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Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA.

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Presentation on theme: "Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA."— Presentation transcript:


2 Developing a safety culture Introduced by Dr David Gozzard, Associate Medical Director, MIAA

3 Assessing Organisational Culture Dame Elizabeth Fradd, Independent Health Advisor

4 What is your Board doing to develop a patient safety culture, what's working and what needs more focus ?

5 ©2013 Robert Francis QC5 “ 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 Is this true today?

6 ©2013 Robert Francis QC6 Evidence of poor care in all types of care settings – 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 Background


8 ©2013 Robert Francis QC8 “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 Descriptions of culture

9 ©2013 Robert Francis QC9 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 Drivers to develop a Cultural Barometer

10 ©2013 Robert Francis QC10 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 – – resources to deliver – support to do the job – a job that offers the chance to develop; and – the opportunity to improve team working

11 ©2013 Robert Francis QC11 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 Barometer Design 2

12 ©2013 Robert Francis QC12 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 The Barometer is designed to:

13 ©2013 Robert Francis QC13 Responsibility for developing a patient safety culture Assurance Duty of Candour The human impact The Board

14 ©2013 Robert Francis QC14 How effective is your Board at leading the development of a patient safety culture ? Group Discussion 1

15 ©2013 Robert Francis QC15 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

16 ©2013 Robert Francis QC16 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. Drivers for a positive Universal culture

17 ©2013 Robert Francis QC17 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 Ingredients of a culture of sharing in Mid Staffordshire report – reflected in Barometer

18 ©2013 Robert Francis QC18 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 The Barometer is…

19 ©2013 Robert Francis QC19 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.

20 ©2013 Robert Francis QC20 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 2. The support I need to do a good job

21 ©2013 Robert Francis QC21 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 3. A worthwhile job with a chance to develop - A

22 ©2013 Robert Francis QC22 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 3. A worthwhile job with a chance to develop - B

23 ©2013 Robert Francis QC23 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 4. The opportunity to improve the way we work in my team - A

24 ©2013 Robert Francis QC24 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

25 ©2013 Robert Francis QC25 “Do you believe action will be taken in response to the results of the questionnaire?” Final Question

26 ©2013 Robert Francis QC26 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 Next Steps

27 ©2013 Robert Francis QC27 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 We strongly advocate;

28 ©2013 Robert Francis QC28 “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 Leadership

29 ©2013 Robert Francis QC29 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 ? Group Discussion 2

30 Tea and Coffee

31 Re-building confidence in Board Leadership Introduced by Deborah Arnot


33 ©2013 Robert Francis QC33 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’

34 ©2013 Robert Francis QC34 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.

35 ©2013 Robert Francis QC35 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. Francis Confirmation

36 ©2013 Robert Francis QC36 ‘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…’. NHS Assessment of bullying

37 ©2013 Robert Francis QC37 There was no bullying ‘whatsoever ’ WHO BASED ON THAT CRITERIA WROTE?

38 ©2013 Robert Francis QC38 Biggest problem for Boards Denial


40 ©2013 Robert Francis QC40 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) Role of Board in Culture

41 ©2013 Robert Francis QC41 Tried and tested has not worked in those organisations with the cultures described by Francis…….. ………………they are good a cover up Difficulty of diagnosis for Non-Executive Directors

42 ©2013 Robert Francis QC42 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 Difficulty of diagnosis for Non-Executive Directors

43 ©2013 Robert Francis QC43 Overarching management culture Beyond process and Board reports Walk the floor Engage with staff at all levels Turn stones Challenge Common sense………… No Magic Bullet

44 ©2013 Robert Francis QC44 Overarching management culture The most important decision Non Executives will take is the appointment of the Chief Executive No Magic Bullet (cont.)

45 ©2013 Robert Francis QC45 Your significant concerns about the quality of the corporate governance cannot be resolved? Public comment and resignation Ultimate Non-Exec Obligation

46 The Role of Managers Introduced by Steve Connor

47 The Role of Managers Nigel Edwards, Senior Fellow, The Kings Fund

48 "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."

49 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.

50 A Question What is the basis of management & leadership ethics in the NHS? Put down some phrases and ideas that describe this?

51 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

52 Is there an issue? Some genuine dilemmas: Individual or collective? Different valuations of outcomes

53 A Question What are the issues that cause you the most ethical concern? And why?

54 Normalising deviance Small steps and compromises Well intentioned trade-offs Failing to act, correct or feedback

55 A Question What approaches do you use to understand and deal with ethical conflicts?

56 An old but useful approach David Seedhouse’s grid – 4 layers: Basic purpose Moral duties Outcomes and priorities Practicalities


58 Ethical culture Five disciplines – Mindfulness – Voice – Respect – Tenacity – Legacy

59 Mindfulness Constant attention Focus on failure Reference back to values Intuition matters

60 Voice Not just a team player able to speak out Leaders create a safe space for difficult conversations People can raise difficult issues

61 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

62 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?

63 Ethical leadership Noble purpose Candour Ceaseless ambition Passion

64 Ethical governance Culture Succession Curiosity and external reference

65 Checklist 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?

66 Final question One action to take home?

67 A practical Response to the recommendations from Francis – from Board to Ward and Ward to Board Facilitated by David Gozzard

68 Question Top 3 combined individual actions you intend to commit to as a result of your learning?

69 Question Top 3 combined board actions?

70 Evaluation, moving forward and close Deborah Arnot and Steve Connor

71 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

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