Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA.

Developing a safety cultureIntroduced by

Dr David Gozzard, Associate Medical Director, MIAA

Assessing Organisational Culture

Dame Elizabeth Fradd, Independent Health Advisor

•What is your Board doing to develop a patient safety culture , what's working

and what needs more focus ?

©2013 Robert Francis QC 5

“ Despite our financial and economic anxieties , we are still able to do the most civilised thing in the world – put the welfare of the sick in front of every other consideration” – Aneurin Bevan 1948

Is this true today?


• Evidence of poor care in all types of care settings

– Bristol Royal Infirmary – 1984 – 95 . Report 2001– Allitt 1991 . Report 1994– Climbe 1999 – 2000 . Report 2003– Shipman 1998 . Report 2000– Mid Staffordshire NHS Foundation Trust – 2005 -08 Public Inquiry report

2013– Baby P – 2006 – 07 . Report march 2009– Maidstone & Tunbridge Wells – 2007 . Report Oct 2007 – Winterbourne View – 2011. Report Dec 2012– Ombudsman Report elderly care - 2011– Patients Association Reports – 2011 / 2012

Background


• “The trouble with culture is everyone blames it when things go wrong but no-one really knows what it is or how to change it” - Prof John Glasby

• “Its how we do things round here” - Prof Charles Vincent• “Organisational culture is informed by the nature of its

leadership” – Robert Francis QC• “What are we going to work for today?” – Prof Sir Ian Kennedy • “It’s what people do when no one is looking” – comment

about bankers

Descriptions of culture


• Too many quick fix solutions• Length of time it takes to affect change• The little things seem less important• Cultural attributes not picked up in measures of quality

and performance• Metrics fail to capture the meaning and reality of care

culture for patients and staff• Lack of a caring / safe culture is a significant factor in all

NHS system failure

Drivers to develop a Cultural Barometer


Design of the Care Culture Barometer 1.

• Research demonstrates a number of key factors which are necessary to maximise staff commitment, engagement and productivity and linked to 4 themes – –resources to deliver–support to do the job–a job that offers the chance to develop; and–the opportunity to improve team working


• The Barometer designers also identified the following dimensions which are embedded within the 4 themes:

– Leadership– Governance– Use of data and Information– Staff attitudes – Staffing levels

Barometer Design 2


• Complement not duplicate other measures or quality programmes

• Act as an early warning system to identify care culture “red flag” areas

• Be easily used by all levels and groups of staff• Be short and quick to complete• Prompt reflection to help identify actions required• Be used as a individual / team or organisation wide activity • Encourage “ward to board” communication

The Barometer is designed to:


• Responsibility for developing a patient safety culture• Assurance• Duty of Candour• The human impact

The Board


•How effective is your Board at leading the development of a patient safety culture ?

Group Discussion 1


The Care Environment

• The environment of care is broader than the notions of patient or person centred care – staff too need an enriched environment to create the same for patients


• Common set of values and standards shared throughout the system

• Committed leadership at all levels to the values• A system that recognises and applies values of transparency ,

honesty and candour. (staff able to speak out without fear ).• Freely available , useful full information on attainments of

values and standards• The use of a tool or methodology to measure the cultural

health of all parts of the system - ----Mid Staffordshire Public Inquiry Report.

Drivers for a positive Universal culture


• Acceptance that patients needs come before ones own• Recognition of the need to empathise with patients and other

service users• Willingness to provide patients with the assistance one would

want for oneself or refer to someone who can help• Willingness to listen to patients to discover what they want

for themselves• Willingness to work together for the benefit of patients • A commitment to draw attention about concerns re safety

and welfare to those who can address them – Mid Staffordshire Public Inquiry Report

Ingredients of a culture of sharing in Mid Staffordshire report – reflected in Barometer


• A series of statements which individuals are encouraged to: • read carefully and score• Consider if they have influence to improve• Consider if they should take any action

The Barometer is…


1. The resources I need to do the job

• I have the facilities and equipment to do a good job• The board has an accurate idea of the quality of care

provided • Overall, I feel fairly trusted, listened to and valued• There are enough staff for me to do my job well• I would recommend the ward / unit as a good place to

work• If a friend or relative needed treatment, I would be

happy with the standard of care provided by this unit / department.


• I feel part of an effective team• I have a regular and effective appraisal• Staff here are generally well managed• I know how we are doing on quality where I work• Bad behaviour is tackled and managed regardless of who it is• I know who my manager / supervisor is• There is strong and visible leadership from senior managers• My manager provides support when I need it• Trust managers have a good understanding of how things

really are• I have good friends at work

2. The support I need to do a good job


• I have a worthwhile job where I can make a difference• I have the opportunity to develop my potential• I understand my role and where it fits in• I am supported to get the training and development I

need • Patients and carers are actively involved in their care• I help promote high quality patient care

3. A worthwhile job with a chance to develop - A


• The values of the organisation are directed towards patient wellbeing and dignity• A positive ethos is visible at every level of the

organisation• Success is celebrated and staff are praised for good

work• Overall there is a positive culture that supports the

delivery of excellent care

3. A worthwhile job with a chance to develop - B


• I am able to improve the way we work in my team• We meet regularly as a team• Staff have a chance to give their views at team

meetings• Staff feel empowered to make changes at work• Staff have positive role models where I work• We do a good job to meet the needs of patients and

service users

4. The opportunity to improve the way we work in my team - A


4. The opportunity to improve the way we work in my team - B

• There is a willingness to change and try new initiatives• I regularly get feedback on what the organisation

learns from patient complaints• I regularly get feedback on what the organisation

learns from incidents• I feel my concerns are listened to• I feel safe, secure and supported to do my job


“Do you believe action will be taken in response to the results of the questionnaire?”

Final Question


• Pilot site refining the Tool’s validity and applicability in practice – discussion groups / on line survey

• Feedback to determine how to use results to affect change • Determine how to maximise organisational benefit through

use as a diagnostic tool • “How to” guide• Literature review – contextual background• Embed within existing metrics

Next Steps


• Universal acknowledgement culture matters • Simple measures which assess & benchmark culture throughout

organisations without adding to the burden of regulation • Enriched environments which address: consistency complacency

and support for front line staff to deliver high quality care• Shared organisational values• Openness which recognises human factors • A strong voice for patients

• Strong leadership which accepts challenge

We strongly advocate;


• “Maintaining a safety culture indeed any kind of culture , requires leadership and on-going work and commitment from everyone concerned” – Prof Charles Vincent in evidence to the Mid Staffordshire Public Inquiry

Leadership


• What is your Board doing to develop a patient safety culture ?

• What is working ?

• As a result of what you have heard today what needs more focus ?

Group Discussion 2

Tea and Coffee

Re-building confidence in Board Leadership

Introduced by Deborah Arnot

FAILURE OF THE LEADERSHIP CULTURE IN THE NHS – IMPLICATIONS FOR NON EXECUTIVE DIRECTORS OF THE BOARD

David BowlesDavid J Bowles & Associates

www.davidjbowles.com


It’s not all bad

The NHS at its best is brilliant and it has some fantastic staff

BUT as an organisation it is ‘sick’


The 2008 reports• The risk of consequences to managers is much greater for not meeting

expectations from above than for not meeting expectations of patients and families;

• If something goes wrong or a newspaper gets on the case find someone to

blame and punish him or her;

• A shame and blame culture of fear appears to pervade the NHS and at least certain elements of the DoH as well;

• This culture generally stifles improvement and... behaviours that are necessary for creating organisational cultures of quality and safety

• Humiliation and CEO fear of job loss are the system's major quality improvement drivers.


20.14 The first inquiry report identified a number of cultural themes which were associated with the deficiencies that had been identified. They were summarised as:

• Bullying; • Target-driven priorities; • Disengagement from management; • Low staff morale; • Isolation; • Lack of candour; • Acceptance of poor behaviours; • Reliance on external assessments; • Denial.

20.15 The evidence obtained at this Inquiry suggests that these negative aspects of culturally driven behaviours are not restricted to Stafford.

Francis Confirmation


‘we frequently encountered differing accounts of the nature [of meetings and telephone conversations]’ In the face of conflicting evidence about what happened in meetings and in phone calls they decided to ‘principally use extracts from relevant correspondence and reports as a more reliable account of the tone and style of communications and therefore relationships…’.

NHS Assessment of bullying


There was no bullying ‘whatsoever’

WHO BASED ON THAT CRITERIA WROTE?


Biggest problem for Boards

Denial


IF THE NHS WERE AN AIRLINE IT WOULD HAVE

BEEN SHUT DOWNA PLANE CRASH A MONTH

In a Nutshell…


Boards should lead by example. Boards should set the right tone and pay particular attention to ensuring the continuing ethical health of their organisations. Non-executive directors should regard one of their responsibilities as being guardians of the corporate conscience. Boards should ensure they have appropriate procedures for monitoring their organisation’s ethical health. (Source ACCA)

Role of Board in Culture


Tried and tested has not worked in those organisations with the cultures described by Francis……..

………………they are good a cover up

Difficulty of diagnosis for Non-Executive Directors


NHS LOTHIAN experiencePolicies and procedures excellentIIP and staff survey not remarkable

Review Methodology•Trusted – unconnected with the organisation•Structured 1:1 confidential interviews•Focus groupsCulture findings in line with Mid Staffs report

Difficulty of diagnosis for Non-Executive Directors


• Overarching management culture• Beyond process and Board reports

• Walk the floor• Engage with staff at all levels• Turn stones• Challenge• Common sense…………

No Magic Bullet


Overarching management culture

The most important decision Non Executives will take is the appointment of

the Chief Executive

No Magic Bullet (cont.)


Your significant concerns about the quality of the corporate governance

cannot be resolved?

Public comment and resignation

Ultimate Non-Exec Obligation

The Role of Managers

Introduced by Steve Connor

The Role of Managers

Nigel Edwards,

Senior Fellow, The Kings Fund

"Respect, Integrity, Communication and Excellence."

"We treat others as we would like to be treated ourselves....We do not tolerate abusive or

disrespectful treatment. Ruthlessness, callousness and arrogance don't belong here."

Code of conduct• As an NHS manager, I will observe the following principles:

– make the care and safety of patients my first concern and act to protect them from risk;

– respect the public, patients, relatives, carers, NHS staff and partners in other agencies;

– be honest and act with integrity;– accept responsibility for my own work and the proper performance of

the people I manage;– show my commitment to working as a team member by working with

all my colleagues in the NHS and the wider community;– take responsibility for my own learning and development.

A Question

What is the basis of management & leadership ethics in the NHS?

Put down some phrases and ideas that describe this?

Is there an issue?• Consequentialist ethics– Actions judged on consequences

• Rule based ethics– Following the rules– Outcomes secondary

• Don’t bring me problems, bring me solutions• Pace setting• Targets, terror & thoughtlessness

Is there an issue?• Some genuine dilemmas:• Individual or collective?• Different valuations of outcomes

A Question

What are the issues that cause you the most ethical concern?

And why?

Normalising deviance

Small steps and compromisesWell intentioned trade-offsFailing to act, correct or feedback

A Question

What approaches do you use to understand and deal with ethical conflicts?

An old but useful approach

David Seedhouse’s grid – 4 layers:

Basic purposeMoral dutiesOutcomes and prioritiesPracticalities

Ethical culture• Five disciplines– Mindfulness– Voice– Respect– Tenacity– Legacy

Mindfulness• Constant attention• Focus on failure• Reference back to values• Intuition matters

Voice• Not just a team player able to speak out• Leaders create a safe space for difficult

conversations• People can raise difficult issues

Respect• A problem– I am a dedicated leader– You are a manager– They are bureaucrats

• Or– I am a tireless advocate for patients– You are a good clinician– They are bean counters

Tenacity & legacy• Tenacity – It takes a long time for a culture to change– Continual re-enforcement is often required – hand

washing, central lines…..• Legacy– Are we good ancestors?

Ethical leadership• Noble purpose• Candour• Ceaseless ambition• Passion

Ethical governance• Culture• Succession• Curiosity and external reference

Checklist• What conversations about ethics do you have • Where do you get advice from• How do you know you are getting it right• Weak signals, intuition and gut feel • How do we perform under stress?

Final question

• One action to take home?

A practical Response to the recommendations from Francis – from

Board to Ward and Ward to BoardFacilitated by David Gozzard

Question

• Top 3 combined individual actions you intend to commit to as a result of your learning?

Question

• Top 3 combined board actions?

Evaluation, moving forward and close

Deborah Arnot and Steve Connor

Please complete your Evaluation Form and hand it to the event team on departure

Post Event information can be found on the Francis Portal – login details on the programme

Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA.

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Transcript of Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA.