Developing a safety culture
Introduced 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 ?
Is this true today?
“ 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
©2013 Robert Francis QC
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Background
• Evidence of poor care in all types of care settings
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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
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Descriptions of culture
• “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
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Drivers to develop a Cultural Barometer
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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
©2013 Robert Francis QC
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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
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–resources to deliver
–support to do the job
–a job that offers the chance to develop; and
–the opportunity to improve team working
©2013 Robert Francis QC
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Barometer Design 2
• 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
©2013 Robert Francis QC
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The Barometer is designed to:
• 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
©2013 Robert Francis QC
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The Board
• Responsibility for developing a patient
safety culture
• Assurance
• Duty of Candour
• The human impact
©2013 Robert Francis QC
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Group Discussion 1
• How effective is your Board at
leading the development of a
patient safety culture ?
©2013 Robert Francis QC
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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
©2013 Robert Francis QC
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Drivers for a positive Universal culture
• 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.
©2013 Robert Francis QC
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Ingredients of a culture of sharing in Mid
Staffordshire report – reflected in Barometer
• 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
©2013 Robert Francis QC
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The Barometer is…
• 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
©2013 Robert Francis QC
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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.
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2. The support I need to do a good job
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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
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3. A worthwhile job with a chance
to develop - A
• 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
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3. A worthwhile job with a chance to
develop - B
• 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
©2013 Robert Francis QC
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4. The opportunity to improve the way we
work in my team - A
• 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
©2013 Robert Francis QC
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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
©2013 Robert Francis QC
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Final Question
“Do you believe action will be taken in response
to the results of the questionnaire?”
©2013 Robert Francis QC
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Next Steps
• 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
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We strongly advocate;
• 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
©2013 Robert Francis QC
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Leadership
• “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
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Group Discussion 2
• 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 ?
©2013 Robert Francis QC
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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 Bowles
David 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’
©2013 Robert Francis QC
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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.
©2013 Robert Francis QC
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Francis Confirmation
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.
©2013 Robert Francis QC
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NHS Assessment of bullying
‘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…’.
©2013 Robert Francis QC
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WHO BASED ON THAT CRITERIA WROTE?
There was no bullying ‘whatsoever’
©2013 Robert Francis QC
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Biggest problem for Boards
Denial
©2013 Robert Francis QC
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In a Nutshell…
IF THE NHS WERE AN
AIRLINE IT WOULD HAVE
BEEN SHUT DOWN
A PLANE CRASH A MONTH
©2013 Robert Francis QC
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Role of Board in Culture
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)
©2013 Robert Francis QC
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Difficulty of diagnosis for
Non-Executive Directors
Tried and tested has not worked in those
organisations with the cultures described by
Francis……..
………………they are good a cover up
©2013 Robert Francis QC
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Difficulty of diagnosis for
Non-Executive Directors
NHS LOTHIAN experience
Policies and procedures excellent
IIP and staff survey not remarkable
Review Methodology
•Trusted – unconnected with the organisation
•Structured 1:1 confidential interviews
•Focus groups
Culture findings in line with Mid Staffs report
©2013 Robert Francis QC
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No Magic Bullet
• Overarching management culture
• Beyond process and Board reports
• Walk the floor
• Engage with staff at all levels
• Turn stones
• Challenge
• Common sense…………
©2013 Robert Francis QC
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No Magic Bullet (cont.)
Overarching management culture
The most important decision Non
Executives will take is the appointment of
the Chief Executive
©2013 Robert Francis QC
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Ultimate Non-Exec Obligation
Your significant concerns about the
quality of the corporate governance
cannot be resolved?
Public comment and resignation
©2013 Robert Francis QC
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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 compromises
Well intentioned trade-offs
Failing 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 purpose
Moral duties
Outcomes and priorities
Practicalities
Ethical culture
• Five disciplines
– Mindfulness
– Voice
– Respect
– Tenacity
– Legacy
Mindfulness
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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
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Noble purpose
Candour
Ceaseless ambition
Passion
Ethical governance
• Culture
• Succession
• Curiosity and external reference
Checklist
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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 Board
Facilitated 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