PRIMARY care teams continue to face unprecedented levels of challenge, change and uncertainty. In addition to the pressures of delivering continuing care, practices are now working to scale-up services back to “normal” in the context of an ongoing pandemic and the clear risk of a second spike in COVID-19 cases emerging at arguably one of the highest periods of demand for general practice. No wonder anxiety levels are high.
If you have a formal leadership role, you will be working (visibly or in the background and of course much more quickly than usual) to understand and assess the nature of risk, make decisions and take action so that appropriate conditions are created within which safety is supported. Setting up safe systems, adapting and embedding safety into policies and procedures (including to raise concerns and report/respond to incidents), ensuring safety of equipment and other environmental factors are massively important.
However, without careful consideration of the “human aspects” of your team, including their wellbeing and the emotional impact of current working conditions, the value of these important risk management activities can be undermined, leading to staff and patient safety not being supported on a day-to-day basis.
Practising and encouraging the following behaviours will act to create a positive environment to support effective adoption of the systems and processes you put in place.
1. Step back and take an overview
Many adverse events arise when situational awareness is diminished. Situational awareness is basically knowing what is going on around us: understanding how this information is impacting on the situation now and predicting how it is likely to evolve. Sometimes it is referred to as taking a “helicopter view”. Given that in the delivery of patient care there are often many complex variables at play, missing or misinterpreting one important element can lead to a patient safety incident.
In the context of a pandemic, where emotional factors are exacerbated, it becomes even more crucial to understand not only what is going on in your practice (and in each area) but also the perceived challenges for each individual member of the team. If a member of the team is experiencing strong negative emotions, or feeling unsupported, they are unlikely to perform as you would expect – particularly if these feelings are experienced over a prolonged length of time.
GP practice leads should be challenging themselves to check in with the team regularly and take time to understand their perspectives and concerns. This will increase their capacity to evaluate the wider situation and more effectively manage risk.
2. Take a deeper look when things go wrong
When things go wrong you almost always have an opportunity to learn something that will allow systems and process risk to be reduced in future practice – but often we fail to ask ‘why’ enough times to get at the underlying factors. Just deciding that you will act differently “next time” may not be enough. Perhaps you need to take time to improve a working relationship, understand another perspective, or perhaps you need to champion change in a problematic system or protocol. If you avoided or delayed doing something, analyse why and take action to fix it rather than expecting to do better next time. If an incident involves a colleague, consider how you can support them to do the same.
3. Ask for help
Asking for help can feel risky and many members of the team, often particularly doctors, find it difficult to demonstrate perceived vulnerability. However, taking the first steps can encourage others to do the same. Teams that are confident enough to engage in more help-seeking behaviours are likely to provide safer care. Communication style is important when there is a direct risk to patient safety, and providing relevant and succinct information will ensure you get the help required. Try using introductory phrases such as: “I need you to come in on this….” or “I need your advice…” Taking time to understand exactly what the issue is (e.g. your capacity or knowledge of patient-specific factors) before seeking help can ensure that your request is not “woolly” – causing additional delay in patient care.
4. Ask for feedback
Asking for feedback (hard as that may be sometimes) is a key component of building a supportive team culture. Listening and providing positive responses and then demonstrating how feedback has impacted your practice will send strong signals about your approachability and in turn reinforce that you can be challenged if necessary to support safety.
5. Give feedback
Letting colleagues know where they could do better is obviously key to improving quality and reducing risk, but it’s important to assess the current “comfort level” within your team before jumping straight in. Regular praise (or encouragement when colleagues are engaging in new activities/roles) has been shown to make it easier for an individual to hear and absorb critical feedback. To ensure trust, you must deliver feedback in a sensitive and considered way. People need to believe the good intentions behind your feedback. In an atmosphere of open feedback, people are less fearful and more likely to disclose problems, ask for help and challenge you when necessary.
People also need to understand exactly what the issue is and why it’s causing a problem. That way they are more likely to be able to gain insight and psychologically ‘buy into’ the need for change and therefore respond positively. For more on delivering feedback and creating feedback cultures check out this webinar on our website.
6. Encourage the team to challenge colleagues' behaviours
I appreciate that this can be difficult (and some will find it more difficult than others), particularly so when the individual you need to challenge is perceived as an expert or “in charge”. An ‘authority gradient’ might not be the single cause of a patient safety incident but it is very often a contributing factor, leading often to delayed action. Trust is crucial in staff feeling comfortable challenging each other and in influencing how that challenge is received. Placing the patient’s safety at the centre of your response is key, and certain situations will require a more assertive approach, even if there is risk of a negative response from colleagues. Low-risk scenarios allow more time for a considered approach. In the current context, it is very important that GP partners and managers enable other members of the team to challenge their behaviours – particularly as those team members may be viewing the patient through a different lens and so may see a situation deteriorating and thus allow the practice to act before it becomes irreversible and leads to a potential safety incident or complaint.
7. Choose how to approach situations with care
How we respond to situations, particularly when under extraordinary pressure, can vary significantly from person to person. Perhaps you become a little more directive? Perhaps you experience anger? Perhaps you are more likely to stay silent until able to acquire more information? All of these internal responses result in external signals or behaviours which have an effect on how others engage with you. Has a receptionist not raised a concern about a patient with you because the last time they did, you took some frustration out on them? Might the new pharmacist take a decision to advise a patient slightly outside their scope of practice because they see you being stressed by other colleagues? By understanding and working to moderate your own responses, along with monitoring how others respond when faced with similar situations, you should be able to select the best approach to maximise the impact of your communication.
How we interface with others is obviously important. In GP practice, individual clinicians can become isolated and work in silos without proactive management/team interventions to prevent this. We are all working towards the same goal but examining patients and situations through differing lenses. Taking a moment to explore the perspectives of others can allow collaboration to improve the outcome of the encounter – both for you and the patient. This has been recognised via multidisciplinary approaches to training which can identify and create solutions to natural, and sometimes ‘historically manufactured’, tensions within and between teams.
8. Follow through on commitments
Internal and external accountability for your own actions is important in managing risk. Take personal responsibility for you own actions – both successes and failures – and follow through on commitments you have made to yourself and others. This will reassure colleagues that you can be relied upon, building respect and increasing your credibility.
9. Be consistent
Your own values and ethical standards should be aligned to those of your colleagues and the organisation, and these should be at the forefront of your mind in any interaction or decision taken. Ensuring this is always the case means colleagues understand the “rules by which you play”. It can also ensure you take the ‘right’ decisions in such times as these where constant change and uncertainty contribute to increased risk challenge. Demonstrating consistency across values such as openness, safety and fairness should mean that colleagues are more likely to trust your motivations and feel able to challenge things that “don’t feel quite right”, which are often the conditions within which patient safety incidents arise.
10. Take time out to reflect and create a plan of action
It is important to take time to understand yourself, your own wellbeing and your capacity. Recognise how you respond emotionally and behaviourally to certain people or situations and how your communication and working preferences align or misalign with your colleagues. Consider how much capacity you have to engage proactively with colleagues across the areas above, and what drains that capacity.
By understanding and practising some of behaviours above (perhaps the ones you find less comfortable) you should be able to see a direct impact on the behaviour of others and strongly influence risk reduction across your teams’ activities at any time, but even more so as you face the difficult months ahead.
Liz Price is senior risk adviser at MDDUS