Objectives To understand how frontline reports of day-to-day care failings might be better translated into improvement.
Design Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS.
Results PCTS fostered psychological safety—a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described.
Conclusions Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations.
Trial registration ISRCTN 34806867.
- patient safety
- healthcare quality
- interdisciplinary teams
- medical ward
- prospective surveillance
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Contributors Study design: SP, SA, MJJ, TA, NS, SJL, IB. Study implementation and data collection: SA, SP, MJJ, SJL, IB. Analysis: SA, SP, NS. All authors contributed to, read and approved the final manuscript. Dr Pannick had full access to all of the data in the study and takes responsibility for the integrity of the data.
Funding This paper represents independent research supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre, Imperial College Healthcare Charity (Grant GG14\1022), and West Middlesex University Hospital NHS Trust. The research by NS is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South London at King’s College Hospital NHS Foundation Trust. NS is a member of King’s Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King’s College London. Its work is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity, the Maudsley Charity and the Health Foundation. NS is the director of London Training & Safety Solutions, which delivers team assessment and training to hospitals on a consultancy basis. No funding source had any role in the design and conduct of the study; collection, management, analysis or interpretation of the data or preparation, review or approval of the manuscript. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.
Competing interests NS is the director of London Training & Safety Solutions, which delivers team assessment and training to hospitals on a consultancy basis.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The qualitative data cannot be shared without identifying participants.
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