Self-reflecting on our safety culture INSERT FACILITATORS NAME HERE

Housekeeping Start & Finish Times Fire Alarm Tea, coffee, lunch Mobiles and pagers Toilets Don’t get too comfy!

Seven Steps to Patient Safety 1.Safety culture 2.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

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

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

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

Characteristics of the bureaucratic organisation Bureaucratic Information may be ignored Messengers are tolerated Responsibility is compartmentalised Bridging is allowed but neglected Organisation is just and merciful New ideas create problems

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

Expanding the framework Reason (1997) revised and added two further levels –Pathological –Reactive –Calculative or bureaucratic –Proactive –Generative Additions approved by Westrum (1999)

Levels of maturity with respect to a safety culture A. Why waste our time on safety? B. We do something when we have an incident C. We have systems in place to manage all identified risks D. We are always on the alert for risks that might emerge E. Risk management is an integral part of everything that we do PATHOLOGICALREACTIVEBUREAUCRATICPROACTIVEGENERATIVE

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

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

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

Snapshot of whole tool (folded out)

Framework Document

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

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

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

What is OUR patient safety culture? Interactive Session Read through the framework - do this on your own

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

Mental Health

Ambulance

Acute

Primary Care

Discuss your perceptions with the person sitting next to you. -Explain why you made the choices you did 2. Work in pairs

3. Group Discussion Where did you place yourselves? Why? What information did you use to make this decision? What other information do you need?

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?

Any Questions?