PCTS established psychological safety, with a hard edge of accountability

By the end of the study period, all staff groups had participated in—and led—HEADS-UP briefings:

(Consultants) contribute as much as anyone else (…) so their voice is being heard, because they suffer from the same frustrations as all of us. (Service manager)

The physio(therapists) or the OTs (occupational therapists) are also flagging things up, that’s how we found it useful. (…) The discharges that did not happen, anyone (who) deteriorated (…) we all learn from what went wrong. (Senior nurse)

Perhaps because different staff groups were perceived as partners in them, the briefings formed a psychologically safe environment in which problems could be discussed openly, without fear of retribution. Team psychological safety does not imply undue permissiveness or unrelenting cheeriness, but a confidence that the team will not embarrass or punish someone for speaking up:

It was more of a constructive exercise, where everyone is then wanting the same outcome, so it wasn’t like, “Oh this didn’t happen, I am angry at you”, it was more like we are all actually in the same team (…) You all have the same end point and I think that is why it is quite safe to bring it up, because it is not confrontational, and it is not personal against someone, it is just what needs to be done. (Foundation doctor)

The style and timeliness of PCTS feedback also contributed to a sense that this was a non-judgemental forum for team learning:

There were a few teaching sessions where (…) we went through things like ECGs (electrocardiographs) that were missed, and then you had a collective opportunity to think (…) It was a very good plot for learning, saying this happened and let’s do some learning and try and prevent it happening again. That is quite helpful. (Foundation doctor)

This psychological safety was not limitless: there were still boundaries around what could be discussed. Although the briefings did prompt teams to consider positive notes from the previous shift, they rarely did so. Reflections often highlighted the overall management of patient flow, rather than specific actions or diagnostic processes that others could emulate. This reflected a reluctance to delve too deeply into any one team member’s performance. Professional identities were protected by assigning problems to other departments, acknowledging procedural complications as foreseeable, or linking delays to understaffing. In this way, perceived threats to professional identity were largely deflected by a projection of blame onto other groups, or attributed to circumstances beyond the team’s control.

More introspective teams, with senior support and increasing psychological safety, did record issues like diagnostic errors, in which they had played a more overt role. However, even in those teams—where the briefings were implemented with greatest fidelity—there could be disputes as to whether certain problems were really problems at all:

The senior nurse disagrees with medical teams’ perceptions that the site moves (moving patients from one ward to another) were inappropriate. She thinks doctors expect patients to remain on the acute medical unit even when they are stable… She felt an inadequate handover perpetuated their concerns.’(Fieldnotes)

Thus, while psychological safety was an important factor in helping staff speak up about their concerns, certain topics remained off-limits, and psychological safety did not guarantee agreement about what were reasonable concerns. These are important limitations:

I think it’s more (than) just raising the issue. (…) Give me a more detailed timeframe, resolution, how do you resolve it? Are you going to get back to me because it’s important? And what will I expect? (Senior nurse)

Where they were most effective, the briefings maintained a ‘hard edge’: team members regulated their own behaviour, knowing that their actions (or inactions) might be flagged up at the next briefing, or in feedback. Junior doctors and nurses were conscious of this internalised discipline (panopticism), acknowledging how it changed their own behaviour and how they could use it to their advantage. A self-reinforcing virtuous cycle emerged, with participation, accountability and feedback:

The group was more aware that if you perhaps missed something like that, it may be brought up later at a HEADS-UP meeting. (…) It made you more accountable. (Foundation doctor)

It certainly works for the VTEs [venous thromboembolism assessments, completed by junior doctors, often at the behest of nursing staff]. There are days that we will have eight or 10 VTEs (to do), so if I (…) give the list to the doctor, the following day (…) there will be one or two, because they know (…) it will be mentioned again, with the consultant. (Senior nurse)

You get more feedback, so you raise concern(s), and then maybe the next day the same issue would crop up, and you actually then get feedback on what they are doing about it, or who they have escalated to. (Foundation doctor)

As we will now describe, airing and recording concerns in this environment helped triage those problems, directing them back to frontline teams or onwards to their managers.

Rapid resolution and meaningful managerial follow-up

To explain their perceptions of PCTS, focus group participants drew comparisons with the existing processes for identifying and resolving ward-level problems. The hospital’s online incident reporting system was considered the formal mechanism by which problems were recorded. The system was not easy to use for this purpose, and there were few attempts to persistently report recurrent problems. As a result, commonplace issues were no longer even considered abnormal—a materialisation of normalised deviance, where staff become so desensitised to deviant practice that it no longer feels wrong:

Some things staff have got so used to that they don’t (report) it. So it’s just become common practice. (Clinical risk manager)

Managers too were frustrated by the incident reporting system. Reports did not necessarily illuminate what was happening at the frontline. Moreover, long delays in processing those incident reports meant that even relatively simple problems were not reviewed for many weeks. As a result, reports that described patient harm were prioritised: where no harm had occurred, little was done. Service managers were aware that they paid attention to only the most serious incidents:

You could go down there (to the ward) and you could see people working very, very hard and you could also sense a lot of frustrations (…) but you weren’t getting to what those frustrations were, and what those issues were. (Service manager)

It has got to that point of being a SI (serious incident, an adverse event with particularly grave consequences) before it is then addressed and taught and learnt from. (Service manager)

In contrast, PCTS helped identify a route for more rapid resolution of practical problems. It provided an acceptable mechanism for staff to log issues into which they had immediate insight. This was a materialisation of second-order problem solving, staff finding a way to bring about a more lasting solution to each issue they encountered. Where issues could not be resolved within the ward team, managers were presented with clear, actionable topics to address. Those managers were then better prepared to handle incipient risks to service quality:

(PCTS) highlighted little things, that could be sorted out quite quickly. It made sure that somebody was allocated to deal with that on the day—or did you follow that through, did that get sorted out? So everything benefits, rather than just going on and on and on (…) Things get sorted out quicker. (Senior nurse)

What I like about it is (that) it is instant and it is thematic very quickly, you understand what the issues are (…) Here is an opportunity to dump them (your daily issues) and suddenly a picture forms out of it (…) And not just here, but there, there, there and there (…) And it hasn’t yet created a significant incident, but clearly there is risk associated with it. (Service manager)

Therefore, PCTS brought about faster resolution of safety and quality issues through a combination of mechanisms. First, increasing self-monitoring within ward teams helped anticipate and mitigate potential problems. Second, senior ward staff at the daily briefings were more quickly aware of issues they could resolve, without having to trawl through a backlog of outstanding incident reports. Third, facilitation drew out thematic problems across departments, bringing them to the attention of middle managers who had struggled to understand the difficulties experienced by their staff. Fourth, the clinical impact of these problems was made clearer to senior executives, who were motivated by these novel frontline narratives to pursue change:

PCTS findings informed the discussion in the Trust morbidity and mortality meeting, chaired by the chief executive, highlighting areas which needed faster examination and transformation, and bringing genuinely new information… Many of these concerns had not been formally addressed either in incident reports or top-down initiatives… It also highlighted new targets for improvement. (Fieldnotes)

However, not all managers were equally enthused. Where PCTS had not provided data that appeared directly useful for them, middle managers did less to hold their service areas accountable for briefing implementation. Board members questioned how best to detect a meaningful signal among the noise of staff reporting (whether through formal incident reports or PCTS). At times, managers seemed nihilistic about the possibility of improvement, or questioned whether their frontline teams truly understood the problems they had reported:

We have two chances of getting (this issue resolved)—fat chance and no chance! We are monitoring (this) on a daily basis but (…) the situation is far from ideal and we have escalated up the chain – not that it has helped. (Support service manager—Fieldnotes)

I would like to get some feedback on (these issues) first (…) Currently they are only perception(s), and following investigation it may be that the risk changes, or the issue is solely around communication of processes already in place. (General manager—Fieldnotes)

Still, the combination of increased frontline efficiency and managerial involvement (at least in some areas) led to a more general sense that things had changed for the better:

(PCTS) would make it clear what was actually deficient. And then I think things did start to change, and you did see the feedback coming through (…) So you could definitely see the evolution of it. (Foundation doctor)

There (are) also the (…) day-to-day things within the team that start running better, and I think you do start seeing those, but it is harder to put a specific, “This was raised, this was done, there was an outcome.” It is a more (…) general change as part of (PCTS). (Foundation doctor)

With a structure in place to coordinate frontline teams and their managers, individual staff found their own practice changing, with unexpected personal benefits. These will now be discussed in more detail.

Changing individuals: reversing normalised deviance, and catharsis

PCTS prompted staff to proactively address issues they may have previously ignored. This was, in effect, a reversal of the normalised deviance that had become so ingrained:

You wouldn’t have identified that (issue) necessarily, because it is just part of your daily (…) life in the NHS, but when it is put like this (with PCTS), it is highlighted, you have got an opportunity to really do something about it. (Service manager)

This particular patient (has been) awaiting echo(cardiography) for the last three days (…) (I) would now question why is it still not done (…) When I wasn’t doing (the briefings), I wasn’t seeing the importance (…) (Now) I tell the Matron, or I tell my Bed Manager […] or I go there myself (…) I go to the department and ask them, “This is what’s happening, this is what I need.” (Senior nurse)

Having made those problems visible once again, the information shared in the HEADS-UP briefings would be used to actively coordinate plans and decisions for the next shift. Aware of pressures on their colleagues, and cognisant that problems were occurring repeatedly, individuals would change their routines:

I tell the physio(therapist) and the OT (occupational therapist): “These are your priorities for today, these are your priorities for tomorrow.” So they already have a plan (…) Like I said, it gives you the structure that you need. (Senior nurse)

The group as a whole became more “present” to (what) happens maybe a couple of times in a week (…) For example if the nursing staff are short (…) just having that in your mind and thinking “No, we need to get all these blood tests done now”, you would appreciate how the service could be best run. I think that made it more efficient. (Foundation doctor)

The improved information sharing, interdisciplinary coordination and efforts to evenly distribute workload produced a more supportive team climate. In this atmosphere, the briefings could become unexpectedly cathartic, giving a voice to junior clinicians to air their personal worries, as well as their clinical concerns:

You felt like you had got a lot of your chest by doing it (…) The next day you could say, “These are the things that went wrong yesterday”, and now I can clear that and start again. (Foundation doctor)

(It) makes you feel more heard, because otherwise you are just venting your concern, but you don’t know if it has been actioned in any way. And then you can provide the objective evidence to move forward, to change something. (Foundation doctor)

The combination of changes in team ethos, triage and individual practice ultimately provoked a new approach to improvement, and a degree of organisational development.

Changing teams and the organisation

Contrary to some leaders’ fears, PCTS did not reduce the volume of formal incident reports. Rather, it provoked new reports, and altered how those reports were addressed. Yet the translation of briefing-recorded incidents into online reports was imperfect, not least because there was no agreed list of high-priority events to be recorded:

Antibiotics had not been given (…) The junior doctors had not seen the procedure report specifying they were needed. No incident report was done, even though (the registrar) specifically asked if one should be completed. (Fieldnotes)

When incidents were reported, PCTS briefings allowed incident investigators to start to collect relevant information. The problems that had provoked the incident were typically captured by the briefing, giving the investigator (often the nurse in charge) a head start in understanding what had happened:

The people involved are already there, they are already able to explain to you, “This is what actually happened from our end.” (…) It’s easier for you to do your incident (investigation) report already because as the investigator you don’t have to call everyone. (Senior nurse)

The emphasis on clinical teams’ accountability also led to a subtler change in incident management. Teams took responsibility for issues that were actually within their power to change, rather than awaiting permission or hoping that the problems would be resolved elsewhere:

Very often before it gets to me, it has been dealt with and sorted out by the teams themselves (…) With HEADS-UP and (incident reporting) together, there is a different approach: (…) “We have discussed it, we have taken on the responsibility of this, we have done as much of this as we can, but here is the point where it has to be escalated and we want to make sure something is done about it, and this is our methodology for doing it.” That is how it feels to me, anyway. (Service manager)

At multiple levels within the organisation, it was clear that this programme had revealed hidden gaps in practice. PCTS proved useful even on wards where teams were already thought to be functioning well:

There is definitely time to do it, there is definitely a need to do it, but (…) you only know that once you have done it. (Service manager)

I don’t think we would have known, unless we had done it, that there was a gap there. (Senior nurse)

Similarly, in safety and governance meetings, PCTS findings highlighted new areas for improvement, many of which had not been addressed in incident reports or top-down initiatives. Those findings enabled managers to make a convincing case for investment, with numerous specific, tangible changes driven by PCTS during the study period [box 1]. These changes were described as ‘quick wins’ by senior managers, with clinicians agreeing that they were at least a relatively rapid organisational response:

It empowers me then as manager for that area to go forward with a business case with the evidence to say we need additional resource, this is the implications of it (…) And it works, so we have an additional (cardiac) sonographer (…) I think we saw very quickly a reduction in delays once that was sorted. (Service manager)

However, internal investment was not necessarily targeted specifically to participating teams. For example, expansion of the phlebotomy service (identified through PCTS as no longer meeting patient needs) primarily benefited non-participant wards, which were deemed by senior management to be more in need of support. Nor was progress guaranteed by repeated ward-level reporting. Changes to structures or processes were more likely when there was an associated financial target; another organisational incentive aligning with the proposed improvement and when clinicians and managers agreed the need for change.

Additionally, some of the concerns raised by frontline staff simply could not be addressed within the organisation. Poor staffing levels, for example, were felt keenly, but reflected a broader national challenge. Creative workarounds and mitigation plans could only go so far in addressing a fundamental shortfall in staff numbers. This was frustrating for the teams completing the briefings. PCTS also identified issues like unsafe inter-hospital transfers, whose resolution would have required close collaboration within a network of hospitals. With many other competing priorities, a local improvement effort was no guarantor of the necessary cooperative drive for change.