Possible mechanisms fostering the normalisation of 1000
Lives+
As discussed in Chapter 2,
we draw on institutional theory to inform our understanding of the generative
mechanisms, specifically the roles of contextual constraints and enablements,
and ensuing reflexive theorisation; and May’s352,353 modulating roles of coherence, cognitive participation,
collective action and reflexive monitoring, thought to foster the normalisation
of 1000 Lives+ in NHS Wales.
Coherence
As expressed in May’s normalisation process theory,352,353 coherence means that a practice –
an ensemble of beliefs, behaviours and acts that manipulate or organise
objects and others – is made possible by a set of ideas about its
meaning, uses and utility and by socially defined and organised
competencies.353 In this
regard, the 1000 Lives+ programme may be seen as a material
object which facilitates the improvement of the patient safety in NHS Wales
through the way in which the health-care team, both individually and
collectively, think about and understand its meaning and carry out the
practices involved.
As evident from patient safety studies undertaken in NHS Wales,210 the coherence and
foundational competence of the 1000 Lives+ programme is clearly
linked to the underpinning MI-PDSA approach.178,219 This method of service improvement has been advocated in
health care for many years420–423
and its widespread adoption in developed health-care systems promotes
health-care actors’ awareness of the MI-PDSA approach as accepted
practice,353 so aiding
its embedding into day-to-day working.186
Cognitive participation
The 1000 Lives+ programme is normalised through ongoing cognitive
participation, defined by May and Finch353 as ‘the symbolic and real
enrolments and engagements of human actors that position them for the
interactional and material work of collective action’.
Although cognitive participation in the 1000 Lives+ programme is
underpinned by the MI-PDSA approach, specifically with regard to the
promotion of a consistent approach across its multicomponent improvement
programmes,424 other
resources make valuable contributions. For example, the 1000
Lives+ programme team, improvement guides and local and
national learning events each facilitate cognitive participation through
education and practice-based skill development. Such learning, whether at an
individual,187,421,425–427 an organisational12,411 or a system-wide level,24,428 is fundamental to health-care practice change, as is the
need for senior organisational leaders to develop a comparable level of
awareness of 1000 Lives+, the MI-PDSA approach and associated
drivers.429 Cognitive
participation thus helps to ensure that systemic and organisational factors
giving rise to patient neglect are addressed,430 while knowledge sharing and trust are
enhanced.431
Collective action
The cognitive participation of social actors gives rise to collective
purposive action aimed at some goal. However, with respect to the 1000
Lives+ programme, such goal-orientation may include
resistance, subversion or reinvention, as well as affirmation and compliance
with the core features of this patient safety programme. The normalisation
of 1000 Lives+ is, therefore, dependent on institutional and
professional work that defines and operationalises the desired features of
1000 Lives+, aligned factors which promote or inhibit social
actors’ enacting of 1000 Lives+ and social
actors’ collective investment of effort in such practices.353
For the 1000 Lives+ programme, two processes which facilitate
collective action are interactional workability and relational
integration.352 These
involve cross-team co-operation,432 notably via enhanced communication;433,434 the development of shared goals, meanings and
expectations;435 and
accountability and confidence in the internal and external credibility
fostered by mandated local and national monitoring of 1000
Lives+. Furthermore, given the explicit steps defined in each
discrete patient safety intervention, 1000 Lives+ represents a
valid and recognised practical aide memoire. In this way, the programme
helps to increase awareness of patient-related issues, procedures and
anticipated risks across functional health-care teams,436 including both public and population health
care.437
Other processes which facilitate collective action are skill-set workability
and contextual integration.352 Skill-set workability describes how work is divided up among
practitioners with different but complementary skills.353 For example, empirical investigation of the
WHOSSC, the focal intervention discussed in Chapter 7, supports the view that defined
allocation of work, where the assessment of intraoperative blood loss is
apportioned to surgeons, patient-specific airways management to the
anaesthesia team and sterility and equipment issues to nurses,438 enhances the performance of
the operating theatre team. However, such task definition does remain
susceptible to entrenched role boundaries and perceived surgical autonomy,
which may impact adversely on safety culture.439 Contextual integration, as the term
suggests, refers to the integration of 1000 Lives+ within a
social context and its interplay with extant structures and organisational
procedures. As May and Finch353 point out, integration may not be easy to achieve in some
contexts and will require collective effort from those involved.
Reflexive monitoring
Practices, even when established, demand reflexive monitoring to ensure
appropriate performance.338,353,440 Patterns of collective
action, and their outcomes, are therefore continuously evaluated by
participants in implementation processes, both formally and informally, and
with a greater or lesser degree of intensity depending on their interest and
involvement.353 The
normalisation of the 1000 Lives+ programme in day-to-day practice
is, therefore, dependent on institutional and professional work that defines
and organises the everyday understanding of 1000 Lives+, aligned
factors which promote or inhibit social actors’ appraisal of 1000
Lives+ and social actors’ collective investment in
its ongoing theorisation and refined understanding.353
Individual and collective reflection of actual practice against explicit and
more tacit norms, while central to the embedding of a practice,356,441–444 may differ markedly from formal governance
procedures and standards, in some cases giving rise to a façade of
legitimacy.85 Empirical
studies of patient safety have also highlighted the human barriers to
incident reporting, despite its central role in organisational learning and
the establishment of a stronger safety culture.412 In the following section, we seek to
examine the views and experiences of individuals and groups during the
institutionalisation of the 1000 Lives+ programme, and so to
understand the processes involved in the operationalisation, subversion or
reconstruction of its associated practices.
1000 Lives+, health-care practice and patient safety
During in-depth discussions with a wide range of health-care practitioners across
NHS Wales, we asked each participant to reflect on the notion of context. As set
out below, transcription 5:01 succinctly expresses the sense of context as
situated, demarcated by relational ties and distinct from that of the wider
organisation.
I think what is key, when you consider the way in which 1000
Lives+ is implemented, is consideration of context. [What do
mean by context?] The immediate area of its implementation and the people
involved. Look, you can work with one ward to implement it. They do it
there, and you can then spread it; but when you do spread it you have to
customise it to make it work for the people who are there – in that
new context. You can’t just pick up something developed in one area
of your organisation and assume it will fit into another without you, at
least, considering where they’re coming from! So, you can’t
really define organisational context – to implement, context has to
be kept really small – you work within that area, have a testing
period, and then spread and renew. That’s how it’s done. I
think that is key to a lot of what we can manage.
Associate Director, case site C2 (014); transcription
5:01
This perception is replicated throughout our discussions and subsequent analysis
of the implementation and operationalisation of 1000 Lives+. As one
respondent described, 1000 Lives+ has normalised in discrete pockets.
This has created disparity between adjacent wards within a given hospital case
site (transcription 5:02, below).
What I see is pockets of interests in 1000 Lives+. It’s
led by individuals who have cultivated a team around them and given them
work to do, so it’s being led by people who are enthusiastic or buy
into certain areas where their interests lie. But it’s not systemic:
there are good pockets in the organisation and areas that aren’t
reached – you can have wards on opposite sides of a corridor where
one’s engaged and the other isn’t. As a consequence,
it’s relying on enthusiasm rather than a systematic approach.
Sustainability at an organisational, corporate level is needed, so that
everything is aligned toward patient safety.
Executive Director, Workforce and Organisation Development, case site
G1 (012); transcription 5:02
Normalisation is, thus, restricted to those who perceive meaning in 1000
Lives+ owing to alignment with their beliefs, and whose cognitive
participation and commitment builds and co-ordinates the engagement of others.
This finding offers explanatory insight into the perceived failure of such
complex patient safety interventions168 and underscores Pawson’s iron law of evaluation: the
expected value of any net impact assessment of any large scale social program is
zero.241
Acknowledgement of the fragmented nature of its normalisation does not, however,
detract from the undeniable focus that 1000 Lives+ offers health-care
practitioners in NHS Wales. Those who value the initiative consider it as
something real and visible that they can use to help them to forward the cause
of patient safety (transcription 5.03, below).
Before 1000 Lives and 1000 Lives+ – before SPI [Safer
Patients Initiative] – people were saying: ‘we want to keep
patients safe, we don’t want to do them harm’. Well, of
course, that’s what we want to do, I mean, that’s a given.
But with patient safety now, we have the 1000 Lives+ logo, we
have information at the front of the hospital; there’s something you
can hang your hat on! It has real organisation! It’s not just some
nebulous patient safety concept. There’s somebody leading it, there
were newsletters, there are graphs so that you can see, you can see the
improvements that have been made. 1000 Lives+ is making it real,
I would say – not that it wasn’t real before – but,
you know, now it has something; it’s tangible, it’s all
coordinated, it’s centralised. So, say if somebody had a good idea
for improving patient safety, rather than saying: ‘shall I go to my
line manager? Well, they’re never any good, they’ll nod but
they won’t do anything, who else can I go to?’.
They’ve got someone you can go to! You’ve got the 1000
Lives+ patient safety group, and you just go on the intranet
and find out the relevant person, and you know they will take it seriously.
They may or may not be managing it but you know they will take it seriously
because that’s what they do – that’s the hat that
they wear – so they’re not trying to juggle between clinical
effectiveness, patient safety, and saving money. Patient safety
isn’t just something competing for their time, their skills and
resources. That is what 1000 Lives+ is: it starts and finishes
with patient safety.
Pharmacist, Antibiotics Medicines Management, case site D2
(020); transcription 5:03
Such coherence appears to resonate equally with patients and with the public
(transcription 5:04).
On the other hand, there is a sense that bureaucratic impatience may be hampering
the successful implementation of 1000 Lives+ across NHS Wales,
leaving some staff in its wake (transcription 5:05, below).
I think with 1000 Lives+ we have been pushed on to get on to the
next ones [improvement programmes] before it’s sort of embedded. For
example, the NEWS Score [National Early Warning Score] is not embedded,
it’s embedding.
Ward manager, case site C3 (T080); transcription
5:05
For instance, although aware of the 1000 Lives+ programme, some key
medical staff remain disengaged (transcriptions 5:06 and 5:07, below).
I’ve had doctors telling me that it’s, you know, not nonsense
but it’s one of those fads. So they’ve obviously made up
their mind they’re not going to pay any attention to 1000
Lives+ and it’s of no relevance to them. I think, as
with anything, you have people just being bloody minded for whatever
reason!
Associate Director, case site F1 (026); transcription
5:06
I think some consultants aren’t aware of 1000 Lives+. They
have it in their peripheral field. They are aware that it exists but it
doesn’t impact on their lives, and some think it’s probably
a good thing but it still doesn’t impact on their lives.
Consultant gastroenterologist, case site F1 (027);
transcription 5:07
The policy pacing and positioning of the 1000 Lives+ programme across
NHS Wales is, therefore, contributing to the fragmentation of its normalisation.
Unequal engagement with the resources offered by this patient safety
intervention further stymies progress, as its main adherents are those who are
involved in, and already agree with, the aspirations of the programme
(transcription 5:09, below).
I think with 1000 Lives+ they’re selling it to those
who’ve bought in – you know, the people who are designing
the programmes and delivering them – I think it’s important
to them. But whether staff in the NHS are really engaged, I don’t
know. I mean, here, and this is a small hospital, we don’t get all
doctors following the sticker initiative [antibiotic prescribing
guidelines]. Some do, some don’t: there’s always an excuse
not to do it, whether it’s too much work, too time-consuming,
whatever, they always have excuses. Another aspect to this, though, is the
rate of turnover. FP1–2s [junior doctors undertaking foundation
training] rotate so quickly, and they may not be within the same health
board, let alone hospital, so there’s little time for them to learn
the system before they’re off again. On the whole, it’s the
staff that don’t rotate that maintain the system against, or
despite, those who are just passing through.
Pharmacist, Antibiotics Medicines Management, case site B2
(001); transcription 5:09
The meaningful engagement of wider NHS staff is undeniably key to the
normalisation and sustainability 1000 Lives+. Specifically,
non-rotating staff are central, as they provide the contextual and relational
continuity necessary for coherence. This is the foundation the programme must
return to, and reinforce, to prevent the dissipation of its goals (transcription
5:10).
Model for Improvement, Plan-Do-Study-Act approach
The central role of the MI-PDSA approach, asserted in Putative
mechanisms fostering the normalisation of 1000
Lives+, is clearly evident in the study’s
participant health boards. This approach provides a recognised framework for
health-care practice change and feedback that, through the Improving Quality
Together website, benefits from institutional work via the ongoing support
of the 1000 Lives+ national programme (transcription 5:11, below,
and transcription 5:12).
The PDSA approach provides a framework for improvement but you still need
leadership, you need ideas and execution, so you’ve still got to
generate the will in the people that you’re working with first.
Then you’ve got to have change ideas that are based on evidence
and not just plucked out of the air – you actually have things
that have to be tested – and then you test them; you
don’t just assume they’ll work in practice. But the
approach gives people the freedom to test them, measure and learn from
the process. So, I think, if I was to say anything, it’s a
framework, and its helped teams to focus on a name, on a measure, that
will tell them whether or not they’re getting towards their aim,
and on a change that will hopefully help them to achieve that aim.
Welsh Government, policy lead (033); transcription 5:11
Transcription 5:13, below, describes the role of PDSA in building coherence,
cognitive participation and collective action to enable health-care staff to
design and deliver practice change.
The model for improvement [MI-PDSA], well it’s, it’s a
tried and tested approach, part of improvement science. Look,
traditionally we’ve gone: ‘here’s a problem;
here’s the solution’, and we’ve tried to fit the
problem to the solution even if it involves putting a square peg in a
round hole just get on and do it! And, for all sorts of reasons, people
don’t just get on and do it because, because things
aren’t fit for purpose. So the issue of using the model for
improvement is you enable people. You start from the very beginning, you
know – you expose the need – you properly measure and
identify the problem and enable people to understand that the problem
lies with them and that they can do something about it, which is quite
empowering. And then, obviously, you guide a solution, and some of those
solutions are their own, though most of the time we take an
evidence-based practice approach. We introduce them to the
evidence-based practice and the methodology – the improvement
methodology – so that they can go out and they can get started
straight away by having an idea, testing it on one patient one time, one
nurse, one doctor! It’s quick and easy, it doesn’t
require whole engagement of masses of staff, they can just go out and
gradually, gradually build and learn from those very small tests of
change and they can adapt existing material to make it fit for purpose.
We’ve got the methodology – it’s simple,
it’s safe – it requires little or no investment at the
beginning in terms of staff resource. There is strong leadership over
supporting all of these programmes, so that there is an accountability
route, so you can’t just go away and do nothing, there are lines
of accountability through local working, through direct and divisional
quality and safety meetings, and then through to the steering –
the 1000 Lives+ steering group – and the quality and
safety committee. But it’s simple, the methodology is simple,
it’s intuitive, logical, and it’s really enabling people
to develop and make the system do what is right to do, easy to do.
Associate Director, case site D1 (049); transcription
5:13
The inherent simplicity of the approach is viewed to aid its adoption and the
sense of local ownership and engagement that underpin its normalisation
across NHS Wales (transcriptions 5:14, 5:15 and 5:16). Moreover, as
illustrated in transcription 5:17, below, the MI-PDSA approach helps in
surfacing the need for improvement, and confidence in the efficacy of its
structured processes gives a sense of security that facilitates positive
small steps towards change.
Well, I think, fundamentally, it provides us with a focal point to get
around the table – to actually acknowledge there’s a
problem in the first place – and that we’ve got a
structure to follow that’s going to take us in the direction
towards solving it. That we might not necessarily solve it in the first
place – it might take a couple of times of going through the
process to resolve it – but it gives us that format to be able
to: it’s a building block to start to look at what the problem
is, within a structured way. And I think it’s something,
it’s almost like a baby’s dummy, I think it’s
something that we just, it’s almost a comfort blanket for
us.
Ward manager, case site G3 (084); transcription
5:17
This markedly positive stance places emphasis on the MI-PDSA’s
incremental approach to service development and the empowerment of staff
(transcription 5:18). However, two issues countervail: the potential for
misuse as an instrument of control (transcription 5:19), and disagreement
over the validity of the evidence base for the efficacy of the 1000
Lives+ programme (transcription 5:20, below).
1000 Lives+ programme team are, in the main, focused on
achieving practical, pragmatic activities across NHS Wales which seek to
generate service improvements and change. But in NHS Wales, on the other
side, you’ve got medical and other professionals – and
academics – who work to a completely different standard of
evidence in terms of rigorous knowledge-based scientific work: you know
how explicit medical or epidemiological statistical modelling is! So,
for them, the introduction of 1000 Lives+ is, well,
it’s completely counter-cultural. The reports that the 1000
Lives programme team were stating were the outcomes of the initial
programme, in terms of mortality statistics, well some view it all as
some political conspiracy that’s being sold to the NHS, and the
public – it’s spin, fluff, crap – it’s
not valid data, it’s not collected in a robust manner,
it’s flawed. Oh God: please save me from the tyranny of
evidence! [What do you mean by the tyranny of evidence?] It’s a
killer phrase, isn’t it, in fact it’s the killer phrase.
[What do you mean?] It’s used by professionals in health care to
stop action, to destroy the potential for change: ‘Oh, we
can’t do that, the evidence-base is too weak; their argument is
flawed, the data’s mismanaged’. [Anything to maintain
the status quo?] Status quo ante! The evidence-based for the 1000
Lives+ national programme has been systematically
attacked by the other factions – for one side, it’s
evidence and truth; for the other, it’s spin and fluff –
and reality is caught in the middle.
Policy lead, Welsh Government (081); transcription 5:20
Board leadership, followership and change
Executive-level leadership of patient safety augments the normalisation of
the 1000 Lives+ programme in NHS Wales (transcription 5:21,
below).
If the job of the Executive Team is not about patient safety –
organisational fitness, systems, processes, governance structures
– then I don’t understand the job!
Executive Director, Workforce and Organisation Development, case
site G1 (012); transcription 5:21
Beyond the board, there is acknowledgement of the need for leaders with
expertise in quality improvement methodology to support staff and maintain
their commitment to patient safety (transcription 5:22, below). Such roles
are, therefore, pivotal for the successful transition of the ownership of
the patient safety agenda from the 1000 Lives+ programme team to
the health board.
My reflection on the PDSA process and instruction is, as a methodology,
it’s a very good one. The problem with regards to its
application is that you need somebody who is a PDSA expert within the
organisation – a leader and change management mentor who can
support the various mini-collaboratives with quality improvement
methodology – to harness what people are doing.
Associate Director, case site F1 (026); transcription
5:22
However, some respondents indicated a degree of resentment about the
obligatory nature of the 1000 Lives+ programme and suggested that
such commands to engage may be left unheeded (transcriptions 5:23, and 5:24
below).
The 1000 Lives+ national programme and the campaign –
it’s command and control rather than a grass-roots culture
change – it hasn’t been created by the people.
It’s not of the people. It’s an imposition. It’s
control. It’s from Cardiff. It’s very much a Cardiff
thing that is being pushed to everyone else because: ‘we know
better’. Outside Cardiff, it feels remote and distant and not
part of us, it’s something that we all recognise as important,
clearly, but we don’t necessarily own it.
Consultant gastroenterologist, case site F1 (T027);
transcription 5:24
There was a widespread belief that effective board leadership of patient
safety is paramount (transcriptions 5:25 and 5:26) but the importance of
clinical leadership of patient safety throughout the organisation, so
directing teamwork, communication and collaboration to deliver the desired
practice change, was also emphasised (transcription 5:27, below).
Clinical leadership is key – credible clinical leadership
– and that’s all about empowerment of band 7 nurses.
When we’re in escalation, when beds are crazy, that’s
when it’s hard. It’s then you need your band 7 nurses to
turn around and tell you what isn’t safe. That’s
something we’re working really hard at but that’s a
whole culture change. But the 1000 Lives+ PDSA cycles did
give them a feeling of empowerment that they could make and own changes,
they could take chances in the way that suited their ward or theatre or
wherever they were doing it: it wasn’t that we were telling them
how to do it, it was about them trying it and seeing how it worked, and
changing it until it did work in their area. So, I think that they, the
areas that did feel empowered through 1000 Lives+, combined
with the data that they were collecting, well they knew whether they
were doing something good or not, and those two things would motivate
change.
Associate Director, case site A2 (T069); transcription
5:27
Teamwork, collaboration and emancipation
For health-care practitioners who have invested meaning in the 1000
Lives+ programme, and who adhere to its practices, the
programme functions as a rallying point, building collective action and
ensuing teamwork. This aids collaboration and communication across different
areas of the employing health board and represents an important aspect of
the institutional maintenance work that helps to reproduce the norms and
beliefs inherent to 1000 Lives+ (transcription 5:28, below, and
transcription 5:29).
There are other nurse managers and practice development nurses within the
organisation that I tend to work with quite closely. For example, with
my colleague in surgery, we delivery similar sort of teaching about 1000
Lives+, so we link up and deliver sessions together. That
way we could pull staff from both of our Directorates, increase numbers,
and it’s easier when you’ve got someone else there. We
also meet as a group four times a year, so any development and training
needs, and that kind of thing, can be discussed and we can agree how
things may be taken forward. I know certain of my colleagues were very
heavily involved with the SPI [Safer Patients Initiative] work and the
first phase of 1000 Lives – they delivered all the corporate
training around the PDSA methodology and that type of thing.
They’re good contacts to have!
Ward manager, case site D1 (T010); transcription
5:28
In teamwork situations, the 1000 Lives+ programme is perceived to
empower health-care staff in roles traditionally subordinate to the
profession of medicine. The emancipation of these staff helps to break down
the entrenched barriers that prohibit challenge and scope for change
(transcription 5:30, below).
1000 Lives+ gives them [nursing staff] the freedom to
question, which they might not previously have had the confidence to do,
as it gives them a format to do it and it’s standardised. Also,
you get less challenge back when you are questioning something because
everybody here’s been exposed to 1000 Lives+.
Theatre manager, case site A1 (T008); transcription
5:30
Empowerment and engagement with others similarly motivated by 1000
Lives+ is seen to have led to patient safety improvements
(transcription 5:31). However, there is a view that the latent potential of
staff is yet to be realised in NHS Wales (transcription 5:32, below).
I think the key to the next step is, if you like, taking the stabilisers
off the bike. 1000 Lives+ has supported staff to do specific
projects and that has enabled them to have the confidence to say:
‘this is why, and this is how we’re going to do
it’. The next step is: ‘this is my idea, and this is
what I want to do’. But how is that picked up and supported by
the organisation when it’s not an external prompt is the
question. I think the NHS is quite bad at thinking about change normally
because we’re reeling from it being imposed.
Associate Director, case site G1 (T011); transcription
5:32
Building the ethos of patient safety: pride and shame in health-care
practice
During discussions with the wide range of health-care practitioners
interviewed across NHS Wales, the 1000 Lives+ programme appeared
to be aligned with feelings of both pride and shame in health-care
practice.
On the one hand, a strong sense of achievement is depicted in transcriptions
5:33 and 5:34 (below) and highlights the reinforcing role of individual
reflexive monitoring – and objective success – in fostering
meaningful engagement.
Our last pressure ulcer was approximately – we’ve had two
in the last three and a half years – we’ve got a very
good record. I’m so proud of our record on pressure ulcer
prevention. We have nurses, now, who’ve never seen pressure
ulcers. I’m really proud of it. I have this massive thing about
pressure ulcers; I have a zero tolerance of them!
Nurse manager, case site A2 (T058); transcription
5:33
If you’ve had 300 days free of MRSA [meticillin-resistant
Staphylococcus aureus], C. diff. [Clostridium difficile] or pressure
ulcers in this organisation, it is celebrated with cake! I think, maybe
a few years ago, I might have been: ‘that’s a bit
gimmicky’ but, actually, the feedback from staff and patients is
really positive, and we make sure that patients are involved in that
celebration. So, we’ll do media, some publicity around it as
well, there’s always features in our local press about a team,
ward or department that’s working particularly well. I think
that’s positive for our organisation but actually it’s
positive from a public perspective because it gives some confidence in
the service. Too often bad news is good news, isn’t it?
Associate Director, case site A1 (T025); transcription
5:34
Indeed, receiving praise for their efforts is seen as central to
staff’s continued motivation and commitment to 1000
Lives+ (transcription 5:35).
This positive stance is, however, balanced by the use of blame and shame,
prompted via the reporting mechanisms inherent to its governance structures
across NHS Wales (transcription 5:36).
Another respondent spoke of the ‘desensitising’ effect of
being perceived to fail, suggesting that this led to an exaggerated
determination not to go beyond the strict parameters of their current task
(transcription 5:37, below).
Rather than bad practice being done, there are less opportunities for
good practice. People are becoming desensitised by public perceptions of
failure. It is normal, now, to sit next to a phone and not answer it
because it isn’t going to be for you, and you’re going
to be interrupted from your job. The nurse is in a tabard saying do not
disturb me on my drug round; that’s wonderful, but
you’ve got three consultants doing their ward round too! In the
good old days, a sister or staff nurse would come round with me. Now,
I’ve got to try and find a nurse and all you get is:
‘it’s not my bay, I’m sorry, I’m on Bay
B’, so they don’t know the patient – how many
nurses does it take to change a light bulb? Oh sorry, that light bulb
isn’t in my bay – it’s that compartmentalised.
The sisters have got an awful time; they’ve got, they’re
getting kind of beaten at all ends. The number of staff you have on the
wards – the ratio of nurses to patients has gone down –
apparently, there’s some paper which says that’s safe
but then there’s all the other things as well. I think
that’s, you know, that’s the concern.
Consultant, palliative medicine, case site A1 (T052);
transcription 5:37
In addition, for those who welcome the new emphasis on patient safety and
take a pride in adhering to the precepts of 1000 Lives+, there
may be a deep sense of shame when failures in patient safety do occur
(transcription 5:38, below).
So, with 1000 Lives+ we thought we’ve cracked it,
it’s done! But I was walking out of the ward one evening at
about 9 o’clock at night, and we have, always on our ward, we
have a policy of putting our safety crosses in the public area. So, I
was walking out of the ward and I saw this red square on the pressure
ulcer monitoring, and I said to myself: ‘some idiot’s
made a mistake on the safety cross’. I went back into the ward
and they said: ‘no, actually, we’ve had a pressure
ulcer’, and we all wanted to cut our wrists, really, it was a
very depressing moment.
Consultant surgeon, case site B1 (T062); transcription
5:38
The ethos of care stimulated by the 1000 Lives+ programme is,
therefore, constrained by the fragmented nature of its normalisation. As
expressed in transcription 5:39, and more so in transcription 5:40 below,
there is a profound disjuncture. For some, 1000 Lives+ and its
associated MI-PDSA approach have been actively embraced, resulting in its
progressive normalisation: 1000 Lives+ is, therefore,
absorbed into daily practice. Yet for others, although
its mandated nature enforces engagement, this has been resisted: 1000
Lives+ is, therefore, only adsorbed onto
(i.e. there is token commitment only and it is not properly integrated)
daily practice – and, in this transitional state, it may fail to
institutionalise across NHS Wales.
Sometimes it can feel we’re doing 1000 Lives+ for the
sake of 1000 Lives+! Well because, you know, people
don’t necessarily see their mini-collaborative within the
context of the overall quality improvement, patient safety improvement
– reducing waste, variation, and harm from the policy
perspective – and I don’t think as an organisation
we’ve been very good at placing those mini-collaboratives within
the context of the overall quality improvement and patient safety
improvement agenda. I think that’s why – it just
sometimes feels like one of those stand alone things that people do
– and, I think, we’ve lost a trick.
Associate Director, case site F1 (T026); transcription
5:40
1000 Lives+ institutionalisation: elaborated understanding of
local implementation
Previously, in Chapter 4,
we set out our analysis of the bureaucratisation of 1000 Lives+
programme across the higher levels of context, thereby defining our preliminary
understanding of the local implementation of 1000 Lives+. Building on
the findings presented in this chapter, we now seek to integrate the role of the
mechanisms that appear to be involved in the normalisation of the 1000
Lives+ programme at lower levels of context.
demonstrates
three ways in which existing institutional logics, or the collective beliefs and
value systems of those involved, may affect the outcomes of an intervention.
First, where logics are not aligned, the intervention may be opposed, with
people deliberately seeking to maintain existing and habitual practices, and
actively challenging attempts to impose new ways of working. Second, where
institutional logics co-exist, while they may not actively reject, people may
nonetheless ignore or give little thought or attention to the imposed changes.
While this may lead to apparent revision of practice, because people’s
values and belief systems have not been changed it is likely that if the
coercive element is removed practice will revert to the status quo ante. Hence
implementation of an intervention can be effective only when beliefs and value
systems are aligned within a particular context, as shown in the third element
of . In these
circumstances, coherence, cognitive participation and reflexive monitoring of
the desired institutional change are fostered and new procedures are absorbed
into daily practice and become routinised over time.
Normalisation of 1000 Lives+: heterarchical meta-mechanism
operating across contextual strata.
:
key point summary
In we
depict the mechanisms that foster normalisation – coherence,
cognitive participation and reflexive monitoring – and set out
the impact on the alignment of institutional logics, as expanded
below.
In point 1, institutional logics are not aligned, limiting the potential
for coherence. In such a scenario the desired institutional change is
resisted, habituated practices continue and attempts to impose change
are challenged.
Under these situated contextual conditions, mechanisms to
generate change, although operational, are ineffectual.
In point 2, institutional logics co-exist without fostering
contradistinction and conflict. However, in this scenario, the potential
for coherence to manifest is limited owing to inattention. Accordingly,
cognitive participation and reflexive monitoring do not occur and
people’s beliefs and values are not revised. A fragile
normalisation occurs, through which the mandated institutional change is
compulsorily imposed onto, but not into, daily practice. However, if
such forces are removed, the desired institutional change may revert to
the status quo ante.
Under these situated contextual conditions, such generative
mechanisms, though operational, are limited.
In contrast, in point 3, the alignment of institutional logics is
complementary. This, we assert, fosters coherence, cognitive
participation and reflexive monitoring of the desired institutional
change, and new practices are absorbed into daily practice.
Under these situated contextual conditions such generative
mechanisms catalyse the desired institutional change and
facilitate the evolution of health-care practice. Furthermore,
such sites act as foci for change through normative and mimetic
isomorphic institutionalism (processes of imitation and
normalisation) and will gradually influence change in initially
less receptive areas (see points 4 and 5).
Importantly, as explored in later figures, such generative mechanisms are
modulated by the relational structures within the situated context,
specifically by the interplay of local leadership, team working and
encultured values.
It is from such environments, which function as foci for change, that areas
initially less receptive to the proposed changes may be gradually recruited
through processes of imitation and normalisation.
sets out
aligned transcription dyads showing divergent stances to normalisation. These
reveal the impact of coherence, cognitive participation, collective action and
reflexive monitoring in a situated health-care context.
Intervention–context–mechanism–agency–outcome
configuration: interpersonal relations.
– portray the institutional change driven by the
bureaucratisation of 1000 Lives+. Our discussion considers three
examples of processes involved in the normalisation of the 1000
Lives+ programme: (1) legitimisation, (2) formalisation and (3)
innovation.
Normalisation of the 1000 Lives+ heterarchical metamechanism
operating across contextual strata: legitimisation.
Normalisation of the 1000 Lives+ heterarchical metamechanism
operating across contextual strata: innovation.
:
key point summary
In we
depict the legitimisation of the 1000 Lives+ national
programme across the Welsh health-care institutional field, centred on
lower contextual strata at health board, hospital multisite department,
hospital site-based ward and individual levels.
In point 1, in situated contexts where logics are in alignment:
Agency – legitimisation – elite institutional
actors and co-opted others embrace 1000 Lives+ and
MI-PDSA approach and embed in health-care policy and performance
frameworks.
Institutional work – creation – elite
institutional actors enact political work to reconstruct rules,
rights and access to resources, thereby linking 1000
Lives+ national programme to tier 1 performance
targets.
In point 2, in situated contexts where logics are in alignment:
Agency – legitimisation – 1000 Lives+
becomes part of the language and positioned-practices of patient
safety in NHS Wales, fostering collaboration and systemic
challenge among institutional entrepreneurs who reassert a new
normative standard to precipitate practice-based change.
Institutional work – creation – elite board-level
institutional actors enact political work to reconstruct rules,
rights and access to resources, thereby linking 1000
Lives+ national programme to the attainment of
the Welsh Government’s tier 1 performance targets.
In point 3, in situated contexts where logics are in alignment:
Agency – legitimisation (moral/pragmatic) – 1000
Lives+ moral and pragmatic legitimacy fosters
mainstreaming of the intervention across NHS Wales.
Institutional work – creation – functional
team’s belief and meaning systems reconfigured.
In point 4, the impact of co-existent or countervailing institutional
logics is depicted as corrosive feedback that challenges legitimisation
and, therefore, normalisation.
:
key point summary
In we
depict the formalisation of the 1000 Lives+ national
programme across the Welsh health-care institutional field, centred on
lower contextual strata at health board, hospital multisite department,
hospital site-based ward and individual levels.
In point 1, in situated contexts where logics are in alignment:
Agency – formalisation – mandated engagement with
1000 Lives+ and the MI-PDSA approach to address NHS
Wales’ organisational failings and attain national
health-care standards.
Institutional work – creation – elite
institutional carriers enact political work to reconstruct
rules, rights and access to resources, thereby linking 1000
Lives+ national programme to tier 1 performance
targets.
In point 2, in situated contexts where logics are in alignment:
Agency – formalisation – multiprofessional and
multisite co-ordination of patient safety via the statutory
Quality and Safety Committee and aligned governance
structures.
Institutional work – creation – elite board-level
institutional actors enact political work to reconstruct rules,
rights and access to resources, thereby linking 1000
Lives+ national programme to the attainment of
the Welsh Government’s tier 1 performance targets.
In point 3, the impact of co-existent or countervailing institutional
logics is depicted as corrosive feedback. However, this is insufficient
to over-ride mandated performance management and governance
processes.
Normalisation of the 1000 Lives+ heterarchical metamechanism
operating across contextual strata: formalisation.
:
key point summary
In we
depict innovation catalysed by the 1000 Lives+ national
programme across the Welsh health-care institutional field, centred on
lower contextual strata at health board, hospital multisite department,
hospital site-based ward and individual levels.
In point 1, in situated contexts where logics are in alignment:
Agency – innovation – individual and
organisational pragmatic evidence-based learning manifests
through adherence to the MI-PDSA approach.
Institutional work – creation – functional
team’s belief and meaning systems reconfigured.
In point 2, the impact of complementary institutional logics is depicted
as positive feedback that supports the formalisation of evidence-based
innovation across NHS Wales.
In point 3, the impact of co-existent or countervailing institutional
logics is depicted as corrosive feedback.
1. Legitimisation:
,
transcriptions 5:02 and 5:24 and show how legitimisation is modulated. In
transcription 5:02 (see 1000 Lives+,
health-care practice and patient safety), complementarity
between bureaucratic state, professional and collaborative logics results in
perceptions of coherence with 1000 Lives+. However, the ensuing
cognitive participation of those who ‘buy into certain areas where their
interests lie’ promotes contained collective action, directed to deliver
the aligned vested interests of those who occupy the orchestrating leadership
position in this situated context.
In contrast, transcription 5:24 (see Building the ethos of patient
safety: pride and shame in health-care practice) depicts the overt
rejection of the dominant logic of the bureaucratic state. Professional logic
is, therefore, shifted from its subordinate role into an ascendant position.
Given the contradiction between these co-existent logics, theorisation prevents
coherence from developing. This inhibits cognitive participation and collective
action. As a result, 1000 Lives+ is viewed as ‘not part of
us’. In this context, decoupling from the national programme arises.
2. Formalisation:
,
and
transcription 5:29 (see reference in Teamwork, collaboration and
emancipation) suggest that formalisation is modulated by
complementarity between bureaucratic state, professional and collaborative
logics. This promotes adherence to the governance structures which support the
1000 Lives+ national programme. However, the subtleties of
individuals’ reasoning and use of the resources provided by 1000
Lives+ are exposed in transcription 5:36 (see reference in
Building the ethos of patient safety: pride and shame in health-care
practice). Although no overt rejection of the dominant logic of the
bureaucratic state is expressed, professional logic and collaborative logic are
not held in a complementary stance. Instead, they occupy a co-existent stance
that fosters professional protection and a lack of collaboration. In this
context, coupling to the governance structures that support 1000
Lives+ is fragile.
3. Innovation:
,
and
transcriptions 5:13 and 5:20 demonstrate how innovation is modulated, while
transcription 5:13 (see Model for improvement and PDSA
approach) illustrates the nuances of normalisation. Once again, the
logic of the bureaucratic state is embraced and held in close alignment with
professional and collaborative logics. This promotes strong coherence with the
1000 Lives+ national programme – ’The model for
improvement [MI-PDSA], well it’s, it’s a tried and tested
approach, part of improvement science’ – resulting in the
cognitive participation, collective action and reflexive monitoring of
health-care staff who ‘can go out and they can get started straight away
by having an idea, testing it on one patient one time, one nurse, one
doctor!’. In contrast, transcription 5:20 (see Model for
improvement and PDSA approach) highlights a profound disjuncture
between the logic of the bureaucratic state and one facet of medical
professional logic – the contestation between care and science373 – that stymies
engagement with 1000 Lives+ owing to disagreement over the validity
of the evidence base: what the respondent in this transcription calls the
‘tyranny of evidence’. This fundamental discord impacts on
theorisation. It limits coherence and erodes the means for meaningful engagement
with 1000 Lives+. As a result, normalisation and, thus,
institutionalisation are hampered.
We suggest that the mechanisms that appear to foster normalisation modulate the
processes of bureaucratisation through amplification of the complementarity or
contradiction between logics in the institutional field. However, of those
considered – coherence, cognitive participation, collective action and
reflexive monitoring – only three are seen as generative mechanisms
(coherence, cognitive participation and reflexive monitoring), while collective
action is simply an outcome of such reflexive theorisation and, thus, an
expression of agency.
In the next chapter we examine and develop I-CMAO configurations for three focal
interventions from the 1000 Lives+ programme using theories of
structure, agency and social change.
