3NWC AHSN & AQuA NWC Academic Health Science Network: AQuA: Cover Lancashire, South Cumbria, Merseyside & CheshireBring together healthcare and academic organisations in partnership with industry, local authorities and other agencies.Key delivery of Patient Safety Collaboratives and supporting members in their Sign Up To Safety work.AQuA:North West health improvement organisationMembership: CCG, Acute, Primary care, Community, Mental Health and Ambulance Trusts across North West EnglandMission is to stimulate innovation, spread best practice and support local improvement in health and in quality and productivity of health services
4Patient Safety Collaboratives NWC AHSN and AQuA are supporting those responsible for patient safety across the region through:Networking eventsCapability building sessions:Improvement Practitioner modulesAdvanced Team TrainingPatient Safety ChampionsHarm-specific WebEx’s.Supporting organisations with Sign Up To Safety@NWCAHSN #NWCSaferNHS
5Twitter @AQuA_Inform @NWCAHSN #NWCSaferNHS Next EventsNWC Patient Safety Network Launch EventDate: Friday 13 March 2015,Venue: TBCWho Should Attend: Safety Leads, Executive sponsors and Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria.To book:Improvement Practitioner: MeasurementDate:, Wednesday 30 March 2015,Venue: Vanguard House, Daresbury.Who Should Attend: Safety Leads, Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria who wish to increase knowledge on measurement for improvement, particularly pertinent to those organisations prospectively measuring and monitoring safety (e.g. Safety Improvement Plans).To book:Improvement Practitioner: Culture for ImprovementDate: Wednesday 22 April 2015,Who Should Attend: Safety Leads, Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria who wish to increase knowledge on how to build a culture for improvement in safety across their organisation.To book:Improvement Practitioner: Human FactorsDate: Friday 1 May 2015,Who Should Attend: Safety Leads, Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria who wish to increase knowledge on Human Factors and errors.To book:Patient Safety Network EventDate: Wednesday 20 May 2015Who Should Attend: Safety Leads, Executive sponsors and Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South CumbriaTo book:@NWCAHSN #NWCSaferNHS
9Feedback from Day 1Gave me a huge insight into patient safety relating to other issuesVery thought provokingPlenty of involvement with the group. Also to share experiences. Loved the Lucille ball clip!
10Feedback from Day 1Only one presentation style for whole day. Needed other activitiesA lot to pack in though especially near the end when my concentration was low
13Fundamental Component of Quality Fundamental DarziSafetyEffectivenessPatient CenterednessFundamental Component of Quality FundamentalInstitute of MedicineSafetyTimelinessEffectivenessEfficiencyEquityPatient Centeredness
24Poor quality care accounts for 25% healthcare budget It Can Save MoneyPoor quality care accounts for 25% healthcare budgetHealthcare associated infections > £1billionCosts of successful litigation circa £800mSafe care is part of the QIPP challenge
28Take Home Message for Executives There is a legal, strategic, operational, constitutional, regulatory, financial, professional and moral responsibility to improve patient safetyYou cannot afford to ignore it
29What does safety mean to you? What does safety mean to patients?Brief intro of the session
30“Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the Boards of Trusts”Berwick Review, August 2013Think about this one
31“ Patients and families are not guests in our organisations, it is we who are guests in our patients lives”Don BerwickPoint to ponder
34‘A safety culture is where staff within an organisation have a constant and active awareness of the potential for things to go wrong. Both the staff and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right.’The notion of safety culture was first explored in safety-critical industries following major disasters,most notably the Chernobyl nuclear accident in 1986 . A common definition of safety culturein the nuclear industry that is now widely adopted across industries suggests that:“The safety culture of an organisation is the product of individual and group values, attitudes,perceptions, competencies and patterns of behaviour that determine the commitment to, and thestyle and proficiency of, an organisation’s health and safety management. Organisations with apositive safety culture are characterised by communications founded on mutual trust, by sharedperceptions of the importance of safety and by confidence in the efficacy of preventive measures.”Safety culture can be described as “the way safety is done around here”, emphasising theimportance of understanding what people actually believe and do . What people believe aboutsafety and the importance given to safety within an organisation will strongly influence theirdecisions, and these beliefs and attitudes are shaped by individual experience and by interactingwith and observing peers . In the literature there is a distinction between safety culture andsafety climate. Safety climate commonly refers to more readily measurable aspects of safetyculture  and can be regarded as the surface features of the underlying safety culture .Assessment of safety climate is becoming increasingly popular and is conducted using quantitativesafety climate questionnaires. A deeper understanding of safety culture requires qualitativemethods as it is concerned with the more enduring underlying culture .In healthcare, the quantitative assessment of safety climate using questionnaires is an establishedapproach and recommended by bodies such as the Joint Commission . Such assessments can beused to :• Identify areas for improvement and raise awareness about patient safety• Evaluate patient safety interventions and track changes over time• Conduct internal and external benchmarking• Fulfil directives and regulatory requirements
36Attributes of high reliability organisations Continuous attitude to improvementLearning cultureHighly trainedRewarded staffFlexibility to deal with change‘Collective mindfulness’ about safety issues,Leadership and frontline staff take a shared responsibility for ensuring care is delivered safely.In order to try and answer this question the Health Foundation commissioned an evidence scan into the characteristics of ‘high reliability organisations’. These organisations work in hazardous environments like healthcare or aviation, but successfully find ways to minimise risk.
37How do we build a safety culture? Sir Stephen Moss‘developing a safety culture doesn’t happen overnight’.Martin Bromley‘culture change isn’t about doing one thing – it’s about doing lots of little things consistently and with purpose (whilst maintaining coordination).’SRFTconsistent leadership, building a sense of individual responsibility at every level.Most experience shows that there is no quick fix. In Sir Stephen Moss’ words, ‘developing a safety culture doesn’t happen overnight’. Organisations need to be in it for the long haul. Perhaps one of the reasons that Salford Royal is succeeding is that there’s been a consistent focus from a stable senior leadership team over the last decade. Working to build a sense of individual responsibility for safety issues in staff at every level has also been key.As Martin Bromley points out in a recent Health Foundation blog, ‘culture change isn’t about doing one thing – it’s about doing lots of little things consistently and with purpose (whilst maintaining coordination).’Measuring how good the safety culture is within an organisation helps to provide a starting point for change. Increasingly NHS organisations concerned with improving safety are using tools such as climate surveys to monitor the attitudes of staff to safety issues and identify areas for development. Patient complaints and feedback are also being looked at more carefully, and patients and families are being more formally involved in improvement work.
38Measuring & Understanding Culture is a good start! Culture Assessment ToolsStaff SurveysPatient and Carer SurveysComplaints / ComplimentsIncidentsSuccesses!!!!
46Action Planning for Improvement Understand your survey results.Communicate and discuss the survey results.Develop plans focused on actions.Communicate plans and clear deliverables.Implement action plans (remember what Jane Reid says about action plans!)Track progress and evaluate impact.Share what works.The delivery of survey results is not the end point in the survey process; it is just the beginning. Often, the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey followup.Seven steps of action planning are provided to give hospitals guidance on next steps to take to turn their survey results into actual patient safety culture improvement:
47Appeared in: Reliability Engineering & System Safety 2012;101:21-34A Novel Tool for Organisational Learning and its Impact on SafetyCulture in a Hospital DispensaryMark A. SujanWarwick Medical School, University of WarwickCoventry, CV4 7AL, UK
48Top Tips Start small Clarify your purpose Choose carefully Use holisticallyDon’t mandateStart small. There is no single ‘organisational culture’. Instead, choose a small team, unit or service to assess the safety culture, preferably testing the survey first to iron out any problems.Clarify your purpose. Do you want to target efforts on areas most in need of improvement, set a baseline for the impact of an intervention, or open up conversations about safety issues?Choose carefully. There any many different tools available, but no single tool is the ‘right one’ – understand their strengths and limitations, and ensure there is a dataset to benchmark yourself against.Use holistically. Used once and in isolation, survey tools are just a snapshot. But as part of a wider suite of tools and targeted measures, and used repeatedly (eg targeting higher risk periods, such as junior doctor rotations), they will be far more illuminating and impactful.Don’t mandate. Culture surveys can facilitate open discussions about risk and safety because staff are engaged in them, not because managers or regulators tell them to do it.
49To do listPlease watch the DVD’s as these will help you in the further modulesPlease ensure you have ed Clare with your visit preference
50Any Questions. Andrea. mcguinness@srft. nhs. uk clare. lancaster@srft Any Questions?