HSRU is funded by the Chief Scientist Office of the Scottish Government Health Directorates. The...

HSRU is funded by the Chief Scientist Office of the Scottish Government Health Directorates. The author accepts full

responsibility for this talk.

Health Services Research Unit University of Aberdeen

Understanding the dynamics of organisational culture change:

creating safe places for patients and staff

NIHR SDO Funded ProjectAuthors: Professor Lorna McKee, Professor Adrian Grant, Professor Rhona Flin, Professor Derek Johnston, Professor Michael West, Christine Miles, Dr Sharon McCann, Dr Steven Yule, Mr Jeremy Dawson, Mrs Kathryn Charles.

Health Services Research Unit

OutlineOutline

• Project aims / objectives• Research problem• Methodology• Key findings• SO WHAT?


Project AimsProject Aims

• To extend the evidence base on organisational culture change and organisational performance

• Identify high/low performance for patient safety and staff well-being and links to organisational culture

• Identify policy and environmental change context issues: focusing on the separation of change receptive and change intransigent contexts and their links to culture, leadership and staff well-being and patient safety performance


Focus: why patient safety?Focus: why patient safety?Patient Safety is ..

'The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.' (Vincent, Patient Safety, 2006, p14)

• One in ten patients admitted to hospitals in developed countries will be unintentional victims of error (OWM, 2000)

• 50% of errors avoidable (OWM, 2000)

• Acute general Hospitals – Severe harm 5017 incidents and 1548 resulting in death

(NPSA: Patient Safety Incidents in the NHS 01/10/06 – 31/12/07)


Why measure staff attitudes Why measure staff attitudes and experiences? and experiences?

• The workforce of an organisation is its most important resource.

• The attitudes and behaviour of staff, and their experience at

work, affect how well they perform in their jobs, and in turn the overall performance of the organisation.

• There are increasing challenges for health care organisations to create safe working environments for staff.

• Reported incidences of stress, violence and abuse against staff and staff injury are growing


Organisational CultureOrganisational Culture

Schein (1991) - Basic Assumptions, values, artefacts and creations

The pattern of shared basic assumptions - invented discovered or developed by a given group as it learns to cope with the problems of external adaption and internal integration– that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems (Schein, 1995:6).


Project teamProject team

COMPARATIVE NATIONAL DATA

STRAND

ORGANISATIONAL

STRAND

STAFF WELL-BEING

STRAND

LEADERSHIP STRAND

UNIVERSITY OF ASTON(West and Dawson)

UNIVERSITY OF ABERDEEN (Johnston)

UNIVERSITY OF DUNDEE(Jones)

UNIVERSITY OF ABERDEEN

(Flin and Yule)

(McKee, McCann and

Charles)

UNIVERSITY OF ABERDEEN


A multidisciplinary, multi-method A multidisciplinary, multi-method research approachresearch approach

Four research strands:

• Organisational strand – organisational level

• Senior leadership strand – senior leadership level

• Staff well-being – frontline nursing staff

• Comparative data strand – NHS National Staff Survey identified eight acute Trusts (A-H) and informed comparative analysis


Sampling frame criteriaSampling frame criteria

HIGH PERFORMANCE

LOW PERFORMANCE

STABLE UNSTABLE

STABLE ANDHIGH PERFORMINGTrusts: B & E

UNSTABLE AND IMPROVINGTrusts: A & H.

STABLE AND LOW PERFORMINGTrusts: C & G

UNSTABLE + WORSENINGPERFORMANCETrusts: D & F


Data sources per strandData sources per strandStrand Trusts Data sourcesOrganisational

4 Depth Case studies A B C D

4 Mini Case studies E F G H

100 semi-structured interviews, Trust documents, observation of five meetings

44 semi-structured interviews, observation of four meetings, Trust documents

Leadership Trusts A B C D E F G H 7 semi-structured interviews with Trust CEOs23 upward appraisal questionnaires completed by executive directors

Staff well-being

Trusts A B C D 233 self completed questionnaires by nurses248 hand held diaries completed by nurses


Key findings across Key findings across strandsstrands

• What does patient safety mean?• Priority for safety• Barriers to patient safety• Links staff well-being to patient safety• Leadership matters• Environmental shocks• Insight into shift (nurses) climate


Patient safety : confounded Patient safety : confounded by complexityby complexity

• Lack of common understanding – risks, complaints, complications.

• No uniformity in roles and responsibilities

• Responsibilities for patient safety distributed

• Reporting processes – need to be stream lined


What is patient safety?What is patient safety?

I just don’t think we’ve used the words

‘patient safety’ in a regular and repetitive way. I think it’s a bit like the word ‘ hygiene’, ‘ hygiene’ never featured in any documentation, we talked about Infection Control, and Infection Control Team will have talked about the problems that they had encountered in getting it high on Agenda, Nursing Director


What is an incident?What is an incident?

You know, something goes wrong, maybe the appendix is very stuck to the bowel and therefore they can’t get it off, you know they can’t make a clean incision, it’s stuck to everything, so they have to (unclear) and actually they nick the bowel while they’re doing it so they have to over sew the bowel and maybe do a de-functioning colostomy, now they wouldn’t see that as an incident. Risk Manager


Lack of awarenessLack of awareness

Long chains of consequences: And secondly I think that genuinely some

people come to work even in health cultures where they are completely oblivious to the consequence of what they do because they only see themselves in the context of what they do and not in the context of what they do and the impact it has on others, and they don’t understand the chain of consequence. Chief Executive


Safe care: an invisible Safe care: an invisible intangible norm - but is it a intangible norm - but is it a

priority ?priority ?

• Competing priorities – financial, achievement of performance targets

• Some trusts better at balancing priorities –adopt a ‘gradualist approach’.


PRIORITY FOR PERFORMANCEPRIORITY FOR PERFORMANCE

• TARGETS CLASH WITH PATIENT SAFETY

The four hour waiting target for A&E and the requirement to reduce the bed base to save money resulted in the number of medical patients that out lied into surgical beds and at one point in time we were in the situation where we put in extra beds in the wards to accommodate patients – there were clear patient safety issues associated with those practices. Director of Nursing.

• A FOCUS ON HIGH PERFORMANCE MEANT THAT STRUCTURES WERE TIGHTLY COUPLED -THERE WAS NO SLACK IN THE SYSTEM

We are a hamster on a wheel because you know clinical areas are very busy and corporately there’s a lot to do – so we’ve stripped out as many of the inefficiencies or cushions that we can – which is good but there’s no room – there’s no slack in the system. Director Corporate Affairs.


Perceived barriers to patient Perceived barriers to patient safetysafety

• Staffing – shortages, skill mixes, access to training, displacement of staff

• Poor communication – professional diversity

• Failure to document procedures• Limited awareness of risk• Limitations in physical infrastructure


StaffingStaffing

If you know you are running a ward with

27 patients and you are the only trained member of staff on and you are working a 12 hour night shift with no break, then clearly you are not doing your best for the patients or for yourself ….and it is a major, major risk.

Risk Manager


Skill mixesSkill mixes

I think the skill mix is wrong and I think

with the changes that are happening in the NHS at the moment, reducing the length of stay obviously means the client group changes as well and their dependency changes. Matron


StaffingStaffing

If I could knit them half a dozen nurses I

would sit and knit some. But I can’t, and I would have to say from my point of view that staffing has to probably be the biggest single threat. Risk Manager


Links staff well-being and Links staff well-being and patient safetypatient safety

Some of the staff well-being is related to

them being stressed out, because there aren’t enough staff, and clearly is going to immediately going to link into patient safety on two grounds, a), the staff are stressed and may not pay attention so much to what they’re doing and b), there’s not enough of them, so I’m quite sure they are linked.

Medical Director


Links staff well-being and Links staff well-being and patient safetypatient safety

I think a very happy member of staff, somebody who is happy in their work, they have got job satisfaction, gives a better service to the patient. The patient feels a lot better because people are happier around them, they’re smiling and you know they are more likely to ask a nurse or point out that something is not right so if they feel unwell or anything like that, any of those complications they may pick up earlier .

Deputy Director of Nursing


Leadership mattersLeadership matters• Senior leadership prioritisation of patient

safety affects performance• Major environmental pressures distracted

many senior leadership teams• High performing Trusts could buffer

environmental pressures• Transformational leadership styles influence

performance• CEO can galvanise staff – communicates vision


Leadership mattersLeadership matters

• Tenure and stability of senior leadership linked to patient safety and staff well-being performance

• Transactional and transformational styles of leadership important

• Dispersed leadership linked to patient safety performance

• Informal leadership role models critical


Broader context and Trust culture Broader context and Trust culture affect patient safety and staff well-affect patient safety and staff well-

beingbeing• Environmental ‘shocks’:

1. PCT reconfiguration2. Trust merger3. Reduction in commissioned services4. MRSA and C-Difficile outbreaks5. Leadership instability6. Financial deficit


Adaptation to environmental Adaptation to environmental pressurespressures

Linked to:• Cultural attributes – staff engagement• Organisational capabilities – learning

processes• Stability - Longevity of tenure - senior

leadership and staff


Typology of TrustsTypology of Trusts

• Resilient• Adaptive• In Recovery• Conservative / Passive


The distribution of Trusts according to The distribution of Trusts according to magnitude of environmental pressure and staff magnitude of environmental pressure and staff

engagementengagement High Engagement

Low Engagement

Low Pressure/ StabilityHigh Pressure / Change

Resilient Trusts A and HA and H

Adaptive Trusts C, D and F

Conservative/ Passive Trust E In Recovery Trusts B and G

Cultural attributes:Good relationships embraces changeClinical involvement, learning cultureLeadership: Directive/ DemocraticProcesses: Highly developedStaff well-being – High performancePatient safety – High performance

Cultural attributesLeadership – Consensual, Inclusive, Cohesive relationships, learning cultureProcesses – Highly developedStaff well –being – low performancePatient Safety – Improving performance

Cultural attributes:Closed, Performance focused Community affiliation, strong relationshipsLeadership: BureaucraticProcesses – slowStaff well-being – High performancePatient safety – High performance

Cultural attributesPerformance priority, clinical relationships strong, Leadership not TrustedLeadership: TransformationalDistracted, bad behaviours (B)Processes – reporting improving, blame cultureStaff well-being – Low performancePatient safety – Low performance


So What? So What? Policy ImplicationsPolicy Implications

• Ensuring senior leadership continuity• Assessment frameworks for environmental, cultural

and organisational capability assessment• Explicit strategy framework for patient safety• Streamlining of reporting and feedback processes• Emphasis on dispersed leadership • Staff engagement promoted – informal methods• Role models – buffering change• Use of PDA diaries to monitor ward safety climate


Thank YouThank You• More information: Project webpage http://www.abdn.ac.uk/hsru/research/del_of_care/org_managment_policy/UDOCC_safeplaces/

• [email protected]

This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme. The views expressed in this publication/presentation are those of the author's) and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health.


Future researchFuture research

• Exploration of dispersed leadership• The role of senior leadership in

promoting patient safety• Exploration of links between staff well-

being and patient safety• Multi-disciplinary research designs• Patient experiences of patient safety

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