Embedding A Patient Safety Culture

Burt Burtun

Learning OutcomesAt the end of this presentation delegates will be able to:• know the origin of MaPSaF• appreciate the theory behind the framework• Identify the characteristics of the different levels of

maturity of the framework• Identify the uses of MaPSaF• Know how to individually record their perceptions of safety

culture • Know how to record their Team’s perception of safety

culture• Know how to agree on the actions they will need to take to

move their team to the next level(s) of Safety Culture

Patient Safety Culture Challenges

• Why is Patient Safety Culture important?• How can we develop a Patient Safety Culture in a

Team/Organisation?• How do we know what our Patient Safety Culture is

now?• What variables do we have to manipulate to create a

Patient Safety Culture Change?• How do we introduce these variables to produce the

change?• How will we know we are making a difference?• How will we know when we get there?

Seven Steps to Patient Safety

1. Safety culture

2. Lead & support staff

3. Integrated risk management

4. Promote incident reporting

5. Involve patients and the public

6. Learn and share lessons

7. Implement solutions

Patient Safety Culture

What is different about these industries?

Seven Steps to Patient Safety

1. Safety culture

2. Lead & support staff

3. Integrated risk management

4. Promote incident reporting

5. Involve patients and the public

6. Learn and share lessons

7. Implement solutions

Reducing Drug Errors

• Medicines do good and cause harm• Leape et al - for South Central(London):

– 29,600 adverse drug events– 296 fatal– 66,600 additional bed days– £44.4m additional costs

• Medication errors are the greatest single source of preventable errors

Reducing Drug Errors

• Effective medicines management achieves:– Improved patient safety– Reduced length of stay– Delivering 18 week wait target– Rapid discharge– Minimised re-admissions– Prevention of admissions

Reducing Drug Errors

• Causes:– 33% linked to look alike / sound alike names– 23% high workload / low staffing– 20% inexperienced staff– 14% transcription errors (data entry)

12/13 11/12 10/11 09/10 08/09 07/08

Scheme £’000 £’000 £’000 £’000 £’000£’000

CNST 1,258,880 1,277,371 863,398 786,991 769,226 633,325

Liabilities to Third Parties Scheme (LTPS)

46,949 48,128 42,435 33,952 33,975 24,986

Property Expenses Scheme (PES)

3,650 4,262 5,546 6,424 3,914 2,730

TOTAL 50,599 52,390 47,981 40,376 37,889 27,716GRAND TOTAL 1,309,479 1,329,761 911,379 827,367 807,115 661,041

• Payments made by NHSLA in respect of negligence claims against the NHS

• Payments made in the financial years 07/08 to 12/13

• As at 31 March 2013, the NHSLA estimates that it has potential liabilities of £22.9 billion, of which £22.7 billion

relate to clinical negligence claims (the remainder being liabilities under PES and LTPS)

Seven Steps to Patient Safety

1. Safety culture

2. Lead & support staff

3. Integrated risk management

4. Promote incident reporting

5. Involve patients and the public

6. Learn and share lessons

7. Implement solutions

“ADDING INSULT TO INJURY” – NHS FAILURE TO IMPLEMENT PATIENT SAFETY ALERTS

(FEBRUARY2010)

• Over 300 NHS trusts (around three quarters of all trusts) had not complied with the required actions in at least one patient safety alert for which the deadline had already passed.

• There are 2,124 separate incidences of patient safety alerts not been complied with by NHS trusts as having been implemented.

• 80 NHS trusts had not confirmed they had complied with 10 or more separate alerts. 35 of these trusts have ‘Foundation Trust’ status.

• One trust had not confirmed compliance with as many as 37 (70%) of the alerts. Two trusts failed to comply with 31 (58%) of the alerts.

• There are over 200 incidences of NHS trusts who have not complied with alerts which are over five years old (issued before December 2004).

• There is no system for monitoring implementation of alerts.

• Neither is there a robust system for checking that NHS trusts who declare themselves as being compliant actually are.

• The information about which trusts have or have not implemented the alerts is not publicly available.

• A request made under the Freedom of Information Act.

• There were 141 instances of non-compliance with alerts in January 2014 compared with 455 in the last report in August 2011 and 2,124 in February 2010.

• Every alert not complied with represents a serious risk to patients, and there are 14 examples of trusts who have still not complied with 3 or more patient safety alerts for which the deadline is past

• There were 13 cases where the deadline has been exceeded by over 5 years.

•

• 141 instances of a patient safety alert not having been complied with

• 83 trusts are recorded as not having complied with at least one alert

• 14 trusts had not complied with at least three alerts

• 17 instances of alerts which had not been complied with which were over three years past the deadline

• 13 instances of alerts which had not been complied with which were over five years past the deadline.

Safer Sharps February 2014 Report

• 84 % of Trusts have revised and published their Sharps policy in the light of EU Directive.

• 39% completed the process in 2013

• 29% had the process in progress in 2013

• 16% of Trusts had no plans to revise their policy in the light of New Regulations

Implications for Trusts

• The CQC should treat non-compliance with any Patient Safety Alert which is past the deadline for completion much more seriously.

• The CQC should require an action plan from trusts who are non-compliant with an alert about how they will comply within a short time-scale.

• …new regulations for the CQC, to underline the mandatory status of Patient Safety Alerts…

• The CQC’s inspection process - audit a sample of alerts which have been declared “completed” to check if they have in fact been completed satisfactorily.

National Patient Safety Alerting System (January 2014)

The three stages of patient safety alerts

Stage 1 –Warning

• Consider if this (the risk issue) could happen/has happened locally;

• Consider if action can be taken locally to reduce the risk; • Disseminate the warning to relevant staff, departments

and organisations

National Patient Safety Alerting System (January 2014)

The three stages of patient safety alert

Stage 2 – Resource (some weeks or months after)• Sharing of relevant local information• Sharing of examples of local good practice that mitigates

the risk identified in the stage one alert; • Access to tools/resources that will help providers

implement solutions to the stage one alert; • Access to learning resources. Ultimately, we plan to offer

continuing professional development (CPD) credits on topics relevant to the alert.

National Patient Safety Alerting System (January 2014)

The three stages of patient safety alert

Stage 3 – Directive

• Trusts to confirm they have implemented specific solutions or actions to mitigate the risk.

• Sign Off – through high level Board involvement

Build A Safety Culture

Time to reflect

Small Group Exercise (5 minutes):

Complete the following statement.

My Organisation’s Safety Culture is….

NPSA Seven Steps to Patient Safety

Step One: Build a safety cultureA safety culture is….• A culture where staff have a constant and active

awareness of the potential for things to go wrong

• A culture that is open and fair, and one that encourages people to speak up about mistakes

• Duty of Candour

• Being Open Policy

The Incident Decision Tree (IDT)

The Incident Decision Tree aims to help the NHS move away from attributing blame and instead find the cause when things go wrong. The goal is to promote fair and consistent staff treatment within and between healthcare organisations.

http://www.nrls.npsa.nhs.uk/resources/all-settings-specialties/?entryid45=59900&q=0%c2%acIncident+Decision+Tree%www.nrls.npsa.nhs.uk/resources/all-settings-specialtiesc2%ac

Manchester Patient Safety Framework

• Originally developed for use in primary care by Manchester University

• Based on Ron Westrum’s (1993) theory of organisational safety – “organisational personality”

• Tailored from a tool developed for the oil industry and used by Shell Plc.

• Now piloted and developed for use in acute, mental health, ambulance settings

The theory behind the framework

Pathological

• Information is hidden• Messengers are “shot”• Responsibilities are shirked• Bridging is discouraged• Failure is covered up• New ideas are actively crushed

Characteristics ofthe bureaucratic organisation

Bureaucratic

• Information may be ignored• Messengers are tolerated• Responsibility is compartmentalised• Bridging is allowed but neglected• Organisation is just and merciful• New ideas create problems

Characteristics ofthe generative organisation

• Information is actively sought• Messengers are trained• Responsibilities are shared• Bridging is rewarded• Failure causes inquiry• New ideas are welcomed

Generative

Expanding the framework

• Reason (1997) revised and added two further levels– Pathological– Reactive– Calculative or bureaucratic– Proactive– Generative

• Additions approved by Westrum (1999)

Levels of maturity with respect to a safety culture

A. Why waste our time on safety?

B. We do something when we have an incident

C. We have systems in

place to manage all identified

risks

D. We are always on

the alert for risks that

might emerge

E. Risk management is an integral

part of everything that we do

PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE

Phase One development: Primary care

• Nine dimensions of patient safety considered

• Content of framework determined through 30+ in depth interviews

• Interviewees included Chief Execs., Clinical Governance leads, practice nurses, PCT managers and GPs

Dimensions of safety covered• Overall commitment to quality• Priority given to patient safety• Perceptions of the causes of patient safety

incidents and their identification• Investigating patient safety incidents• Organisational learning following PSIs• Communication about safety issues• Personnel management and safety issues• Staff education and training about safety• Team working around safety issues

Phase Two Development

• NPSA involvement• Adaptation and revision of

framework using focus groups• Production of four versions

(acute, primary, mental health, ambulance)

• Pilot testing of final versions in workshops

Snapshot of whole tool (folded out)

Framework Document

What can MaPSaF be used for?• To facilitate self-reflection on safety culture maturity

of a given healthcare organisation and/or team• To help a team recognise that patient safety is a

complex multidimensional concept • To stimulate discussion about the strengths,

weaknesses and differences of the patient safety culture in a team, between staff groups or in an organisation

• To help understand how an organisation and/or team with a more mature safety culture might look.

• To help evaluate any specific intervention to change the safety culture of your organisation and/or team

What MaPSaF is not:

• A performance management tool for comparing or benchmarking Trusts

• A way of apportioning blame if an organisations culture is perceived to be not sufficiently mature

Directorates & Specialties

Clinical Governance & Risk Committees

Trust Boards

Multi-disciplinary Teams

Professional Groups

Who can MaPSaF be used by?

Wards & Departments

What is OUR patient safety culture?

Interactive Session

Read through the framework- do this on your own

1. Recording your perceptions

On the evaluation

sheet provided

mark, using a ‘T’

and an ‘O’, your

perception of how

mature the

safety culture is.

‘T’ = Team

‘O’= Organisation

Mental Health

Ambulance

Acute

Primary Care

Discuss your perceptions with the person

sitting next to you.

- Explain why you made the choices you did

2. Work in pairs

3. Group Discussion

• Where did you place yourselves?• Why?• What information did you use to make this

decision?• What other information do you need?

4. Action Planning

• What are our strengths and weaknesses?• What level do we want to get to for each risk dimension?• How do we get there?• Who needs to be involved to make it happen?• What next?

Remember!

“An expert is someone who knows some of the worst mistakes that can be made in his subject and how to

avoid them.”

Werner Heisenberg (1901 – 1976), German physicist

Any Questions?

Resources to Support Patient Safety

http://www.nrls.npsa.nhs.uk/resources/type/toolkits/

OR

patientsafetyhelpdesk@npsa.nhs.uk

References and Resources

Staff engagement and/or

ownership/priority given to patient safety

Seven steps to patient safety

www.npsa.nhs.uk/sevensteps

Introduction to patient safety e-learning

www.npsa.nhs.uk/health/resources/ipsel

Medical error

www.saferhealthcare.org.uk/IHI/Products/Publications/MedicalError

Engaging clinicians

www.npsa.nhs.uk/site/media/documents/1342_EngagingClin.pdf

References and Resources

Reporting patient safety incidents

National Reporting and Learning System

www.npsa.nhs.uk/health/reporting

Patient Safety Observatory report

www.npsa.nhs.uk/site/media/documents/1280_PSO_Report.pdf

Engaging clinicians

www.npsa.nhs.uk/site/media/documents/1342_EngagingClin.pdf

References and Resources

Investigating patient safety incidents and learning

from them

Root cause analysis e-learning toolkit and training

www.npsa.nhs.uk/health/resources/root_cause_analysis

References and Resources

Communicating about patient safety incidents with patient and carers

Being open policy, e-learning and one day training workshops

www.npsa.nhs.uk/health/resources/beingopen

References and Resources

Supporting staff involved in a patient safety incident

Incident Decision Tree

www.msnpsa.nhs.uk/idt2/(kht2ahft1belwmja2tlgre45)/index.aspx

Being open policy, e-learning and one day training workshops

www.npsa.nhs.uk/health/resources/beingopen

References and Resources

Teamwork and team

communication

Team Climate Assessment Measure (2006)

Safe handover: safe patients

www.npsa.nhs.uk/site/media/documents/1037_Handover.pdf

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