Adapt Monitor work-as-done and adapt to achieve sustainable change
Organisations should adopt a systems approach and avoid searching for blame. Systems thinking means recommendations for improvement should focus on system change and design, not individual performance.
What the data said: Events other than adverse events and incidents, which might provide opportunities for useful learning
- Patient feedback about their experience, e.g., being confused about where to go or struggling with physical access
- Patient behaviours that indicate potential problems with engaging with the community diagnostic service, e.g., appointment booking and did not attend (DNA)
- Staff behaviours that highlight discrepancies between procedures / protocols and the realities of work, e.g., staff having to rely on high DNA rate to complete paperwork
- Staff feeding back concerns, e.g., security, lack of availability of equipment, multi-tasking and excessive workload