Helen Hughes in conversation with Air Ambulance Kent Surrey Sussex (24 February 2021)

Summary

An organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again.

At the recent Future of Hospitals event from Health Plus Care Online, Helen Hughes, Patient Safety Learning's CEO, speaks with Dr Duncan Bootland, Medical Director at Air Ambulance Kent Surrey Sussex (AAKSS), who was recently rated as outstanding by the Care Quality Commission across all five of its inspection key lines of enquiry.

In this recording of the session, Helen and Duncan talk about the safety culture synergy of healthcare and aviation and how behaviour impacts on safety, considering the values-based approach being championed by AAKSS.

Content

Video transcript

Helen: Hello, everyone. I'll introduce Duncan in a minute, but just to say who I am. I'm Helen Hughes. I'm the chief executive of Patient Safety Learning. We're a small charity and we do what we do best, what we say on the tin. Patient Safety Learning is about sharing knowledge and learning to improve patient safety.

And one of the ways we do that is through our free—this is my plug—our free knowledge-sharing platform for patient safety called the hub. And you'll have details in the pack that goes out with this, but we'd really welcome you looking to see the resources that are on there, getting some benefit from them and sharing your experience about how we improve patient safety.

But that's enough about me. Now it's Duncan's turn. Absolutely delighted to be in conversation with Duncan. He's going to introduce himself and then we're going to dive into a whole series of questions about patient safety, Duncan's journey to here with patient safety and the amazing work they do down in Kent. Over to you, Duncan. 

Duncan: Thank you. As you say, I'm Duncan Bootland. I'm the medical director at Air Ambulance Kent, Surrey, Sussex. And what I thought I'd do is just tell you a bit about the service and then I'll tell you a bit about me and then a bit about what we do and that will hopefully feed into our discussion about patient safety and how that impacts and how we manage that in terms of our air ambulance work.

So  we're, as we say in the title, an air ambulance and we serve the South East of England, it's about four and a half million people. We work alongside our colleagues in the NHS, particularly the Ambulance Service, but we're an independent charity and we function  predominantly through the generosity of people donating to us from the South East of England.

We're tasked to patients either with critical illness or critical injury and our role is to treat them at the point of injury or the scene of their illness and bring to them a standard of care that you otherwise wouldn't get until you arrived in hospital. And then we transport people to hospital as quickly as we can.

We'll deal with people with anything from severe injury due to road traffic incidents through to cardiac arrest due to coronary artery disease. So, quite a wide range of critical illness really. We provide two teams, between 6am in the morning and midnight, and then a team that runs between midnight and six in the morning. So we fly 24 hours a day, every day of the week, every day of the year. We're the only air ambulance in England that does that. And that provides us an opportunity to serve our community, but also as you can imagine, working at night provides challenges that we don't see in the day so much. 

Our team is a dispatcher, somebody who sits in the ambulance centre and is searching for jobs for us, the jobs where we'll add the most benefit to the patients. We have two pilots on each team,and then an experienced doctor and an experienced paramedic. Our  paramedics come from the ambulance service and our doctors come predominantly from a background in emergency medicine, aneasthesia or intensive care.

They come to us as clinicians and then we train them for six to eight weeks to get them up to a point where they understand our processes and our systems and that's what I did eight years ago. So I came to the air ambulance as a consultant at that point in emergency medicine and trained with the service and have stayed ever since.

And I now work between both the NHS and the air ambulance, which gives me a nice, interesting perspective on both organisations. In terms of patient safety, I mean, I've talked about the fact that we work day and night and all the challenges those bring. We treat people who are really very unwell and that's where we feel we bring the most benefit.

We undertake procedures outside the hospital that are perhaps a bit unusual. We'll deliver roadside emergency anaesthesia, chest surgery, blood transfusions. So interventions that themselves carry an element of complexity and challenge to them. And so that combination of the environment we work in, the group of patients we work with and for, and the interventions we bring, adds a number of challenges for us.

And so we've worked very hard over the years to develop systems and processes to try and manage the patient safety risks around those. We think we do that pretty well. It's an organisation I'm enormously proud to work for. And so it's a real privilege to come and talk about it. 

Helen: Thank you, Duncan.  I'd like to pick up a couple of things in terms of size for people that might not know about the service. You covered the geography of South East of England, but in terms of I don't know, number of patients you'd be supporting in a year, your budget as an organisation, something about the scale, because we may come back to that  about the size of the organisation and whether that influences the culture of safety. Just to give some idea of scale really. 

Duncan: Yeah, so we attend about three jobs per shift. We've got one 12 hour shift, two eight hour shifts and then one night shift. And the night shifts are not quite as busy as the day shifts, maybe one or two patients at night.

So that gives you an idea of the activity of what we're doing. In terms of finance we raise in the region of 15 or 16 million pounds a year to run the service. And that's about what it costs us to run it. 

Helen: Thankyou. I'd like to pick up to start with your pride in the organisation and rightly so from, you know, external inspectors reports and others. You're highly commended for being excellent across the whole range of indicators. Has it always been like that? Have you been good for a very long time? Are you improving? Where are you in your journey to excellence?

Duncan: Um, so I, I've been involved for eight years and, and over the eight years, I think we would feel we've been high performing during that period of time.

Our CQC rating, which you mentioned, we're immensely proud of, that was our first formal CQC rating last year. And it is something we're very proud of, but in many senses, we're more proud of our culture internally than our external assessments and that has always been the case.

We take great pride in the way that we work and the relationships we have within the organisation and that has always been there, certainly within the last eight years, whilst I've been a part of the organisation. 

Helen: One of the bits of work we do in Patient Safety Learning and a report that we've done is looking at organisational foundations for patient safety. What needs to be in place as an organisational level around leadership and governance? Whether you have the right data and insight to inform performance, whether you're engaging patients and families, these six core foundations. But the key one that we often describe is the culture that wraps around everyone.

There's a lot of talk about patient safety culture and an open and just culture. How would you describe it in your service? If you were describing it to the people that are joining this webinar, but also to patients, family members, how could you smell and taste it? What does it mean for you?  

Duncan: So it's often a really difficult thing to describe, isn't it? Health is a really difficult thing to describe. And a colleague who works in the NHS and has experience with the air ambulance said to me not long ago, What is it? What's the difference between the  organisations? I think there are a few things. I think first and foremost, there's trust amongst the people within the organisation and that  trust allows a degree of honesty about what we do. 

I think you mentioned just culture. To have just culture, you have to have honesty, but you have to have trust. You have to have trust that when you open yourselves up to explaining what hasn't gone as well as you want it to go, that's going to be received in the right way, that it's going to be received in a positive way. And I think if I was to just distil down everything we do, that's the central core of the Air Ambulance Organisation, is that we trust one another, that we know that exploration of when we haven't got things quite right is done in a fair manner, and that it applies to absolutely everybody in the organisation. We work very hard on our flat hierarchy, but we understand that isn't just about the difference between professional groups, that isn't just about working on scene, that is about everything that we do. That's absolutely about how we debrief cases and how we look for learning. Everybody takes part in that. 

Helen: So maybe you could, you could unpick that a little bit more for us about how, how you might do that. You know, if you've got teams during, say, um, I don't know, pick a, pick one of the teams. If they're out during the day and they're attending to three emergencies, how would they reflect on what's happened. their learning? If something didn't go as well, what would that feel like if you were a member of that team?

Duncan: So I think there are a few levels to it. The first is that there is a culture and once you get a culture, it becomes sort of self propagating of coming back from jobs and debriefing that job immediately.

So we'll discuss it amongst ourselves in the small group that went to the job to ask one another, “What did you see? What do you remember? What do you, what was your impression of what just happened?” And then, ”What did you see that we could have done better? What did you see that I could have done better?”

That's a normal part of the way that we behave, both on the really high acuity jobs and on the lower acuity jobs so that that becomes a normal part of what we do. And then as an organisation we invest pretty heavily in terms of resource and time in providing a forum for reviewing cases.

So every week we will set aside a day to review cases and other learning. Our clinical teams are split into two teams, a blue team and a red team. And that provides each team with one day, every fortnight to review cases plus other learning. And so every job there'll be an informal debrief when we get back and then we use that time to more thoroughly debrief cases where there's more important or wider learning. 

Helen: So let me just capture that. So that's one day of fortnight that is devoted to that. Why do you think that's valuable and what do you get from that? 

Duncan: So it's a big investment of time and as I say, I worked across the NHS and the air ambulance. And so I totally understand that, I think you can't underestimate the luxury of time to debrief things and we don't underestimate that. To be honest, if you want to engender patient safety, if you want to engender high performance, you have to provide time for it. There is no way around that. That being said, if the culture within those days wasn't right,  that time wouldn't be well spent. 

One of the things that is interesting to watch is that you can make use of the time in your NHS work to do this. As long as the culture for using that much more limited time is set right. And that's the key point to us. We don't lose sight of the luxury of this day once fortnight to meet and learn and review cases, but it is embedded in the fact that we do that in the right way with the right culture.

Helen: So I'm fascinated when you said, people train for six to eight weeks. So people that have just worked in the NHS and haven't worked, possibly in that culture, or indeed with that amount of debriefing time, maybe even on a daily basis, let alone this fortnightly review. What are people's responses when they come in? Are they delighted? Surprised? Shocked? Puzzled? I mean, what's their emotional response to it? 

So I think all of the above, if I'm honest. Last week we welcomed a new doctor into our service through our induction week. They arrive and they get a full week's worth of training and then they get set off on the period of six to eight weeks of clinical practice where they're supervised. And what I said to them and what I say to all of the new doctors is you'll get more feedback in a year than you've ever had in your clinical career. Feedback is quite heavily weighted to that first couple of months with us. 

Helen: And is it always welcomed? 

Duncan: I was just going to say that it comes as a surprise to people and it’s exhausting. It is absolutely exhausting getting lots of feedback. And when you're constantly seeing things that you could improve, it is exhausting and we recognise that. Predominantly it is very well received. 

But the skill of feedback for us is picking the right moment. When people have had enough feedback and it's time just to give them a break. By the nature of the people we select, they tend to take it pretty well, but it is a big culture change for people. 

Helen: When we have discussions about this in patient safety forums more broadly, I think people that are non-clinical, like myself, have this expectation that there will be feedback loops, formal accountability loops. But also learning loops that would happen as a matter of course, in clinical teams or with individual clinicians. And it always is quite a surprise to me that that doesn't happen in a systematic way as you've identified. I think it's variable across different healthcare settings.

Duncan: And I think to say that only the air ambulance does it isn’t true, but I think we've worked at it pretty hard and I think there are some lessons that all of us can take back to our NHS employment that we can share with people. 

Helen: Is this unique to you or do you think this is very similar for the air accident services throughout the country? Is there something about the nature of the work and how you're organised that lends itself or has created this kind of culture and way of working? 

Duncan: So I certainly can't talk for all air ambulances. I think in many, there's a pretty strong clinical governance culture and set up. The nature of the jobs that we go to lend themselves to needing a strong clinical governance setup because you're dealing with situations where you need to get it right. And so I think most ambulances will have a pretty robust clinical governance system, whether all of them invest to the extent that we do, I couldn't say. 

Helen: So could you give us a little bit of the flow? What would be the kind of learnings that would come from a shift? What kind of discussions would the team have as part of a debriefing, the kind of issues that people are reflecting on that they could improve on either personally, as a team or indeed reflections of the wider system? Give us a little idea of the kind of granularity of that.  

Duncan: To roughly divide stuff up into technical and non technical skills, we will look at all of it. And there will be things that we can work on in both areas. Certainly that when you're new to the work, the technical stuff, there's often bits and pieces you can pick up.

The more experience you get and the slicker you get at the technical aspects of the job, the more the debriefs tend to focus on the non technical skills—the CRM, the crew resource management on scene, stuff that we look at all the time, that we're always thinking about how we could improve. 

We often arrive on scene with an ambulance, people we don't know. And people of varying experiences and abilities on scene. We've all got to work in that and CRM becomes a central piece of that jigsaw. And so we think a lot about that. We reflect on that an awful lot.

We're thinking about process we've got very standardised process. We think that standardisation is good for us, but we're always looking to refine and improve it. And we put out experienced, good people and if they come and tell us that the process doesn't quite work or it could be made better then we want to know that because we want to refine that process. 

Helen: You mentioned working with ambulance crews on the scene. In terms of giving feedback, do you do joint learning with those colleagues or is this something that is much more specific to you as an organisation? How do you deal with those kinds of cross organisational boundaries? 

Duncan: Yeah, so like I say, giving feedback is a really delicate thing. So we will not infrequently have situations where we do a debrief on scene where there's time and ability for us all to do a debrief. But you have to be very careful about debriefing in the heat of the moment. We do that clinical governance session day every fortnight and we will often invite guests in and certainly members of the ambulance service who are involved in jobs so that we can talk about those jobs together, so that we can get their perspective. Particularly their perspective on the job and so that we can share some of our learning.

Covid has made a lot of that stuff more challenging, trying to run some of these sessions virtually makes it more difficult, but certainly when we were doing face to face work, we would often have members of the ambulance service and that was actively encouraged to come in and share the learning. 

Helen: I think you said, correct me if I'm wrong, please do, that a lot of your staff and the clinical staff are part time, so they're still working in the NHS? Is there a mix? 

Duncan: Yes, there's a mix. We have some members of staff who are employed full time with us and some who split their roles between the NHS and the organisation. 

Helen: So what do you think are the lessons from the part timers? Do they try to take those lessons back to the NHS? How easy is it to do that? Are the cultures and the systems and processes very different? What's that interface? 

Duncan: I think the cultures are quite different and that's probably the biggest challenge in taking lessons back. I'm absolutely sure that all of our NHS staff take lessons back and in fact, we employ a group of people on secondment who come to us for a year and then go back to their NHS jobs and one of the advantages for the wider system is so that we can share learning. They can bring learning to us and then take learning back to their organisations.

Certainly that's something that we've done in the emergency department that I work in, in Brighton. We've taken some of those lessons from HEMS and used them to help us design processes and systems within the department. But I think the biggest challenge, as we talked about at the beginning, is the cultural difference, that the level of trust in the air ambulance is that you can afford a degree of honesty that is a bit more difficult in some of the NHS environments that people work in.

I think our acceptance of standardisation is very deeply rooted within our air ambulance work. There's been a big change in the NHS the last five years or so, but certainly we're not working with the same foundations that we have in the air ambulance.

Helen: So those things are different. For those colleagues who haven't had the benefit of being seconded in and then sharing that, how would some of that knowledge and insight be distilled and shared with colleagues in, say, emergency departments? How would they find out about it?How would they try and gather the essence of this? As you know, from Patient Safety Learning, we like to share learning. How is it done? How could it be done? What more is needed? 

Duncan: I wouldn't want to say that there's such a divide between different healthcare providers—there's crossover in all of this. In terms of sharing lessons, we think it's really valuable having NHS employees come to work for us, and either split a role with the NHS or come to us for a period of time and then go back. So that's a really important part of how we share what we do. 

In terms of a wider piece, we do a few different bits with the air ambulance. There's an educational piece that we do with our colleagues around managing trauma, but with a focus on the technical aspects of things. 

Covid has made things much more challenging but we've always allowed external guests into a proportion of our clinical governance sessions, so that we can allow people a view of what we do and how we do it. That hopefully is interesting, not just from a clinical perspective, but from a process perspective as well.

So we're very keen to share the way we do things and I wouldn't want to give the impression that there aren't brilliant things that are done in the NHS, because there really are. When I talk about my own department, I have colleagues who've set up fantastic things. I just think we're maybe a little bit further along that road in the air ambulance environment than we are in some of the NHS environments. 

Helen: Do you run training courses or advisory webinars for others to learn?  

Duncan: In terms of the medicine, yes, we do. In terms of the process, no, we do that through exposure rather than through calls. That's an interesting idea. Might come back to you on that one. 

Helen: You've mentioned a couple of times about particular challenges during lockdown, during Covid. Have they given you any advice?What are the kind of patient safety risks or staff safety risks that have emerged in that time and how have you had to address them? Have you had to respond differently or put in new systems and processes, new ways of working? What's been the biggest challenges for you on both patient safety and staff safety?

Duncan: So I think first and foremost, we always say our primary responsibility is for staff safety. The most important thing for all of us in leadership positions in the organisation is everyone comes home safe at the end of the day.

And when Covid became apparent in the community 12 months ago, it became clear to us that our first responsibility was to protect staff from becoming infected with it. So our  approach to personal protective equipment changed essentially overnight. We had to provide a much higher level of personal protective equipment to crews in terms of Tyvek suits and FFP3 masks and face visors than we would have done beforehand.

We did that very successfully and the crews were fantastic in taking that on board and literally overnight learning a whole new way of delivering care, or delivering care in the same way but behind a whole new level of PPE. In terms of the challenges around patient care,  probably the biggest one is that it does slow things down slightly on scene, the PPE requirements, but our biggest challenge really is in terms of communication on scene.

The masks make it much more difficult to hear people and the suits rob you of an awful lot of visual cues about who's who on scene. And those two things combined, we've noticed have been one of our significant challenges around Covid. 

Helen? Can I go into detail on that? I was just thinking in terms of if you do have serious patient safety incidents, if something goes wrong and patients are avoidably harmed what is your organisational response to that? Talk me through how you understand that that's happened, how you report it, what you do about it. Investigating, engaging with patients and family members. What's your approach to serious incidents? 

Duncan: It depends slightly on how we pick up that a serious incident may have occurred. 
So obviously, most often, the crews will come back from a job and tell us that something has occurred that they feel uncomfortable about or they think hasn't gone as it should have gone, and that's our first line of safety. And our culture supports that, and the crews feel very comfortable about coming and talking to us about that.

Our next layer is that all of our cases get reviewed by a manager before being signed off as finished and that provides the manager an opportunity to say that doesn't quite look right, or I'm not happy about what went on here. This then gets flagged for one of the clinical governance consultants to review in one of our clinical governance sessions and we always afford the crew an opportunity to discuss this case or discuss this situation before we reach a final decision on what did or didn't happen. Alongside that we have an incident reporting system that we use and we use the incident reporting system for everything. So any incident at all from minor day to day stuff all the way through to serious incident reporting. That allows us to track and monitor what's going on within the organisation. If we get to a point where we feel there's been a serious incident or potential serious incident and that gets fed up through our governance system within the organisation and then it comes to me as the medical director. As I say we work alongside our ambulance service and so then we would feed into their governance process as part of reporting the serious incident. 

Helen: It does sound as if what you're doing is supplementing with a kind of open transparent review discussion. It doesn't leave that to one side and then the boots come on and there's a serious incident investigation. It's a supplemental approach. 

Duncan: I mean, it doesn't run separately to our standards or clinical governance processes.  It's very important to us that regardless of the severity of the incident, we have an opportunity to learn from it, both individually and as an organisation. And so it's very important to us that all our cases that have potential learning associated with them get discussed in our clinical governance board.

Helen: And does that go all the way up, that clinical governance structure and reporting? Does that all get reviewed right up to your board?  

Duncan: Yes. So our board has a medical trustee Andy Rhodes, and he runs a clinical governance service delivery group. And so we would flag any incidents there.

Helen: It’s probably quite complex given the nature of your work, but in terms of patient and family engagement, if there's any kind of review or learning or feedback response? How's that managed? 

Duncan: So our relationships with our families work both ways. If we feel that there's been a significant incident that we need to speak to them about, then we will contact them about that.

We then have a very open process for families to contact us, either if they have concerns or comments. As you'll understand, a lot of the patients don't remember exactly what's happened to them and they want that piece of the jigsaw filled in and we're very happy to do that. So it works both ways. 

Helen: One thing I was going to ask—and I was talking to your colleague, David, your chief exec, about this—was about the contributory factors or influences on how your culture has emerged in the way it has. We were discussing size, hence my question earlier about how big you are in terms of activity and budget, which is how organisations tend to measure themselves. When you compare your organisation with a trust like Brighton—I don't know how big Brighton is, but it has hundreds of billions in turnover as an organisation—do you think there's a factor in you being the size of organisation you are that supports, encourages and reinforces that culture? It's obviously a loaded question, but do you think it's more difficult in bigger organisations? What factor do you think it has?

Duncan: So I think being a smaller organisation is helpful. As I've mentioned earlier, I think  if I was going to try and describe the core reason why our culture is good, it's because of trust, and trust is easier when the relationships are not distant. Where you've got close relationships, building trust is easier. I think in a smaller organisation that is easier. I think that is the key point though, that developing trust within organisations is about those personal relationships.

And that's something that we could all learn;  that we have to work at the relationships on a local level within an organisation in order to generate trust, to have a good culture. When I think about the NHS, which is a massive organisation, that for me is what this is about. It's about developing trust between people so that at each level, everybody trusts the level above or the level above that, so that we feel we can have these conversations that sometimes are difficult. They can be professionally unsettling conversations but in order for us to always get the learning out, you've got to have them.

Helen: I was gonna ask what happens if someone, one of your members of staff presents behaviours that might undermine that trust. How would you respond to that set of circumstances? Does that happen very often? If it does, how would you deal with it?

Duncan: So it doesn't happen very often and partly that's, I think, because of the people we are able to select and partly that's because of the induction process. Because you're immersed in it, you come to understand it fairly rapidly. We haven't had too many issues about trust.

What there is sometimes an issue around is when you're on a very, very busy scene with a very sick patient, everyone's memory is slightly fallible. And so when you're trying to debrief, particularly if there are a few days between the debrief, the memory of that stuff can be a bit challenging. We do have access to some video recording footage, where we can video ourselves on scene and that can be helpful in teasing those bits apart. 

Any issues around trust are addressed very early on in the governance process. And it's explained right at the beginning that our success is based on honesty within our clinical governance system. Because if we're not honest with one another, then we just can't learn the lessons that we need to learn. 

Helen: Well, our time is practically up. I can't believe how quickly that's gone. It's been a fantastic conversation. I've learned so much. Really, really good. Are there any final comments, assuming that most people that will be watching this will be in either frontline clinical roles or will be in patient safety roles? There's no magic wands around culture and patient safety but do you have any key messages to people that are watching? 

Duncan: I think this is all possible wherever you work, in whatever environment you work in, and I think it is about trust. I think it's about organisations, at the local level and the larger level, understanding that you have to engender trust amongst your staff, that they're going to be treated fairly when they open themselves up to what is potentially a mistake that they've made or an issue that they've had.

I think that's what it's all about and I think if we can all work at that, we will all make patient safety better.

Helen: Thank you very much. A very powerful response and final comment from you, Duncan. Thank you so much for your time today. So appreciate it.