1. Assessing patient safety using the Manchester Patient Safety Culture framework (MaPSaF)
Facilitator: Prof. Dianne Parker
University of Manchester
and
Safety Culture Associates Limited
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.

2. NHS: 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
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.’

3. 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.

4. Characteristics of the pathological organisation
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.

5. 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.

6. 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.

7. 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.

8. 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
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
C. We have systems in place to manage all identified risks
B. We do something when we have an incident
A. Why waste our time on safety?
PATHOLOGICAL
REACTIVE
BUREAUCRATIC
PROACTIVE
GENERATIVE

9. 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 patient safety incidents
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.

10. 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

11. What MaPSaF is not:
A performance management tool for comparing or benchmarking organisations
A way of apportioning blame if an organisation’s 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.

12. Who can MaPSaF be used by?
Clinical Governance & Risk Committees
Professional Groups
Boards
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.
Directorates & Specialties
Multi-disciplinary Teams
Wards & Departments

13. What is YOUR patient safety culture?
Interactive Session
What is YOUR 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.

14. 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.

15. Short break We will collate the results from the whole group
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.

16. 3. Whole 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.

17. Results for Dimensions 1-4

18. Results for Dimensions 5-9

19. 4. Action Planning What are our strengths and weaknesses?
Table discussions of 3-4 key issues
Report back to plenary
Where are we now
Where do we want to get to?
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.

20. Thank you
Any Questions?