Event Blog: Safer Leadership Learning Session 3

Beginning in April 2016, Salford partners; Salford Clinical Commissioning Group, Salford City Council, Salford Royal NHS Foundation Trust, Greater Manchester West Mental Health NHS Foundation Trust, Salford Together and Haelo, embarked on an ambitious improvement programme to make Salford the safest health and social care system in the UK. Over the next 2 years, health and care partners across Salford will build on learning from the successful Making Safety Visible programme.

Safer Leadership developed and working with partners aims to inspire leaders across Salford to think and act differently to bring about city wide change. Changing how we think, so we can change how we act.

Using the Measurement and Monitoring of Safety Framework, leaders will be challenged to reframe their perception of safety by assessing the health and care system through three lenses, Past, Present and Future.

Follow our event blog for the latest updates and to access resources from the day. To join the conversation on Twitter use #SaferLeadership. Agenda available here.



And we’re off! Abigail Harrison, Director of Innovation at Haelo, opens up the final Safer Leadership Learning Session with a fantastic ice breaker using pennies. Choosing a penny, the tables talk about that year and that they achieved on that year.

Introducing the day with the Safer Salford animation, Abi highlights the other work streams making up Safer Salford and explores the relevance of the programme of work and it’s foundation in the Measurement and Monitoring of Safety Framework. Reviewing the key findings from the previous two learning sessions including the significance of data and the importance of culture, Abi recaps and brings us up to date:

Learning Session 3 is to focus on the future.


Abi now introduces Katharine Goldthorpe, Director of Improvement at Haelo, who joins the Learning Session to tell a personal story of how the use of data transformed the way she works. She cites a previous role in London where systems and processes weren’t working. Her role was managing paediatrics services with a complex population with dedicated clinicians who were through sheer workload on the verge of burning out. Katharine uses the example of complaints around safety issues at which she would be dealing with 8 at any one time. The saving grace was a progressive CEO who believed in methodology for change. The CEO brought in expertise who understood data for improvement not judgement. She explores the positive way in which understanding data impacting her working life.

“You start to feel like you have a bit more control over it. Never going to be perfect but helps.”

Know your data!

The teams are now given case studies to read and then discuss on their multi disciplinary tables which leads to lively debate. Abi leads the reflections which will be used for actions at the end of the day.

The room is now split into two with a set of three 20 minute sessions. First up is Clare Nolan and Emma Dean from Greater Manchester Fire and Rescue Service who discuss the Fire Services approach to embedded data including their base risk model. Read more here.

Now introducing Siobhan Farmer, Public Health Consultant at Salford City Council, identifies that public health looks at the mass of data that will affect population health. The Council aim is to integrate data in order to identify trends across the whole population. Siobhan demonstrates the latest in data presentation and how public health are innovating in terms of their relationship with data.

We switch to the other room now where Chief Inspector Glenn Jones from Greater Manchester Police who discusses the Greater Manchester Police history with data as a tool for assessment and efficiency.

Back for the first break, we enter into presentations from participants of the Safer Leadership programme beginning with Ilse Berger, Stroke Consultant from Salford Royal NHS Foundation Trust who explores the effect of the programme relating to designing new care pathways. Working on redesign of the spinal pathway, Ilse commented “it made me think again about safe implementation of the IAT services in a different way…….[I’m] looking forward to getting feedback from the group.” Used the framework as a foundation to improve services, Francine Thorpe expresses that “this is the exact reason why we started this programme to make clinicians think differently about safety.”

Next up is Clare Gibbons who has been working within the Safer Handover team who is presenting on the Safer Handover Rapid Improvement Event. Read the full event review here. Clare talks through the lessons leant including huge commitment to change system, technology was highlighted as a necessary aspect to the evolution of efficiency in handover and how the system needs to be sustainable. This was done by examining the current state and looking forward to what a future ideal state would look like. Conclusions included safety at handover has to be a priority and integration is key to reduce incidents and risk and to ensure patient centric approach.

Abi now introduces our keynote speaker, Derek Cartwright, Chief Executive of North West Ambulance Service (NWAS) who presents on Leadership and Safety Culture across a Complex System. Derek begins by describing synergy with the previous presentations and providing context to the complex operating systems in which NWAS operates. Derek discusses the issue of ambulance turnaround and delayed transfer of care and Abi then leads a fascinating Q and A session.

We’re back from lunch! With Lindsay Harper, Director of Pharmacy at Salford Royal NHS Foundation Trust, who is talking us through her QI journey with the Safer Medicines work stream which main aim involves integration and learning across the health and care economy with partners (including mental health services) working collaboratively to ensure clarity and that the patients journey is efficient.

Abi leads the reflection on the project and asks the team to apply the remaining elements of the Measuring and Monitoring of Safety Framework as next steps.

Next up we have Carl Macrae, Senior Research Fellow at University of Oxford and Improvement Science Fellow at Health Foundation who leads a session on Preventing Harm in Pathway Design – an exploration and worked example of using failure modes and effects analysis (FMEA). This will help the team find predictive and proactive ways of analysing safety issues in their systems. Carl begins with system analysis – starting with basic assumptions.

Carl talks the team through a FMEA process using the universal example of getting to work which leads to a very lively debate on the complexity and simplicity of the current process, how to redesign the system and how to convey the process to colleagues who are less methodical and more creative. The tables now break away and evaluate their own systems with the FMEA process.

Abi now takes the teams through action planning which encompasses reviewing the maturity matrix, individual target setting and developing system wide definitions of safety. Francine Thorpe, Director of Quality and Innovation at Salford Clinical Commissioning Group closes Learning Session 3 with a recap of her takeaways from the day which incorporates the power of population data at identifying trends and engaging marginal communities.

Really helpful to look at data from other parts of the system.”

The Safer Leadership Summit will be held on Thursday 19th October. All details here.

Follow or continue the conversation on Twitter using @SaferSalford and #SaferLeadership


Carl Macrae – Preventing harm in pathway design
Derek Cartwright – NWAS – Leadership and Safety Culture Across a Complex System
Emma Dean – GM Fire and Rescue Service – Predicting and preventing harm
Glenn Jones – GM Police – Leadership through data
Ian Everall – Salford City Data Explorer – Linking datasets
Nick John – Haelo – Using SPC for Prediction
Siobhan Farmer – Salford City Council – LA use of research and intelligence
Team – Safer Handover
Team – Ilse Burger
Team – Safer Medicines
Terrence Fernando – Salford THINKlab – Troubled Family Project


The Kings Fund: Leading across the health and care system
Health Foundation: Using safety cases in industry and healthcare
IHI: Failure Modes and Effects Analysis (FMEA) Tool