Five top tips for using safety culture surveys

Building a positive safety culture

A positive safety culture in health care can be thought of as having a collective responsibility for patient safety, from the ward to the board. This is a common characteristic of high reliability organisations, where a constant concern about safety is weaved into the organisational fabric.

So how can organisations focus on building a positive safety culture? A good first step is to measure the existing safety culture of a particular team or unit, using a safety culture survey. Research shows that one third of NHS trusts in England are currently using surveys to measure their safety culture and identify issues.

Useful tips

We spoke to three organisations about the benefits of using safety culture surveys and asked what advice they might offer to others. Here are their five top tips for using safety culture surveys:

• 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.

Insight from teams who’ve used safety culture surveys

‘I’ve worked in the NHS for 30 years, and I can testify to the impact that these conversations [using safety culture surveys] have had.’

Alison Lovatt is Clinical Improvement Network Director at the Yorkshire and Humber Improvement Academy. The Academy is using the Safety Attitudes Questionnaire (Teamwork and Safety Climate) developed by the University of Texas, as part of its Improving the Safety of Frontline Care programme. Working with multi-disciplinary teams, the first thing they did was to test the safety culture:

‘The aim was to test the impact of a set of interventions we were introducing, but also for the survey to be an intervention in its own right.’

Alison recalls the survey scores for a particular team, which were positive across the board except for one question – only 13% of staff said they would feel safe on the ward as a patient. After running focus groups, they found this was due to concerns about staffing levels at particular times of day. The solution was to change the staffing schedules and introduce safety briefings.

Professor Peter Spurgeon is Director of the Institute of Clinical Leadership at Warwick Medical School, which supported the Health Foundation’s Safer Clinical Systems programme. Peter worked with eight NHS teams to systematically identify risks in their clinical pathways, and used the Safety Culture Index to provide a picture of the safety environment they were working in (email research@perform.gotadsl.co.uk for details of this tool).

Six out of the eight sites recorded a significant overall improvement in their scores from the start to the end of the programme, with most change seen around ‘participation in decision-making’. Peter suggests these tools can be very valuable as long as you are clear about what they can and can’t tell you:

‘It’s not a measure of safety but of people’s attitudes towards it. So a low score suggests a higher probability of safety being compromised, but cannot show you where or in what form. What it does give you is an invaluable overall picture of the safety environment and a sense of where something is wrong, allowing you to investigate further.’

Jodie Whittle and Andrea McGuinness are both Improvement Advisors at AQuA. They used safety culture surveys with a range of organisations as part of the Health Foundation funded Community Safety Aimed at the Frail Elderly (Com SAFE) and Patient Safety Champions Programmes (PSC).

Using the free-to-access Manchester Patient Safety Framework (MaPSaF) and the Patient Safety Culture Survey (PSCS) tool, the teams sought to demonstrate an improved safety culture following a number of interventions.

Seven teams from Com SAFE completed the PSCS survey, with five demonstrating an improved safety culture. Of particular interest was the insight gained into the two that didn’t. They discovered that this was because staff had become aware of previously unknown safety issues, many of which were out of their control to affect (eg staffing levels). For all the teams, the opportunity to open up conversations about safety challenges comfortably and without prejudice was an undoubted benefit. As Andrea McGuinness says:

‘Sharing the survey results is a unique opportunity for staff to talk about issues directly within their teams and with the board, in a way that is seen as constructive and not critical.’

• Evidence scan: Measuring safety culture
• Evidence scan: Does improving safety culture affect patient outcomes?
• Event report: Safety culture: What is it and how do we monitor and measure it?