Patient Safety Culture Tools

Bristol Royal Infirmary ReportFinal report

• It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed.

• Many failed to communicate with each other, and to work together effectively for the interests of their patients. There was a lack of leadership, and of teamwork.

Bristol • The culture of the future must be a culture

of safety and of quality; a culture of

openness and of accountability; a culture of public service; a culture in which

collaborative teamwork is prized; and a culture of flexibility in which innovation can

flourish in response to patients’ needs.

Bristol• A culture of safety in which safety is everyone’s

concern must be created. Safety requires constant vigilance. Given that errors happen, they must be analysed with a view to anticipate and avoid them.

• A culture of safety crucially requires the creation of an open, free, non-punitive environment in which healthcare professionals can feel safe to report adverse events

What defines your Trust’s culture?

“the total of inherited ideas, beliefs, values and

knowledge which constitute the shared basis of social

action”

"The feature that distinguishes the best health organisations is their culture."

Liam Donaldson writing in BMJ 1998; 317:61-5.

What is a safety culture?• safety is considered in everything you do

and there is a balanced approach when things go wrong - you ask why and how

• constant vigilance - always alert to expect the unexpected

• understand what they should do when things do go wrong

• are open to and make, suggestions for change and improvement

• believe their actions make a difference to themselves and to others

What is TCAM • The TCAM programme is made up of a

questionnaire and a set of development sessions

How does it work? • The TCAM questionnaire measures team

climate and teamwork, particularly team behaviours essential to the maintenance of patient safety and effective patient safety incident management in clinical settings.

•  • The TCAM development sessions help teams

work together to improve team climate.

• How can TCAM help?

• There is increasing evidence that the climate within a team has a major impact upon patient safety and care. The TCAM questionnaire enables teams to identify the areas of team climate that they can improve, and the TCAM development sessions provide the opportunity to work on these areas.

 • The TCAM questionnaire measures team organisation and team

culture using 11 different Dimensions. Some of the Dimensions have Components that specifically relate to patient safety and effective patient safety incident management in clinical settings. The team’s responses to the questionnaire highlight where the team is doing well and where it can improve in terms of team working.

• The TCAM development sessions provide the team with an opportunity to work on the areas where they can improve.

Team Co-ordinator• The team co-ordinator will

– administer the TCAM questionnaire, – produce a report from the TCAM questionnaire – arrange and facilitate all sessions. – send a copy of the TCAM questionnaire responses

and the co-ordinators log to Aston Organisation Development (info@astonod.com) to assist in the continued development of TCAM.

Team members• Team members need to

– complete the TCAM questionnaire and return it promptly to the team co-ordinator.

– attend the TCAM questionnaire feedback sessions

– attend any TCAM development sessions the co-ordinator arranges.

What materials are available to run TCAM?

• The Co-ordinators guide

• TCAM theory

• TCAM questionnaire

• The Template for scoring TCAM

• The Template for the TCAM report

• The Team member resource book

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

X

X

X

X

X

X

X

X

1. Commitment to Quality

2. Priority given to Patient Safety

3. Incident Reporting

4. IncidentInvestigation

5. Learning from Patient Safety Incidents

6. CommunicationAbout Patient Safety

7. Personnel Management of Safety

8. Safety Education andRisk Management

9. Team working inRisk Management

1 2 3 4 5

Board responses?

X

X

X

X

X

X

X

X

X

Nurse responses?

X

Framework Document

Snapshot of whole tool (folded out)

Facilitator Guidance

Trust MaPSaF Toolkit• Hard copies of the tool relevant to

your care setting

• Copies of the Facilitators Handbook

• Internet resources: slide presentation & speaker notes

What can MaPSaF be used for:• To facilitate self-reflection at various levels

within an organisation• To promote patient safety as

multidimensional concept • To stimulate discussion about cultural

strengths and weakness• To highlight differences in perceptions of

staff groups • To view how a mature safety culture might

look.• To evaluate how interventions and change

may have impacted on your safety culture

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

Primary care contractors

Who can MaPSaF be used by ?

Wards & Departments

Maturity Levels

1. Why waste our time on safety?

2. We do something when we have an incident

3. We have systems in

place to manage all identified

risks

4. We are always on

the alert for risks that

might emerge

5. Risk management is an integral

part of everything that we do

Any Questions?