Embedding A Patient Safety Culture Burt Burtun Introduce yourself and make sure that everyone in the room knows each other. State that the purpose of the session is an opportunity to self-reflect on how much progress the team and/or organisation has made in developing a mature safety culture.

Learning Outcomes At the end of this presentation delegates will be able to: know the origin of MaPSaF appreciate the theory behind the framework Identify the characteristics of the different levels of maturity of the framework Identify the uses of MaPSaF Know how to individually record their perceptions of safety culture Know how to record their Team’s perception of safety culture Know how to agree on the actions they will need to take to move their team to the next level(s) of Safety Culture

Patient Safety Culture Challenges Why is Patient Safety Culture important? How can we develop a Patient Safety Culture in a Team/Organisation? How do we know what our Patient Safety Culture is now? What variables do we have to manipulate to create a Patient Safety Culture Change? How do we introduce these variables to produce the change? How will we know we are making a difference? How will we know when we get there?

Seven Steps to Patient Safety 1. Safety culture Lead & support staff 3. Integrated risk management 4. Promote incident reporting 5. Involve patients and the public 6. Learn and share lessons 7. Implement solutions State that the National Patient Safety Agency, a Special Health Authority with responsibility for improving patient safety in organisations providing NHS-funded care, issued a document called the 7 Steps to Patient Safety. Today’s focus group is concerned with the first one of the 7 steps; building a safety culture.

Patient Safety Culture

Seven Steps to Patient Safety 1. Safety culture Lead & support staff 3. Integrated risk management 4. Promote incident reporting 5. Involve patients and the public 6. Learn and share lessons 7. Implement solutions State that the National Patient Safety Agency, a Special Health Authority with responsibility for improving patient safety in organisations providing NHS-funded care, issued a document called the 7 Steps to Patient Safety. Today’s focus group is concerned with the first one of the 7 steps; building a safety culture.

Reducing Drug Errors Medicines do good and cause harm Leape et al - for South Central(London): 29,600 adverse drug events 296 fatal 66,600 additional bed days £44.4m additional costs Medication errors are the greatest single source of preventable errors

Reducing Drug Errors Effective medicines management achieves: Improved patient safety Reduced length of stay Delivering 18 week wait target Rapid discharge Minimised re-admissions Prevention of admissions

Reducing Drug Errors Causes: 33% linked to look alike / sound alike names 23% high workload / low staffing 20% inexperienced staff 14% transcription errors (data entry)

Payments made by NHSLA in respect of negligence claims against the NHS Payments made in the financial years 07/08 to 12/13 12/13 11/12 10/11 09/10 08/09 07/08 Scheme £’000 CNST 1,258,880 1,277,371 863,398 786,991 769,226 633,325 Liabilities to Third Parties Scheme (LTPS) 46,949 48,128 42,435 33,952 33,975 24,986 Property Expenses Scheme (PES) 3,650 4,262 5,546 6,424 3,914 2,730 TOTAL 50,599 52,390 47,981 40,376 37,889 27,716 GRAND TOTAL 1,309,479 1,329,761 911,379 827,367 807,115 661,041

As at 31 March 2013, the NHSLA estimates that it has potential liabilities of £22.9 billion, of which £22.7 billion relate to clinical negligence claims (the remainder being liabilities under PES and LTPS)

Seven Steps to Patient Safety 1. Safety culture Lead & support staff 3. Integrated risk management 4. Promote incident reporting 5. Involve patients and the public 6. Learn and share lessons 7. Implement solutions State that the National Patient Safety Agency, a Special Health Authority with responsibility for improving patient safety in organisations providing NHS-funded care, issued a document called the 7 Steps to Patient Safety. Today’s focus group is concerned with the first one of the 7 steps; building a safety culture.

“ADDING INSULT TO INJURY” – NHS FAILURE TO IMPLEMENT PATIENT SAFETY ALERTS (FEBRUARY2010) Over 300 NHS trusts (around three quarters of all trusts) had not complied with the required actions in at least one patient safety alert for which the deadline had already passed. There are 2,124 separate incidences of patient safety alerts not been complied with by NHS trusts as having been implemented.

80 NHS trusts had not confirmed they had complied with 10 or more separate alerts. 35 of these trusts have ‘Foundation Trust’ status. One trust had not confirmed compliance with as many as 37 (70%) of the alerts. Two trusts failed to comply with 31 (58%) of the alerts. There are over 200 incidences of NHS trusts who have not complied with alerts which are over five years old (issued before December 2004).

There is no system for monitoring implementation of alerts. Neither is there a robust system for checking that NHS trusts who declare themselves as being compliant actually are. The information about which trusts have or have not implemented the alerts is not publicly available. A request made under the Freedom of Information Act.

There were 141 instances of non-compliance with alerts in January 2014 compared with 455 in the last report in August 2011 and 2,124 in February 2010. Every alert not complied with represents a serious risk to patients, and there are 14 examples of trusts who have still not complied with 3 or more patient safety alerts for which the deadline is past There were 13 cases where the deadline has been exceeded by over 5 years.

141 instances of a patient safety alert not having been complied with 83 trusts are recorded as not having complied with at least one alert 14 trusts had not complied with at least three alerts 17 instances of alerts which had not been complied with which were over three years past the deadline 13 instances of alerts which had not been complied with which were over five years past the deadline.

Safer Sharps February 2014 Report 84 % of Trusts have revised and published their Sharps policy in the light of EU Directive. 39% completed the process in 2013 29% had the process in progress in 2013 16% of Trusts had no plans to revise their policy in the light of New Regulations

Implications for Trusts The CQC should treat non-compliance with any Patient Safety Alert which is past the deadline for completion much more seriously. The CQC should require an action plan from trusts who are non-compliant with an alert about how they will comply within a short time-scale. …new regulations for the CQC, to underline the mandatory status of Patient Safety Alerts… The CQC’s inspection process - audit a sample of alerts which have been declared “completed” to check if they have in fact been completed satisfactorily.

National Patient Safety Alerting System (January 2014) The three stages of patient safety alerts Stage 1 –Warning Consider if this (the risk issue) could happen/has happened locally; Consider if action can be taken locally to reduce the risk; Disseminate the warning to relevant staff, departments and organisations

National Patient Safety Alerting System (January 2014) The three stages of patient safety alert Stage 2 – Resource (some weeks or months after) Sharing of relevant local information Sharing of examples of local good practice that mitigates the risk identified in the stage one alert; Access to tools/resources that will help providers implement solutions to the stage one alert; Access to learning resources. Ultimately, we plan to offer continuing professional development (CPD) credits on topics relevant to the alert.

National Patient Safety Alerting System (January 2014) The three stages of patient safety alert Stage 3 – Directive Trusts to confirm they have implemented specific solutions or actions to mitigate the risk. Sign Off – through high level Board involvement

Build A Safety Culture Time to reflect Small Group Exercise (5 minutes): Complete the following statement. My Organisation’s Safety Culture is….

NPSA Seven Steps to Patient Safety Step One: Build a safety culture A safety culture is…. A culture where staff have a constant and active awareness of the potential for things to go wrong A culture that is open and fair, and one that encourages people to speak up about mistakes Duty of Candour Being Open Policy Read the definitions of safety culture from the slide. State that basically, a safety culture is ‘the way we do things around here, our approach to risk management, the way we think and behave in response to risks in our healthcare environment.’

The Incident Decision Tree (IDT) The Incident Decision Tree aims to help the NHS move away from attributing blame and instead find the cause when things go wrong. The goal is to promote fair and consistent staff treatment within and between healthcare organisations. http://www.nrls.npsa.nhs.uk/resources/all-settings-specialties/?entryid45=59900&q=0%c2%acIncident+Decision+Tree%www.nrls.npsa.nhs.uk/resources/all-settings-specialtiesc2%ac

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 Explain that one framework which allows teams and organisations to think about their safety culture is the Manchester Patient Safety Framework. This is a tool that was originally developed in a collaboration between the National Primary Care Research Development Centre and Manchester University’s Psychology department and is based on We strum's theory of how organisations process information. It was first developed for primary care organisations, based on an original tool developed for the oil and gas production company, Shell. Shell’s tool is called ‘Hearts and Minds’ ; it enables staff to self-reflect on their progress in developing a mature and robust safety culture. This tool was based on numerous interviews with managers and chief executives. The tool developed for primary care has now been piloted in all NHS care settings and there is a version specifically for each.

The theory behind the framework Pathological Information is hidden Messengers are “shot” Responsibilities are shirked Bridging is discouraged Failure is covered up New ideas are actively crushed Westrum differentiated between three types of organisation in terms of how they process information; pathological, bureaucratic and generative: Pathological, is where people don’t really care about safety and are only driven by regulatory compliance and not getting caught. At this level you can hear people say things like “of course we have accidents, it’s a dangerous business”. Team working across the organisation (i.e. bridging) is ignored and so is bad news. Staff are discouraged from highlighting safety issues.

Characteristics of the bureaucratic organisation Information may be ignored Messengers are tolerated Responsibility is compartmentalised Bridging is allowed but neglected Organisation is just and merciful New ideas create problems The next level is Bureaucratic. This is where an organization is comfortable with systems and numbers. A risk management system has been implemented successfully and there is a major concentration upon the statistics and ticking the boxes to demonstrate that the organisation is safe. Staff who highlight safety issues are tolerated, but still unwelcome. Bridging, i.e. learning across the organisation, is allowed but its benefits are neglected. In bureaucratic organisations lots of data is collected and analysed, and people feel comfortable making changes to procedures and processes. There are many audits and people begin to feel they have cracked it but they are really just ticking boxes to demonstrate to external regulators they are safe, and safety is not integral in the hearts and minds of staff.

Characteristics of the generative organisation Information is actively sought Messengers are trained Responsibilities are shared Bridging is rewarded Failure causes inquiry New ideas are welcomed Generative organizations set very high standards for safety and it is ingrained in the hearts and minds of all staff throughout the organisation. They are honest about failure, but use it to improve, not to blame. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing unwelcome news. People live in a state of ‘chronic unease’ and are mindful of what could go wrong, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next. At this level bad news is actively looked for, because it provides the best opportunity to learn, so messengers are trained and welcomed.

Expanding the framework Reason (1997) revised and added two further levels Pathological Reactive Calculative or bureaucratic Proactive Generative Additions approved by Westrum (1999) Westrum’s framework was later expanded by Reason (1997) who added two further categories; reactive and proactive to show the stages in between pathological and bureaucratic and bureaucratic and generative respectively.

Levels of maturity with respect to a safety culture E. Risk management is an integral part of everything that we do D. We are always on the alert for risks that might emerge C. We have systems in place to manage all identified risks The Levels of Safety Culture used in MaPSaF The best way to understand an safety culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before. The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, the Generative. Pathological, is where the prevailing attitude is ‘why waste our time on safety?’ Reactive, is where safety is taken seriously, but it only gets sufficient attention after things have already gone wrong. Calculative or bureaucratic organisations are those which have a tick box culture and approach to managing safety. This is where an organization is comfortable with systems and numbers. Proactive: Proactive organisations consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, not just in theory. Generative organizations are the nirvana of a mature safety culture. They live in a state of ‘chronic unease’ and are mindful of what could go wrong, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next. At this level bad news is actively looked for, because it provides the best opportunity to learn, so messengers are trained and welcomed. NB THIS SLIDE REPEATS SOME OF THE INFORMATION ON PRECEDING SLIDES TO FAMILIARISE THE AUDIENCE WITH KEY TERMS B. We do something when we have an incident A. Why waste our time on safety? PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE

Phase One development: Primary care Nine dimensions of patient safety considered Content of framework determined through 30+ in depth interviews Interviewees included Chief Execs., Clinical Governance leads, practice nurses, PCT managers and GPs MaPSaF was developed in two phases; In the first phase of development, the University of Manchester team carried out interviews with a range of primary care staff. Nine dimensions of patient safety were identified from a review of the literature and these were corroborated by opinion leaders from primary care organisations. The for each dimension of patient safety, a description of what an organisation would look like on each of Westrum and Reason’s categories was developed.

Dimensions of safety covered Overall commitment to quality Priority given to patient safety Perceptions of the causes of patient safety incidents and their identification Investigating patient safety incidents Organisational learning following PSIs Communication about safety issues Personnel management and safety issues Staff education and training about safety Team working around safety issues The nine dimensions identified for primary care were identified as follows: Overall commitment to quality Priority given to patient safety Perceptions of the causes of patient safety incidents and their identification Investigating patient safety incidents Organisational learning following PSIs Communication about safety issues Personnel management and safety issues Staff education and training about safety Team working around safety issues For each of these dimensions a description of what an organisation or team would look and feel like for each of the five organisational types was developed. The output of this work was a matrix or framework, similar to the format of the one you have in front of you now.

Phase Two Development NPSA involvement Adaptation and revision of framework using focus groups Production of four versions (acute, primary, mental health, ambulance) Pilot testing of final versions in workshops In Phase Two of MaPSaF’s development the NPSA funded the Manchester team to develop a version of MaPsaF for acute, mental health and primary care settings. Two focus groups comprising a range of staff from mental health, acute and ambulance settings were used to identify the dimensions of patient safety for their particular care setting. Group discussions were held with teams from each of the four sectors in order to adapt the original primary care version to the other sectors and to ensure the content of the framework was agreed upon. Possible ways to use the framework were also considered and discussed. The output of these group discussions were the four versions of MaPSaF which have been finalized and produced in Manchester. The use of the framework was piloted in the four sectors in early 2005 in a number of workshops. The labelling of the dimensions differs slightly across the four health sectors: Primary, Acute, Mental Health and Ambulance. Once the content of the frameworks had been developed they were piloted in each care setting to ensure that they were fit for purpose.

Snapshot of whole tool (folded out) This is a bigger image of the MaPSaF framework

Framework Document This is the tool itself – it starts A4 size and folds out to a large table-top size – ideal for group work and for encouraging discussion. The tool comes with full supporting explanatory notes and explains some of the background to its development.

What can MaPSaF be used for? To facilitate self-reflection on safety culture maturity of a given healthcare organisation and/or team To help a team recognise that patient safety is a complex multidimensional concept To stimulate discussion about the strengths, weaknesses and differences of the patient safety culture in a team, between staff groups or in an organisation To help understand how an organisation and/or team with a more mature safety culture might look. To help evaluate any specific intervention to change the safety culture of your organisation and/or team Read the uses of MaPSaF from the slide

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 Stress the point that MaPSaF is not a performance management tool and should not be used as such. It is best used as an educational tool and as a stimulus for discussions about an organisation’s or team’s safety culture. Evidence from the focus groups and pilot work suggests that MaPSaF provides a neutral framework for having discussions about safety culture which might otherwise not be identified.

Who can MaPSaF be used by? Clinical Governance & Risk Committees Professional Groups Trust Boards Directorates & Specialties Multi-disciplinary Teams Read out the different types of professional groups and stakeholders who can use MaPSaF, emphasising that because it is accessible to so many groups it can identify differences in perceptions between groups and individuals; are often the first indicator that there is further work needed to improve safety culture. Wards & Departments

What is OUR patient safety culture? Interactive Session What is OUR patient safety culture? Read through the framework - do this on your own So what is out safety culture really like? What I’d like to do now is read through the MaPSaF framework and think about how mature our organisation and/or team is on each of the dimensions of patient safety. It is better to read across the framework horizontally, reading through the descriptions of each dimension of patient safety one at a time. We’ve got plenty of time so don’t worry.

1. Recording your perceptions On the evaluation sheet provided mark, using a ‘T’ and an ‘O’, your perception of how mature the safety culture is. ‘T’ = Team ‘O’= Organisation As you read through each dimension of patient safety, I’d like you to mark on your evaluation sheet where you think the organisation and/or team are. What’s our level of maturity on each dimension of patient safety? Are we reactive on some dimensions but proactive on others? Use a T to denote your perception of where the team is and an O to denote your perception of where the organisation is. There are no right or wrong answers and I’d like you to do this exercise on your own. The aim is to identify and explore your perceptions. We’ve got about 30 minutes so do take your time.

Mental Health

Ambulance

Acute

Primary Care

2. Work in pairs Discuss your perceptions with the person sitting next to you. Explain why you made the choices you did Now I’d like you to pair up with the person sitting next to you and discuss each other’s perceptions together. Explain to each other why you rated the Team and/or the organisation as you did. Remember, there is no right or wrong answer. It is not a test so don’t worry if you have different viewpoints.

3. Group Discussion Where did you place yourselves? Why? What information did you use to make this decision? What other information do you need? Okay, let’s discuss each other’s perceptions as a group now. Would one pair start and share with the group their perceptions and the reasons we have placed ourselves at certain levels in the framework? At this point it is important to ensure that all pairs views are heard and to time manage the discussion effectively. The questions on the slide can be used as prompts to drill down to the reasons why staff rated different dimensions of patient safety in a particular way.

4. Action Planning What are our strengths and weaknesses? What level do we want to get to for each risk dimension? How do we get there? Who needs to be involved to make it happen? What next? After filling in the evaluation sheet as a group you should direct the group towards thinking about what actions you need to take to move your organisation/team to the next level(s) of safety culture. Structure the discussion using the questions on this slide and the table in Appendix 1 of the Facilitator’s Guide.

Remember!

Any Questions?

Resources to Support Patient Safety http://www.nrls.npsa.nhs.uk/resources/type/toolkits/ OR patientsafetyhelpdesk@npsa.nhs.uk

References and Resources Staff engagement and/or ownership/priority given to patient safety Seven steps to patient safety www.npsa.nhs.uk/sevensteps Introduction to patient safety e-learning www.npsa.nhs.uk/health/resources/ipsel Medical error www.saferhealthcare.org.uk/IHI/Products/Publications/MedicalError Engaging clinicians www.npsa.nhs.uk/site/media/documents/1342_EngagingClin.pdf

References and Resources Reporting patient safety incidents National Reporting and Learning System www.npsa.nhs.uk/health/reporting Patient Safety Observatory report www.npsa.nhs.uk/site/media/documents/1280_PSO_Report.pdf Engaging clinicians www.npsa.nhs.uk/site/media/documents/1342_EngagingClin.pdf

References and Resources Investigating patient safety incidents and learning from them Root cause analysis e-learning toolkit and training www.npsa.nhs.uk/health/resources/root_cause_analysis

References and Resources Communicating about patient safety incidents with patient and carers Being open policy, e-learning and one day training workshops www.npsa.nhs.uk/health/resources/beingopen

References and Resources Supporting staff involved in a patient safety incident Incident Decision Tree www.msnpsa.nhs.uk/idt2/(kht2ahft1belwmja2tlgre45)/index.aspx Being open policy, e-learning and one day training workshops www.npsa.nhs.uk/health/resources/beingopen

References and Resources Teamwork and team communication Team Climate Assessment Measure (2006) Safe handover: safe patients www.npsa.nhs.uk/site/media/documents/1037_Handover.pdf