Shine 2012
Application form
Please read before completing the form
Before completing this application form please ensure that you have read the Guidance
Notes and the Call for Proposals where the selection criteria are outlined.
Please complete the document in a font of at least 11pt. Please do not exceed the
maximum limit of 5,000 words.
Please email your completed application form and budget to
applications@health.org.uk (in Word and Excel format respectively) with the following
filename:


Application form: Lead organisation name - Lead contact name.doc
Budget: Lead organisation name - Lead contact name.xls
The subject line of the email should be: Shine 2012 application. No hard copy is
required.
The deadline for receiving applications is 12.00 noon 17 July 2012. Late
applications will not be considered eligible and therefore will not be reviewed.
The application form has been designed to give assessors all the information they need
to review your proposal; please do not attach supplementary information. We will not
read attachments we have not requested.
Please send any questions you may have to shine@health.org.uk
1. Summary
This section provides the Health Foundation and assessors with key information about
your project at a glance.
1.1 Lead organisation
Organisation name
NHS Education for Scotland (NES)
Type of organisation Special Health Authority
Registered address 2nd Floor, Hanover Buildings
66 Rose Street
Edinburgh
EH2 2NN
The application should be led by the organisation where the innovation is being tested.
This is also the organisation with whom we will contract should the proposal be
successful. This organisation will receive the funding from the Health Foundation and will
be expected to manage the budget and distribute it among the partner organisations
through local agreements as required. Please tell us what type of organisation this is, for
example a voluntary organisation or NHS body.
1.2 Primary contact for this proposal
Full name and title
Dr Paul Bowie
Job title
R&D Lead for Safety & Improvement
Office/contact address
NHS Education for Scotland, 2 Central Quay, 89 Hydepark
Street, Glasgow, UK G3 8BW
Email
paul.bowie@nes.scot.nhs.uk
Telephone
0141 223 1463
Alternative contact name Mrs June Morrison
( e.g. PA) if applicable
Alternative contact email june.morrison@nes.scot.nhs.uk
Alternative contact
0141 223 1450
telephone number
You should name a person from within the lead organisation who will be the project’s
primary contact. This should be the person whom the Health Foundation can contact if
we require further information or clarification throughout the assessment period and
preferably the duration of the project.
1.3 Project title
*Addressing the emotional barriers hindering the constructive investigation of
patient safety incidents and promoting a human factors framework to facilitate indepth analysis in primary care
Please indicate a title that briefly explains the overall aims of your project (25 words
maximum).
*We are aware from the teleconference call that the Health Foundation may give greater
priority to innovative safety improvement ideas which are more ‘proactive’ than ‘reactive’
in nature. However, we would argue strongly that important socio-cultural and
behavioural step changes are necessary before many health care professionals feel
empowered enough to proactively engage in patient safety initiatives (rather than react –
if at all, or to a sub-optimal standard – when something goes wrong). For most
clinicians, their first (and possibly only) interaction in learning from error and systemsfailure will be via team-based educational techniques such as significant event analysis.
However, there are numerous deep-seated problems involving diverse but interrelated
factors such as the NHS blame culture, individual emotional reactions to disclosure of
incidents and the subsequent standard of incident investigations which need to be the
focus of improvement efforts before clinicians are psychologically ready to take the next
step and engage more explicitly and proactively with the patient safety agenda.
1.4 Abstract
The problem
The limited evidence base suggests that between 1 and 2% of clinical consultations with
patients in primary care may contain an adverse event (The Health Foundation, 2011a).
Given that there are around 1 million consultations in UK primary care every day, it is clear
that the potential scale of the problem is of great concern to all.
However, there is strong evidence to suggest that many team-based investigations into
patient safety incidents in primary care are poorly conducted (McKay et al, 2009; Bowie et
al, 2008). Two key issues contribute.
First, the emotional reaction to negative feedback can interfere with the ability to assimilate
and process the information beyond the ‘self’ level (Kluger & De Nisi, 1996) and thereby
potentially impede an objective and constructive approach to patient safety incidents. We
also know that primary care clinicians are highly selective in the types of safety incidents
they highlight for team-based discussion and analysis (Bowie et al, 2005a).
Second, practitioners lack a structured analytical framework that can be used by primary
care teams when analysing patent safety incidents. Although there is strong engagement
with SEA in primary care, the evidence for its impact on improving the quality and safety of
patient care is limited. There is now good evidence to suggest that the standard of
reflection and critical analyses of such events is poor in a substantial proportion of SEAs
undertaken by primary healthcare teams with most lacking a necessary understanding of
the human and systems-based factors underpinning these incidents. While basic guidance
has been published, a theory-informed framework to strengthen and guide the processes
by which healthcare professionals can analyse patient safety incidents more effectively is
clearly lacking.
Consequently there are multiple implications associated with what is highly likely to be a
routine everyday occurrence in UK primary care settings, including: numerous missed
opportunities for individual, team-based and wider organisational learning from patient
safety incidents to minimise the risks of recurrence; wasted time, efforts and financial
resources associated with participating in (frequently predictable) sub-optimal learning and
improvement efforts; the impact on stress and sickness levels amongst the primary care
workforce, not least of which is the longer term impact on the psychological well being of
healthcare professionals (Sirriyey et al, 2010); and the chance to increase patient
involvement in safety issues directly affecting them and, paradoxically, enhance patient
satisfaction with experience of care.
The proposed solution
Our own extensive experiences, supported by the limited evidence base (Sirriyey et al,
2010; Scott et al, 2009; O’Beirne et al, 2012; Wu & Steckelberg, 2012), suggests a
pressing need for an innovative educational intervention that can provide a structured,
meaningful way for clinicians (undergoing training and trained) to disclose their errors and
to forestall any negative emotional barriers and impacts in subsequent interactions with
healthcare colleagues, which are often critical to the personal coping process and the
standard of subsequent incident analyses by the care team.
We propose, therefore, to design, develop and validate a ‘guiding tool’ to enable the
individual clinician to:
1. Reflect upon and become more aware of the emotional reaction and psychological
consequences associated with being part of a patient safety incident in order to
achieve a state of emotional and psychological readiness to move on to the next
stages – task and process levels
2. Raise awareness of the psychological barriers which operate when approaching a
team-based investigation of a patient safety incident.
3. Undertake the analysis of a patient safety incident within the team by applying a
human factors-based framework to differentiate the personal/individual and system
levels issues at play (adapted from Flin et al, 2010 and Moray 2001).
The expected benefits and outcomes
1. The Patient
 Improved analyses of patient safety incidents will inform more effective change and
improvement and reduce risks of harm to patients
 Increased patient engagement will improve experience and satisfaction with the
care process as a result of more explicit involvement by being made aware of an
incident investigation and receiving a summary of the final learning report
2. The Individual Practitioner
 Redress of the blame culture will be achieved by redirecting perceptions of solely
personal emotional experiences of liability/fault to a more objective systems-based
approach based on human factors principles
 Deeper insight into the emotional response to dealing with patient safety incidents
(whether directly involved or not), will engender increased understanding and
empathy and the need to provide professional reaffirmation and personal
reassurance to colleagues
3. The Healthcare Team
 Improved team dynamics will be acquired through having a positive empathic
understanding of the psychological barriers affecting individuals involved in patient
safety incidents and will prompt a standardised and more constructive and
meaningful team-based investigation and analysis
4. The Organisation
 Improved interface discussion will facilitate shared learning
 A human factors approach by definition prompts an organisational level response -


where appropriate this should impact learning and policy at a strategic level
The concept of human factors will be imbued across the organisation by
demonstrating its practical application to clinical care
Improved sharing of incidents offers the potential to improve organisational level
data via enhanced engagement in incident reporting systems
Provide a summary of your project in plain English. This summary should enable a nonexpert to understand how the innovative proposal will improve quality and demonstrate
an understanding of the costs and benefits associated with the intervention. You should
use the headings in the text box.
REFERENCES
Bowie P, Pope L & Lough M (2008). A review of the current evidence base for significant event
analysis. Journal of Evaluation in Clinical Practice 14 (4): 520-536
Bowie P, Halley L, Gillies J, Houston N & de Wet C (2012). Searching primary care records for
predefined triggers may expose latent risks and adverse events. Clinical Risk 18:13—18;
doi:10.1258/cr.2012.011055
Bowie P, McKay J, Dalgetty E, Lough M (2005a). A qualitative study of why general practitioners
may participate in significant event analysis and educational peer review. Quality & Safety in
Health Care 14: 185-189
Bowie P, McCoy S, McKay J, Lough M (2005b). Learning issues raised by the educational peer
review of significant event analyses in general practice. Quality in Primary Care 13: 75-84
Cox S J & Holden J D (2007). A retrospective review of significant events reported in one
district in 2004–2005. Br J Gen Pract. 1; 57(542): 732–736.
Blamey, A., and Mackenzie, M. (2007). Theories of change and realistic evaluation: peas in a pod
or apples and oranges? Evaluation, 13 (4). pp. 439-455. (doi:10.1177/1356389007082129)
Bradley N, Power A, Hesselgreaves H, McMillan F and Bowie P (2009). Safer pharmacy
practice: a preliminary study of significant event analysis and peer feedback. International Journal
of Pharmacy Practice 17: 283–291.
De Wet & Bowie P (2011). Screening electronic patient records for preventable harm: a trigger
tool for primary care. Quality in Primary Care 19:115-25
De Wet C & Bowie P (2009). A preliminary study to develop and test a global trigger tool to
identify undetected error and patient harm in primary care records. Postgraduate Medical Journal
85 176-180
Flin R et al (2009). Human factors in patient safety: review of topics and tools. World Health
Organisation, Geneva.
Ginsburg L, Castel E, Tregunno D, et al (2012). The H-PEPSS: an instrument to measure health
professionals’ perceptions of patient safety competence at entry into practice. BMJ Qual Saf
(2012). doi:10.1136/bmjqs-2011-000601
Kluger AN, DeNisi A. (1996). Effects of feedback intervention on performance: A historical review,
a meta-analysis, and a preliminary feedback intervention theory. Psychol Bull 119(2):254-284.
McKay J, Bradley N, Lough M and Bowie P (2009). A review of significant events analysed in
general medical practice: implications for the quality and safety of patient care. BMC Family
Practice 10:61
Moray N (2000). Culture, politics and ergonomics. Ergonomics 43;868
O’Beirne M, P Sterlin, L Palacios-Derflingber, S Hobman & K Zwicker (2012). Emotional impact
of patient safety incidents on family physicians and their office staff. J Am Board Fam Med
25;177-183
The Health Foundation (2011a). Report: Improving Safety in Primary Care – Research Scan
(November 2011)
The Health Foundation (2011b). Report: Improvement Science - Research Scan (January 2011).
Pawson R & Tilley N (1997). Realistic Evaluation. London: Sage
Sargeant J, Mann K, Sinclair D, van der Vleuten C, Metsemakers J (2006). Understanding the
influence of emotions and reflection upon multi-source feedback acceptance and use. Advances
in Health Sciences Education DOI 10.1007/s10459-006-9039-x.
Sargeant J, Mann K, van der Vleuten C, Metsemakers J. Reflection (2009): A link between
receiving and using assessment feedback. Advances in Health Science Education Theory
Practice, 3: 399-410.
Sargeant J, McNaughton E, Mercer S, Murphy D, Sullivan P, Bruce D (2011). Providing
feedback: Exploring a model (Emotion, Content, Outcomes) for facilitating multisource feedback.
Medical Teacher 33(9):744-749.