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Herepath A, Kitchener M, Waring J. A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study. Southampton (UK): NIHR Journals Library; 2015 Sep. (Health Services and Delivery Research, No. 3.40.)
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A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study.
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This chapter continues our examination of the institutionalisation of the 1000 Lives+ patient safety programme in NHS Wales. Presented in three main parts, it is focused at contextual levels below the field level and explores interpersonal and individual engagement with 1000 Lives+ to gain a deeper understanding of its progressive normalisation across NHS Wales.
First, guided by the model proposed by May et al.,352,353 we analyse the patient safety literature to consider mechanisms that may foster the normalisation of complex interventions in daily health-care practice. Second, we enrich this explanatory analysis through consideration of in-depth discussions held with a wide range of health-care practitioners concerning their perceptions of the normalisation of 1000 Lives+ and the development of patient safety practices in NHS Wales. Specifically, we examine the 1000 Lives+ MI-PDSA approach, the distributed leadership and the teamwork inherent to its operationalisation. We then illustrate the nuanced impact of pride and shame in building the ethos of patient safety and examine the pragmatic issues that foster institutional coupling to, or decoupling from, such activities. Finally, we elaborate our understanding of the local implementation of the 1000 Lives+ programme. This forms the foundation for our analyses of the three focal interventions presented in Chapters 6–8.
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.
Figure 12 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 Figure 12. 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.
![FIGURE 12. Normalisation of 1000 Lives+: heterarchical meta-mechanism operating across contextual strata.](/books/NBK316550/bin/10-1007-06-fig12.gif)
FIGURE 12
Normalisation of 1000 Lives+: heterarchical meta-mechanism operating across contextual strata.
Figure 12: key point summary
In Figure 12 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.
Table 10 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.
TABLE 10
Intervention–context–mechanism–agency–outcome configuration: interpersonal relations.
Figures 13–15 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.
![FIGURE 13. Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: legitimisation.](/books/NBK316550/bin/10-1007-06-fig13.gif)
FIGURE 13
Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: legitimisation.
![FIGURE 15. Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: innovation.](/books/NBK316550/bin/10-1007-06-fig15.gif)
FIGURE 15
Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: innovation.
Figure 13: key point summary
In Figure 13 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.
Figure 14: key point summary
In Figure 14 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.
![FIGURE 14. Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: formalisation.](/books/NBK316550/bin/10-1007-06-fig14.gif)
FIGURE 14
Normalisation of the 1000 Lives+ heterarchical metamechanism operating across contextual strata: formalisation.
Figure 15: key point summary
In Figure 15 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: Table 10, transcriptions 5:02 and 5:24 and Figure 13 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: Table 10, Figure 14 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: Table 10, Figure 15 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.
Summary
In Chapter 5, we analysed the cultural change inherent to normalisation of the 1000 Lives+ programme at the level of the functional team. We explored the role of contextual constraints and enablements, and ensuing reflexive theorisation, across the dynamic interplay of multiple logics, and considered the modulating roles of coherence, cognitive participation and reflexive monitoring.
- Institutionalisation of the 1000 Lives+ programme in NHS Wales: normalisation, h...Institutionalisation of the 1000 Lives+ programme in NHS Wales: normalisation, health-care practices and patient safety - A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study
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