1. Innovation and Health Connected Presented by: Insert name Andrea McGuinness Safety Portfolio Lead

2. Housekeeping
Mobile Phones
Toilets
Fire Alarms
Fire Exits

3. NWC AHSN & AQuA NWC Academic Health Science Network: AQuA:
Cover Lancashire, South Cumbria, Merseyside & Cheshire
Bring 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 organisation
Membership: CCG, Acute, Primary care, Community, Mental Health and Ambulance Trusts across North West England
Mission is to stimulate innovation, spread best practice and support local improvement in health and in quality and productivity of health services

4. Patient Safety Collaboratives
NWC AHSN and AQuA are supporting those responsible for patient safety across the region through:
Networking events
Capability building sessions:
Improvement Practitioner modules
Advanced Team Training
Patient Safety Champions
Harm-specific WebEx’s.
Supporting organisations with Sign Up To Safety
@NWCAHSN #NWCSaferNHS

5. Twitter @AQuA_Inform @NWCAHSN #NWCSaferNHS
Next Events
NWC Patient Safety Network Launch Event
Date: Friday 13 March 2015,
Venue: TBC
Who Should Attend: Safety Leads, Executive sponsors and Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria.
To book:
Improvement Practitioner: Measurement
Date:, 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 Improvement
Date: 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 Factors
Date: 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 Event
Date: Wednesday 20 May 2015
Who Should Attend: Safety Leads, Executive sponsors and Safety Champions/Teams from across Lancashire, Cheshire, Merseyside and South Cumbria
To book:
@NWCAHSN #NWCSaferNHS

6. Patient Safety Champions Programme
Day 2

7. The Team
Jodie
Clare
Bernie
David
Andrea
Amanda

9. Feedback from Day 1
Gave me a huge insight into patient safety relating to other issues
Very thought provoking
Plenty of involvement with the group. Also to share experiences. Loved the Lucille ball clip!

10. Feedback from Day 1
Only one presentation style for whole day. Needed other activities
A lot to pack in though especially near the end when my concentration was low

13. Fundamental Component of Quality Fundamental
Darzi
Safety
Effectiveness
Patient Centeredness
Fundamental Component of Quality Fundamental
Institute of Medicine
Safety
Timeliness
Effectiveness
Efficiency
Equity
Patient Centeredness

14. It’s The Law

15. It’s Every Person’s Right To Expect Safety

16. It’s NHS Strategy

17. It’s NHS Strategy

18. It’s How Performance Will Be Judged

19. - Primary Care

20. - Secondary Care

21. It’s How We Are Regulated - now

22. Its how we will be regulated - future

23. It Can Save Money

24. Poor quality care accounts for 25% healthcare budget
It Can Save Money
Poor quality care accounts for 25% healthcare budget
Healthcare associated infections > £1billion
Costs of successful litigation circa £800m
Safe care is part of the QIPP challenge

25. It Can Preserve Income

26. It’s A Professional Responsibility

27. It’s The Right Thing To Do

28. Take Home Message for Executives
There is a legal, strategic, operational, constitutional, regulatory, financial, professional and moral responsibility to improve patient safety
You cannot afford to ignore it

29. What 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 2013
Think about this one

31. “ Patients and families are not guests in our organisations, it is we who are guests in our patients lives”
Don Berwick
Point to ponder

32. Are we on target?
At what cost?

33. Patient Safety Culture
Andrea McGuinness
Since the publication of An Organisation with a Memory [10] there has been a growing interest in
the topic of safety culture within the NHS. Research has shown that factors such as an emphasis on
production, efficiency and cost, or professional norms for perfectionism among healthcare providers
may combine to create a culture contradictory to the requirements of patient safety [30]. The
establishment of a “no-blame” culture within the NHS that facilitates the reporting of and the
learning from incidents has become one of the cornerstones of patient safety improvements. There
is now awareness that major cultural transformations must accompany structural and procedural
changes in order to achieve and sustain desired improvements in quality and safety of care [31]. Healthcare organisations need to learn about organisational deficiencies that may cause latent
failure conditions in the work environment
© 2014 AQuA

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 [32]. A common definition of safety culture
in 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 the
style and proficiency of, an organisation’s health and safety management. Organisations with a
positive safety culture are characterised by communications founded on mutual trust, by shared
perceptions of the importance of safety and by confidence in the efficacy of preventive measures.”
[33]
Safety culture can be described as “the way safety is done around here”, emphasising the
importance of understanding what people actually believe and do [34]. What people believe about
safety and the importance given to safety within an organisation will strongly influence their
decisions, and these beliefs and attitudes are shaped by individual experience and by interacting
with and observing peers [32]. In the literature there is a distinction between safety culture and
safety climate. Safety climate commonly refers to more readily measurable aspects of safety
culture [35] and can be regarded as the surface features of the underlying safety culture [36].
Assessment of safety climate is becoming increasingly popular and is conducted using quantitative
safety climate questionnaires. A deeper understanding of safety culture requires qualitative
methods as it is concerned with the more enduring underlying culture [32].
In healthcare, the quantitative assessment of safety climate using questionnaires is an established
approach and recommended by bodies such as the Joint Commission [34]. Such assessments can be
used to [30]:
• 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

35. ‘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 the style and proficiency of, an organisation’s health and safety management. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.’
Organising for Safety: Third Report of the ACSNI
(Advisory Committee on the Safety of Nuclear Installations)
Study Group on Human Factors. Health and Safety Commission
(of Great Britain). Sudbury, England: HSE Books, 1993.
© 2014 AQuA

36. Attributes of high reliability organisations
Continuous attitude to improvement
Learning culture
Highly trained
Rewarded staff
Flexibility 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.

37. How 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).’
SRFT
consistent 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.

38. Measuring & Understanding Culture is a good start!
Culture Assessment Tools
Staff Surveys
Patient and Carer Surveys
Complaints / Compliments
Incidents
Successes!!!!

39. Patient Safety Culture Assessment Tools

40. Patient Safety Culture Survey
AHRQ has established comparative databases as central repositories for survey data from organizations that have administered the AHRQ patient safety culture survey instruments. The databases serve as important resources for sites wishing to compare their patient safety culture survey results to those of other sites in support of patient safety culture improvement.
The table below indicates the planned data submission time periods for the Surveys on Patient Safety Culture.
Planned Surveys on Patient Safety Culture Data Submission Periods
 are done every 2 years in USA
Hospital Survey on Patient Safety Culture & Medical Office Survey on Patient Safety Culture due 2015
Nursing Home Survey & Community Pharmacy Survey on Patient Safety Culture due 2016
As of October 2014, the number of international users that have administered the hospital survey now includes 59 countries, with 27 different translations. The nursing home survey has been administered in eight countries and translated into six languages. The medical office survey has been administered in 14 countries and translated into five languages. Lastly, the community pharmacy survey has been administered in five countries and translated into three languages.
AHRQ survey there is increasing evidence available about the
Validity and reliability of their dimensions.
© 2014 AQuA

41. Developing a culture survey for:
To support patient safety and quality improvement they sponsored the development of patient safety culture assessment tools.
Developing a culture survey for:
Hospitals*
Medical Offices
Nursing Homes
Pharmacies
© 2014 AQuA

42. Health care organisations can use these survey assessment tools to:
Raise staff awareness about patient safety.
Diagnose and assess the current status of patient safety culture.
Identify strengths and areas for patient safety culture improvement.
Examine trends in patient safety culture change over time.
Evaluate the cultural impact of patient safety initiatives and interventions.
Conduct internal and external comparisons.
© 2014 AQuA

43. © 2014 AQuA

46. Action 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:

47.
Appeared in: Reliability Engineering & System Safety 2012;101:21-34
A Novel Tool for Organisational Learning and its Impact on Safety
Culture in a Hospital Dispensary
Mark A. Sujan
Warwick Medical School, University of Warwick
Coventry, CV4 7AL, UK

48. Top Tips Start small Clarify your purpose Choose carefully
Use holistically
Don’t mandate
Start 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.

49. To do list
Please watch the DVD’s as these will help you in the further modules
Please ensure you have ed Clare with your visit preference

50. Any Questions. Andrea. mcguinness@srft. nhs. uk clare. lancaster@srft
Any Questions?