High reliability and positive reporting
In our previous blog introducing this series we looked at the idea of health systems and organisations striving to become highly reliable to improve patient safety. One key aspect of high reliability is a preoccupation with failure, with organisations viewing errors and near misses as opportunities to learn and make improvements.
In discussing the role of culture in this, in our last video in this series Phil Taylor, Chief Product Officer, RLDatix and Helen Hughes, Chief Executive, Patient Safety Learning considered how incident reporting systems can only be effective when supported by a positive safety culture. They also discussed the essential role of learning, not just from when things go wrong, but also from success.
In this latest blog, we look at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety.
Positive reporting and learning from success
One notable example of peer-to-peer positive reporting in the UK is Learning from Excellence, established by Dr Adrian Plunkett (Consultant Paediatric Intensivist at Birmingham Children’s Hospital) in 2014.
In the Learning from Excellence programme, positive reporting is described as “a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting”.  It aims to draw on learning from examples of good practice, which may often be missed by the traditional focus on preventing harm by learning from error.  This can involve capturing examples of excellent clinical practice, highlighting situations where new learning has been implemented to improve care, or recognising the positive contributions of colleagues which have improved outcomes.
The system involves the use of simple reporting forms that provide an opportunity for peer-to-peer positive feedback. The Learning from Excellence approach emphasises the importance of keeping the data captured simple, quick, and easy to use for frontline staff.  These forms can include simple questions such as:
- Who achieved excellence?
- What did they do that was excellent?
- Name one thing we could do to develop excellence in this area.
This has now been implemented in several different contexts, with one example being in Birmingham Children’s Hospital, where it was applied in relation to antimicrobial resistance.
Antimicrobial resistance occurs when bacteria and viruses change over time and no longer respond to medicines, making infections more difficult to treat and increasing the risk of disease spread and harm.  One of the key causes of this is exposure to antimicrobial therapy, a significant proportion of which is inappropriate, which has made reducing/optimising its use an important priority for the NHS in the UK. 
This project at Birmingham Children’s Hospital aimed to reduce antimicrobial consumption in a Paediatric Intensive Care Unit (PICU), where “an estimated 40-80% of patients in the PICU receive antimicrobials”.  This project aimed to use the positive feedback processes inspired by Learning from Excellence to encourage antimicrobial stewardship good practice, reducing antimicrobial consumption rates. It was judged to be a helpful quality improvement intervention, with findings suggesting that this supported a reduction in total antimicrobial consumption, reinforcing good practice through positive reporting.
How positive reporting relates to high reliability
There is a balance to be struck between the use of positive reporting and more traditional incident reporting of error and harm. They can both contribute to the creation of a safety culture focused on learning and improvement, a key underpinning for any high reliability organisation. Combined, they can serve to widen the range of events used to gain insights and learning, rather than focusing on a small set of incidents that result in failure.
The use of both incident reporting and positive reporting in healthcare also links into the wider patient safety discussion about the Safety-I and Safety-II approaches.  Safety-I is the more traditional approach to safety management, identifying and responding to errors and where harm has occurred. Safety-II refers to taking a broader approach, emphasising the need to consider all aspects of the system and how it works. Positive reporting can be seen as one means by which to move towards a Safety-II approach, not focusing solely on error when considering patient safety.
Positive reporting can also provide an important means of improving morale and staff wellbeing, supporting the recognition and celebration of good practice that can then be shared more widely. There is strong evidence that staff learn and perform more effectively and safely when there is positive feedback on performance. 
This can be powerful when celebrating where lessons learnt that have improved outcomes, illustrating the value of reporting processes, fundamental to developing a learning organisation. As mentioned earlier, in their previous video conversation Helen Hughes and Phil Taylor discussed the role that positive reporting can play in helping to reinforce a safety culture in healthcare organisations, key to achieving high reliability. Providing avenues for staff to share and highlight areas where good practice results in improved outcomes may help to do this by reinforcing the value of reporting, clearly demonstrating how the organisation uses this to inform and make changes.
Many existing case studies are focused on the implementation of this approach in teams or specific departments. If adopted more widely, this can then be opened up to further examination, for example considering the impact that a whole organisation adopting positive reporting across the board may have on patient safety outcomes.
Further reading and resources
Learning from excellence website: This features a number of resources explaining more about Learning from Excellence and support its implementation.
GREATix: Improving culture, wellbeing and patient safety through positive feedback: An interview with Ben Watson, a Strategy Implementation and Quality Improvement Manager in the Scottish Ambulance Service, talking about the development of a positive peer-to-peer feedback system in his trust.
NHS Education for Scotland: Safety Culture Discussion Cards. To help us think and talk about our Safety Culture, including reporting culture.
Getting It Right First Time: A national programme designed to improve the treatment and care of patients by reviewing health services.
Global Patient Safety Action Plan (Final Draft): Strategic Objective 2 – High reliability systems (pages 23-30)
 Learning from Excellence, Learning from Excellence: Start-up guide, Last Accessed 26 May 2021. https://learningfromexcellence.com/download/537/
 Adrian Plunkett and Emma Plunkett, Learning from excellence in healthcare, Hindsight 31, Winter 2020-21. https://www.skybrary.aero/bookshelf/books/5940.pdf
 Learning from Excellence, Learning from Excellence website, Last Accessed 20 April 2021. https://learningfromexcellence.com/about/
 World Health Organization, Antimicrobial resistance, 13 October 2020. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance#:~:text=What%20is%20antimicrobial%20resistance%3F,spread%2C%20severe%20illness%20and%20death.
 HM Government, Tackling antimicrobial resistance 2019-2024: The UK’s five year national action plan, 24 January 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/784894/UK_AMR_5_year_national_action_plan.pdf
 Alison S. Jones, Rhian E. Isaac, Katie L. Price, and Adrian Plunkett, Impact of positive feedback on antimicrobial stewardship in a paediatric intensive care unit: a quality improvement project. Paediatric Quality and Safety, 4(5), e206, 2019. https://journals.lww.com/pqs/Fulltext/2019/09000/Impact_of_Positive_Feedback_on_Antimicrobial.5.aspx
 Professor Erik Hollnagel, Professor Robert L Wears and Jeffrey Braithwaite, From Safety-I to Safety-II: A White Paper, 2015. https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf; Centre for Applied Resilience in Healthcare, Safety I and Safety II, Last Accessed 26 May 2021. https://resiliencecentre.org.uk/safety-i-and-safety-ii/
 Shmuel Ellis, Bernd Carette, Frederik Ansell and Filip Lievens, Systematic Reflection: Implications for Learning from Failures and Successes, 2014. https://journals.sagepub.com/doi/abs/10.1177/0963721413504106