Healthcare. A Just Culture... where are we now?

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A Just Culturewhere are we now?Doing The Right Thing

Patient safety through a just culture in HealthcareTracy Boylin Maria Paviour

Maria Paviour Company Ltd 2015mariapaviour.com

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What will change culture?AttitudeValuesTargets

Maria Paviour Company Ltd 2015mariapaviour.comAttitude wontResearch: Jeni Cross Colorado Behaviour changes behaviourNeuroscience; decision-making has strong emotional element - driven from limbic system/habit part

Values wont:Research: Jeni Cross Colorado Social NormsNeuroscience: counter to survival coding - survival depends on being part of a group

Targets wont: Research: Dan Pink people perform worse when targettedNeuroscience: Lose the ability to make big connections i.e. stop being creative vital for problem solving

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Targets = Threat = Poor Performance

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comHow many people can say that targets have improved the culture of their organisation please note Im not asking who has improved the business, only who believes that TARGETS are specifically responsible for this improvement?

Target / threat driven (lead and managed)Hierarchical in conflict with Existential (values mismatch)A Psychopathic fiction (leadership)

This is what happens to our focus and ability to see the big picture when we are under threat.We cant see the big picture, only our own small area of focus.3

Targets = Threat = Poor Performance

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comTargets and the definition of madness

Definition of madness Einstein: Doing the same thing and expecting a different result.Targets are proven by research and neuroscientific evidence to undermine performance

Neuroscience - They create a threat response in the brain results:We become too focussed (cant see wood for the trees), lose creativityReactive behaviours

Relevance to diagnosis and treatment of patientsProblem solving significantly impaired (diagnosis)Poor decision making (treatment)inability to co-operate (care)

Where is the threat coming from?

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Targets = Threat = Poor Performance

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.com

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Targets = Threat = Poor Performance

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comTARGETS COME FROM THE TOP AND BEAR DOWN ON US ALLA Role Culture of levels and layers, with authority passing down from the top with the patient facing clinicians attempting to deliver quality care.What do we want to achieve?

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You cant change culture

CULTURE = result of actions taken

ACTIONS = emotional environment (how we treat people)

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comThere is a good reason we find the idea of changing culture so boggling

You can only change the practicesCulture = result of actions takenActions = emotional environment how we treat people

The emotional environment is HOW WE TREAT PEOPLE its not a policy or a rule or a document. Its what really happens.

If you aim to change culture you are creating a false environment and will do more damage than you prevent.

Culture needs to be Authentic to be Just and Ethical.

We need to ask what do we see, hear and feel and what do we WANT to see hear and feel?We need to consider culture in terms of our values not the corporate the real ones what really matters here?

Exercise: forget the corporate big boys (the values we state on the web site) what really matters here?

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The effects of threatTyranny rewards bullyingSelf preservation at any costBendable valuesArrogance as a survival mechanism

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comThreat correlates to Tyranny

Tyranny - Tyrannical leadership rewarded targets = bullying The system rewards those who bully

The question we ask is: Who survives here? End masse: ethics enable survival individually ethics can isolate you

Values Bend to Maintain Status Quo = Perpetrator Victim Collaborator Bystander - Resister 3% we change our values hierarchy (i.e. when honesty may move on the hierarchy)

Arrogance as a survival mechanism professionals who are existing in a bullying culture use arrogance to mark out their professional boundaries the Drive for perfection -intolerance for error shaming and therefore covering up

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Answers? Break the Psychopathic CycleThe PSYCHOPATHICCycle

TARGETSTHREAT CULTURE, LOW MORALE, LOSS OF EMPOWERMENTREACTIVITYERROR INTOLERANCEILLUSION OF PERFECTIONPSYCHOPATHIC FICTIONSNARROW FIELD OF VIEW LOSS OF PATIENTCENTRICITYEMPATHYLITEDISCHARGE OF RESPONSIBILITY& BLAME GRANDIOSITY

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comARROGANCEHUNT FOR THE GUILTYcycle of disenfranchisement

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The AspirationBreak the vicious cycle of the disenfranchisedPATIENTCENTRIC DRIVEN FROM BOTTOM UPACCOUNTABILITYCycle of courageLEARNING CULTURESHARED PURPOSECO-CREATION, COLLABORATION

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.com

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Cohesion & shared valuesRecognition of what worksMutual supportInnovation, creativity and change

The ManifestationPATIENTCENTRIC DRIVEN FROM BOTTOM UPACCOUNTABILITYCycle of courageLEARNING CULTURESHARED PURPOSECO-CREATION, COLLABORATIONBreak the vicious cycle of the disenfranchised

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.com

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What are the answers?Build Emotional Engagement

Substantially reduce the 3As

Increase the Value for Money and Patient Satisfaction

Maria Paviour Company Ltd 2015mariapaviour.com Build engagement its easier than trust

Trust is easy to lose and difficult to build. Its earned.

If we want a caring culture - Start by caring.12

Transactional/Emotional Engagement and Wellbeing

Maria Paviour Company 2015mariapaviour.com

Maria Paviour Company Ltd 2015mariapaviour.comWhat are people like when emotionally engaged how will this create a Just and Caring culture?

Transactional engagement Enjoys the job, the team, but is not committed to the organisation does not feel fully part of the mission highly stressed.

Emotional engagement Loves the organisation and feels part of the mission. Feels part of the purpose highly energised

Emotional engagement happens when engagement and wellbeing peak. This is the only true form of engagement (CIPD)

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Financial Reasons - Absence EXAMPLEIndustry statisticsDay sickness absence per annum per personaverage salary per annumNo. of employeesvalue of days lost to sickness paSavings on lost daysUK Average sick days9.530k75008.4mCost of agency staff:18.1m UK Engaged Company Aspirational2.530k75002.2mSavings on lost days 6.2m plus Cost Agency Staff15.9m

Maria Paviour Company Ltd 2015mariapaviour.comCosts 18mSavings 16m14

EXAMPLEIndustry statisticsAttrition Rateaverage salary per annumNo. of employeesCost of attrition/Replacement @ 150%Savings on lost daysUK Average sick days14.6%30k750049.2m UK Engaged Company (Aspirational)5%30k750016.2mSavings 33m

Financial Reasons - Attrition

Maria Paviour Company Ltd 2015mariapaviour.comCosts 50m

Savings 33m15

Where do we start?PRIORITY 1

Diagnose your Well being and Emotional Engagement levels

1 SD point improvement in engagement would save NHS 24m from absence alone in acute trusts.

Maria Paviour Company Ltd 2015mariapaviour.comThe NHS should, above any organisation, understand the vital nature of diagnosis before you begin treatment Who or what will resist diagnosis? the disease of course!

What has created this infection? How do we neutralise this infection cut out the gangrene of this infection?

Take the temperature of the organisation care for each individual Honest feedback this is currently counter-culture

Results:NHS sector research Aston University 2009 high degree of correlation between good employee engagement scores / range of desirable outcomes for patients.patient satisfaction is significantly higher in trusts with higher engagementThe % of staff receiving job-relevant or health and safety training, well-structured appraisal meetings, good support from immediate line managers=patient satisfaction. high engagement = lower standardised patient mortality rates, (even when controlling for prior patient mortality) Patient mortality rates were approximately 2.5% lower in those trusts with high engagement VS medium.engagement= absenteeism. 2009 NHS employees absent 10.7 million days = a loss of 10.3 million days annually =cost of circa 1.75 billion =loss of 45,000 FTE each year. YOU MUST BE INTERESTED IN THIS!150,000 in salary costs alone for an average acute trust. Given the 164 acute trusts in the UK this represents a potential saving of 24.6 million each year, not including non-salary costs or the prospect of similar savings in other NHS trusts.

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PRIORITY 2

Well being FIRSTPull people out the riverGo upstream stop people falling in

Where do we start?

Maria Paviour Company Ltd 2015mariapaviour.comPull people out the river AND stop people falling in the riverFinancial benefitsBenefits to patients

NHS needs to pull dow