Human factors in healthcare

What makes things go wrong? โ€“ and what can we do about it? #MatExp

I said I would write. Steller story...

This story is dedicated to Sam @SamMajumdar and Flo @fwmaternitykhft, two incredible person-centred clinicians who embrace innovation. Sam is my 'life mentor', teaching me to believe in what I am doing, encouraging me every step of the way and teaching me to go with the flow. Flo is that flow. ๐Ÿ˜‰ My fabulous, courageous partner in crime in #MatExp, constantly pushing the boundaries and proving that real engagement works.

I had been looking forward to speaking at a special seminar, jointly hosted by the Clinical Human Factors Group and the West Midlands AHSN. It was a lovely sunny day as I walked across Birmingham

I didn't know much about the Clinical Human Factors Group. But Sam told me they are excellent and that is good enough for me. Sam is one of the 3000 people regularly receiving news of their six-monthly open seminars, which are always massively oversubscribed. He kindly tipped me off when he saw that they were running a maternity event in partnership with the West Midlands AHSN.

But I had 'previous' with @WMAHSN! They have been hugely supportive of Whose Shoes. As well as featuring in their awards, they have become actively involved in my work. It would be too big a digression to tell you about #CovMindTheGap ... but you can watch the film here. ๐Ÿ˜‰

And so I was invited to speak at this CHFG/West Midlands patient safety seminar. What a brilliant opportunity to build on the two workshops that #FabObs Flo and I had run at the launch of the Maternal and Neonatal Health Safety Collaborative #MatNeoQI in London back in April !

The launch event had been an extraordinary day, right in the heart of influence and decision-making. I never thought I would get the chance to decorate the Houses of Parliament with Whose Shoes bunting. ๐Ÿ˜‰ Wonderful to see improvements in maternity care so firmly on the map. You can read the story here.

Some of the movers and shakers came along to our session. Do you recognise anyone?

The work Flo and I had done theming some of the cards for #MatNeoQI, and particularly the cards from the new 'Nobody's Patient' project, stood me in good stead as I prepared for the Human Factors seminar in Birmingham.

I was to speak about #MatExp. It felt auspicious the opening session was happening in 'Kingston Theatre'. Not only is #FabObs Flo a consultant obstetrician at Kingston Hospital, but we ran #KHFTWhoseShoes there, incl. two really innovative workshops exploring operating theatre culture! The themes of this work, and how patient safety and patient experience are inseparable, are central to CHFG.

You can read the #KHFTWhoseShoes theatres Steller story here.

The Clinical Human Factors Group was established by Martin Bromiley. Like so many of the amazing people I meet through my work, Martin has turned a personal tragedy (Martin's wife died during a routine hospital procedure) into work that explores the lessons and prevents the same thing happening to others. You can read about Martin here.

The whole programme looked really interesting and Martin got things off to a great start. The audience comprised a very mixed group of healthcare professionals and others passionate about quality improvement.

As you might imagine, I was a big fan of the Whose Shoes colouring โ€“ red, blue, yellow and green represent the different voices, different perspectives. Again, it felt auspicious.

We were shown an extraordinary film. I think it bought tears to everyone's eyes. The NHS are usually brilliant at out and out emergences. But what if a series of individuals have nagging doubts... low in the hierarchy... perhaps lacking in confidence. Everyone is so busy... Recording is inadequate or misleading... ?

You can watch the film here.

I was not surprised to find at the end that Tapas โ€ชMukherjee @321tapas โ€ฌ is the script writer. I met this extraordinary young man at an innovation event last year - he has such a vision for portraying healthcare issues in just the right way. The film I saw before was amusing, so he clearly has a range of styles to strike the right note.

Moira Durbridge (new-to-Twitter โ€ช@moirasafetyQ) โ€ฌ & Angie Doshani from Leicester spoke about the film their team had produced. Angie is a consultant obstetrician. I wondered whether she knew about #MatExp. I wondered whether she was on Twitter. Another #FabObs, clearly...

Next up was Professor Mark Radford from NHS Improvement

Apparently Mark wasn't allowed to talk about what he planned to talk about because public officials can't talk about things that matter during election campaigns! My paraphrase, not Mark's. ๐Ÿ˜‰ For the avoidance of doubt. Anyway, what he did talk about was very interesting indeed. Psychology. What makes people tick. Power dynamics. Hierarchy. Tradition. Medical model vs social model. Surgeons having their own coffee lounges. And coloured hats. No hierarchy, just people and all that... Listening to Mark speak almost made it worth enduring a general election campaign! Almost. ๐Ÿ˜œ

Mark challenged people to take this graphic back to their workplaces and see how they measured up. Wow! A call for action too. We clearly needed to sign this guy up as a #MatExp #stormtrooper.

And yet he hadn't mentioned #MatExp. And he hadn't really mentioned coproduction with women and families โ€“ just flattening the hierarchy across professionalsโ€ฆ

Someone jumped up from the audience and asked exactly the question that was in my head. But with a much better pose than I could ever have mustered! ๐Ÿ‘๐Ÿผ

I was spared a very difficult decision about which breakout session to go to. I was genuinely interested in all of them. I was hoping to speak to Mark and it was obviously meant to be. Catherine MacLennan, founder of The Pinks N Blues, arrived just as Mark left the lecture theatre. We -er-๐Ÿ’ฅ#MatExp-๐Ÿ‹-ed him. That new very transitive verb needs to be in the Oxford dictionary shortly. ๐Ÿ˜‰

We are known for #MatExp-ing. people who share our values ๐Ÿ˜‰

We hoped that Mark would come to our workshop. He was interested โ€“ or at least was very polite! โ€“ but he had a very important meeting... We told him about #MatExp โ€“ 700 million Twitter impressions โ€“ and how we're linking strongly with his team via 'Nobody's Patient', exploring key areas where women and family fall through gaps in services, particular between maternity and neonatal care.

Mark invited us to send him a couple of slides about #MatExp that he could include in future presentations. Will have to think what to include! I always love it when Baroness Cumberlege gives us a mention. ๐Ÿ˜€

We are proud that our #MatExp work helped shape 'Better Births'. Whose Shoes was used at all the national maternity review listening events. At the Birmingham event, Catherine was writing her story alone at the back of the room. We hadn't met in person at that point: #MatExp was bringing everyone together.

All our resources are now available, coproduced and sourced by authentic voices. These are just the ones from the new 'Nobody's Patient' project. We have as many again in the original more generic #MatExp project.

Catherine and I needed to plan for our afternoon workshop. I was the invited speaker, but I try to bring in women and families who have been part of the project. It is far more authentic! I had similarly really enjoyed presenting with fab Leigh Kendall at #Quality2017!

We almost chatted for too long. Catherine & I could talk all day. Before we knew it, people were arriving and our session was underway!

It was hard to know how to use the time. If we have 3 hours, we can really stretch people. If we have 7 minutes, we can do a Pecha Kucha. We had been told 50 mins, but now it was only about 35 โ€“ what to chop? ๐Ÿ˜ฌ

We gave a short presentation. You can see it here. Telling people about #MatExp #WhoseShoes and how they can get involved. We talked about how anybody can be a leader and gave lots of really practical examples.

Flo's story about who can be a leader. Anyone and everyone!

We had a rolling series of slides, set to music, filled with practical ideas to make a difference, including ways to break down barriers, promote empathy and get everyone working together.

Catherine told the story of our amazing focus group in Birmingham, bringing together a group of people who have experienced the loss of a baby in the second trimester. One of three groups who we found seem to fall between cracks in traditional services and care pathways. I think both of us found this one of the most moving things we have ever done. You can read about it here.

This powerful graphic was produced by Anna Geyer, New Possibilities, who recorded live the key points arising from the session. This has fed directly into '#NobodysPatient', and the resulting quality improvement work.

Catherine offers amazing peer support via the Pinks n Blues. Sometimes it is hard for formal services to know how best to support this work but 'Nobody's Patient' is helping people to understand the huge value. The seminar provided some amazing new connections and reinforced some emerging ones. #MatExp is an extremely supportive community where we all help each other find the right people to collaborate with us.

We talked about creativity. About fun. The FUNdamentals of building a change platform. About the creative process that we used to run our competition to win a Whose Shoes workshop. Sherwood Forest Hospital won it with a wacky limerickโ€“ so of course we had to announce the winners creatively! Watch out Robin Hood video here! ๐Ÿ˜‚

We talked about how #MatExp is spreading and the exciting opportunities to speak โ€“ including at prestigious world conferences! Read this Steller story for an informal visit to the Quality and Safety forum. It was an amazing event and Leigh and I were incredibly proud to co-present with Zel Maikori, brilliantly reducing mortality rates in Nigeria.

Whose Shoes is all about creating a relaxed environment and helping people build rapport so that they talk openly and honestly. It was very ambitious to try and get some meaningful discussions going in the very short time we had, in a very hot room and with everyone sitting in rowsโ€ฆ but we gave it a goโ€ฆ

Flo and I had put a few scenarios and poems in folders, themed to topics that we thought would be most relevantโ€ฆ

I suggested that people split into little groups, #JFDI style...

Three groups. Three topics. Great conversations startingโ€ฆ

And even within that very short time, an action-focused approach. ๐Ÿ’œ Stress busters in one group.๐Ÿ’œ Does your organisation actively encourage people to take breaks or make it 'heroic' not to? A practical solution from one hospital โ€“ a midwives break board!

We finished with our rabble rousing #MatExp film, which we showed at NHS Expo last year, including a RAP personally commissioned by Sarah-Jane Marsh! Here it is! ๐ŸŽฅ

Sue was the 'rapporteur' who reported back about our workshop to the plenary session. Some things had clearly struck a chord with her ...

I'm looking forward to looking at the slides from the sessions I missed. Emma Plunkett spoke about Learning from Excellence โ€“ a wonderful project that started at Birmingham Children's Hospital and is spreading very quickly. I am really looking forward to bringing Whose Shoes to the newly merged Birmingham Women and Children's Hospital โ€“ contemplating how Learning from Excellence and Whose Shoes might flow into an even bigger wave.

There have already been positive outcomes from my double act with Catherine. I'm delighted she has been invited to join our Whose Shoes session at Warrington in July โ€“ RCM midwifery service of the year, 2017!

It was lovely to receive the WMAHSN recognition last year โ€“ but far more important to me when it leads to new opportunities which help make a difference.

A huge thank you to everyone involved in #MatExp and for the difference you are all making. Always difficult to do this justice! Here is a link to our full slide deck. I will send it now, (together with the Steller story!) to the CHFG team and I think they will add it to their fab round-up of the seminar.

Thank you CHFG / West Midlands AHSN for this important opportunity and for your imaginative seminar. Catherine and I โ€“ and the whole #MatExp gang, if you are up for a challenge โ€“ look forward to working with you further in the future! ๐Ÿ˜˜ Gill @WhoseShoes nutshellcomms.co.uk

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