home case management project had continued to develop and had secured additional funding from the West Midlands Academic Health Science Network to continue the development of the service. New initiatives included Learning from Excellence and Appreciative Inquiry, reduction in pressure ulcer incidence and implementation of quality boards in care homes. Staff told us, and we saw, that pressure ulcer incidence within private nursing homes had decreased and increased numbers of people were able to die in their care home where they had staff who knew them, rather than in an acute hospital. The full report can be found on the CQC s website. Walsall Healthcare 9

10 CASE STUDY: NEWLYN COURT The Safer Provision and Caring Excellence (SPACE) programme supports care homes within Walsall and Wolverhampton. One of the care homes that is part of SPACE is Newlyn Court which recieves funding from the programme. Using The Kings Fund research tool, Is your care home dementia friendly? last year Newlyn Court launched a research based programme to improve resident experience, person-centred care, orientation and safety. The Small Changes Big Difference programme was set up to ensure the care home improved its environment to help improve patient safety. Walks around the home were conducted identifying areas where environmental change would benefit residents. Pre and postimprovement scores were completed and the views of residents, families and staff were also taken into account. Introducing clocks to help residents awareness of the time, rest stops on long corridors for mobile residents and linking the interior to outdoor green spaces were just some of the improvements suggested. Following the suggestions made, postimprovement scores demonstrated a dramatic upswing. Residents are now able to identify key areas due to the introduction of images and signs. Rest stops have proven to be popular and as a result, there have been no falls at the home since their introduction. Toilets are now easily identifiable which has now increased resident independence and promoted dignity. Links have also been created to ensure patients have access to green spaces. Speaking about the programme, Helen Sneyd, Deputy Manager at Newlyn Court, said: The changes have made an enormous difference to residents we ve had lots of positive comments and we ve seen huge changes in behaviours. The dining room now gives clear indicators for the room s purpose and residents are calmer and less restless. Colour coding the toilet doors to make them easier to find has improved independence for residents. Visitors have commented on the calm atmosphere and homely environment. Staff are taking pride in the home and are more motivated to come forward with suggestions for improvements and things to try which we are using our Appreciative Inquiry training to capitalise on their ideas. For the future, we are completing the orientation work on the upstairs corridors soon and also on giving the bathrooms a better visual identity and clues to purpose. We are also expanding our linking work for the outside spaces to incorporate the green space research to give residents a better experience, reduce aggression and confusion and to enhance their lives. The SPACE programme has been enormously supportive and helpful to us, giving us lots of opportunities and increased access to new ideas. As a result of making the changes, Newlyn Court was recognised at the Wolverhampton SPACE Awards 2017 and picked up the environment award in recognition of the work undertaken to make improvements to the environment, improving orientation and creating meaningful spaces with identified collaboration with residents, family and staff. 10

11 OVERVIEW: SCRIPT In the UK, medication errors account for 10% 20% of all adverse events in the NHS, and preventable harm from medicines is estimated to cost more than 750 million each year. To address the training need relating to medicines management and medicines optimisation, an elearning programme for nurses has been developed, based on the established successful SCRIPT programme for Foundation trainee doctors. The aims of the project include: Creating an elearning platform for qualified nurses that can support their Continuing Professional Development (CPD) and process of revalidation Maintain and develop professional knowledge and competence of qualified nurses, relating to the use of medicines Encourage safe and effective medicines management by developing modules that reflect current practice in the UK SCRIPT has been developed by the West Midlands Academic Health Science Network (WMAHSN) and the West Midlands Patient Safety Collaborative in collaboration with OCB Media, Universities of Birmingham and Coventry and Warwickshire Partnership NHS Trust. WMPSC helped to fund the Medicines Safety section of SCRIPT. Nursing SCRIPT recently saw the release of the Advanced Pain Management module, bringing the number of available modules up to 18 and completing the suite of modules commissioned by the WMAHSN. The modules are freely available to all qualified NHS nurses and associated professions in the West Midlands and is offered on membership to WMAHSN. There are over 1,330 users of SCRIPT across 44 NHS Trusts and CCGs. The Nursing SCRIPT elearning programme has helped one Trust deliver their mandatory training more efficiently. Worcester Health and Care NHS Trust, a large Community and Mental Health Trust, is the first to mandate modules for all nursing staff. Staff will be completing three modules on a threeyear rolling programme, meaning one module is completed per year. Since implementing the training in April 2017, the Trust has seen a 92% completion rate for the first module. Managers monitor adherence using two-weekly reports generated through SCRIPT s dedicated management website. According to the Trust's Chief Pharmacist, John Morrison, Nursing SCRIPT has almost certainly had a positive impact on patient safety. He explains how the Trust chose which modules to mandate: Once we had established that SCRIPT was a possible option then I set up a focus group to look at it. This consisted of a number of different nurses, of different grades, from different parts of the trust. We then met to discuss and a recommendation was made to the Medicines Management and Safety Committee on which modules to mandate. We chose three based on a three-year rolling programme and allowed the Director of Nursing the final say on the order. By doing it this way we felt we had greatest buy-in across the Trust. 11

12 CASE STUDY: THE Q COMMUNITY In 2017, over 100 people with health and social care backgrounds from the West Midlands region joined the Q Community. The Q Community s mission is to foster continuous and sustainable improvement in health and care. To support the growth of Q, the West Midlands Patient Safety Collaborative (WMPSC) have been working in partnership with the Health Foundation to help the community flourish and develop in the West Midlands. Opportunities have been created enabling new Q Community members in the West Midlands to share ideas and collaborate to make health and care better. People who were interested in joining the Q Community were asked to reflect on their knowledge and experience of improvement and how they can benefit and contribute to the community. One of the new members of the Q Community West Midlands is Dr Rob Dalziel, Participatory Research Officer at Healthwatch Dudley. Dr Dalziel tells us what he hopes to get out of joining the community and why he has joined Q. Why did you apply for a place on the Q Community? I wanted very much to be part of a group of people with varied skills and experiences and a common interest in contributing to conversations that facilitate an inquisitive and thinking outside of the box approach to problem solving and learning from each other. I was particularly fascinated by the idea of a large network of connected people across a large geographical area and in different types of organisations and jobs all working together to identify and promote examples of excellent healthcare and treatment across the NHS. How proud are you to be part of the Q Community? I m very happy to be part of the Q Community which is an exciting and innovative initiative designed to make the most of the different talents and expertise that individuals possess. It is doing this through collaborative working and the sharing of experience and ideas to produce practical outcomes and solutions to problems that could not have been achieved by organisations or individuals working in isolation from each other. What do you hope to get out of being part of the Q Community? I hope to build strong and enduring relations with amazing people, improve my understanding of the healthcare landscape, learn more about what is happening to improve people s experience of healthcare services, and contribute to work that means there is more effective treatment and better health and wellbeing outcomes. IMAGES: Q IMAGES: COMMUNITY Q Communtiy CONFERENCE Event -- JULY July

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14 OVERVIEW: MATERNITY One of the key priorities for WMPSC is Maternity. The Maternal and Neonatal Health Safety Collaborative is a programme led by NHS Improvement (NHSI) to support improvements in the quality and safety of Maternity and Neonatal units across England. The aims of the programme are to reduce the rates of maternal deaths, stillbirths, neonatal deaths and brain injuries that occur during or soon after birth by 20% by 2020 and 50% by This national ambition requires all NHS Trusts (plus independent providers) who provide Maternity services in England to make measurable improvements in safety outcomes for women, their babies and families and to exchange ideas and best practice. There are six key agreed requirements of Patient Safety Collaboratives in support of the national programme: 1. Support the aims of the national programme 2. Develop local Mat Neo learning systems 3. Provision of Quality Improvement (QI) coaching 4. Support Safety, Communication, Operational Reliability & Engagement Survey (SCORE) culture survey 5. Provide measurement for improvement expertise & support 6. Provide Life quality improvement (QI) and facilitate sharing of learning Here are examples of local delivery the West Midlands Patient Safety Collaborative have helped to support the Maternal and Neonatal Health Safety Collaborative with: West Midlands SCORE safety culture survey debriefing training day, co-hosted with South West Patient Safety Collaborative in January 2018 to train a local cohort in debriefing skills West Midlands Learning from Excellence/ Appreciative Inquiry Maternity specific event April 2018 Mat Neo Learning sets have been supported by WMPSC Maternity Lead Ongoing support of West Midlands Maternity units The first region-wide Mat Neo Local Learning System meeting took place in June 2018, with 47 Maternity and Neonatal professionals from across the region attending The WMPSC has an established track record of supporting safety in Maternity. Such as in the scale-up of an established TeamSTEPPS programme at University Hospitals Birmingham, formerly Heart of England NHS Foundation Trust. TeamSTEPPS broadly consists of: Human performance team training - often described as human factors Quality improvement approaches to safety issues Cultural aspects that support change (see page 15) Another example of work currently taking place is the ongoing development of safer care around emergency caesarean section. Learning from this has led to supporting a region wide fetal deterioration project, which commenced in June 2018 (funded by WMPSC). This is facilitated by a Chartered Ergonomist, two of the WMPSC team and a Regional Obstetric Lead. WMPSC is also supporting Walsall Healthcare Trust with a programme using human factors and ergonomics insights to develop multi-disciplinary team skills drills. The aim is to impact on a number of measurable clinical outcomes that should contribute to still births, child brain injury and neonatal deaths in line with the national ambition outlined above. West Midlands Patient Safety Collaborative will be supporting wave two of the national programme to reduce cerebral palsy through improving uptake of magnesium sulphate in preterm deliveries. For more information about the Maternal and Neonatal Health Safety Collaborative, visit the NHS Improvement website. For local developments, please contact Ann Abbassi, WMPSC Maternity Lead: ann.abbassi@ wmahsn.org. 14

15 CASE STUDY: TeamSTEPPS PRIMARY CARE The West Midlands Patient Safety Collaborative supported the Modality GP Partnership to test the implementation of a TeamSTEPPS model in Primary Care to maintain safety. TeamSTEPPS combines team performance (human factors) and quality improvement methods. This was linked to a wide change team model in the Partnership looking at more structured multidisciplinary team caring for patients (as part of a Vanguard programme which aims to link local hospitals to improve their clinical and financial viability. There are four types of Vanguards: Integrated Primary and Acute Care Systems, Multispecialty Community Providers, Enhanced health in care homes and Urgent and Emergency Care). WMPSC funded Health Services Management Centre University of Birmingham to undertake a qualitative evaluation of the project with the end goal of aiming to increase safety for patients. This evaluation focused on the effectiveness of the TeamSTEPPS approach adopted by two practices within the Modality Partnership in the West Midlands. The Modality Partnership is a single GP organisation that operates across 20 different locations in Sandwell and Birmingham. The chosen case study sites were practices that had undergone the TeamSTEPPS training, and have begun to implement the approach. Practices within the Modality Partnership agreed to implement TeamSTEPPS as part of moving to a team-based way of working. The training was delivered by an individual who has had specific training in TeamSTEPPS, with teams then being free to develop their own approaches to change, utilising the tools and techniques which have been introduced to them in their training. Use of Team STEPPS Practice A provides primary medical services to approximately 3,600 patients. Four GPs work part-time at the practice. Practice B has 7,448 patients and 6 GPs who work at the practice (a mixture of full-time and part-time). Each practice had identified a Change Team of three to five staff who had undertaken the training (four modules; three online, and then face to face workshops). This Change Team then determined how TeamSTEPPS could best support their change initiative, and was responsible for implementing this in their practices. A trained TeamSTEPPS facilitator provided initial training and offered ongoing support to these Change Teams. Overall TeamSTEPPS was seen as valuable across both practices, and the range of staff who participated. Whilst some varied in their enthusiasm, all felt the tools were valuable contributors to increased communication and improved the ability to raise issues of safety for patients. The key findings were: TeamSTEPPS had an impact on culture by helping people reconnect to their purpose, feel part of the team, and feel more confident about raising concerns in the interest of patients Communication mechanisms had improved and the huddles appeared to be helping teams connect and share the workload more equitably, reducing isolation for individual practitioners Both the trainer, in terms of delivery style, and the training were flexible enough to meet the varying needs of teams. Adapting the programme to reduce the amount of work on individuals and using the face-to-face training time as an opportunity to build the team, were seen as important elements for success The role of the leader is key and in General Practice it is likely to be a GP who needs to be the champion in order for the project to progress 15

16 COMMUNICATIONS/ENGAGEMENTS The West Midlands Patient Safety Collaborative (WMPSC), hosted by the WMAHSN, supports members with innovative solutions to help deliver on improving patient safety. It aims to improve safety and continually reduce avoidable harm by helping organisations to work together to develop, implement, share and spread proven safety practice and interventions based on rigorous, evidencebased scientific methodologies. We have been communicating with our audiences through a number of channels and below are just some of the results from the last financial year. 371 followers gained 404,500 Facebook engagements 400 Twitter impressions Newsletters sent 15 Newsletters subscribers 773 1,180 Twitter followers

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20 Contact details psc wmahsn.org wmahsn.org PtSafetyWM facebook.com/westmidlandspatientsafetycollaborative