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In 2001 Salford Royal NHS Foundation Trust was a poorly performing trust. Today, it is widely considered the leading trust in safety and quality improvement.

It has won a host of awards, most recently the NHS/Nursing Times patient safety award for overall safety culture, in July 2012. Elaine Inglesby, Executive Nurse Director, explains how they’ve achieved so much in a short space of time.

Salford Royal receives consistently high ratings for service as well as patient and staff satisfaction. What makes it different?

If a staff nurse came into this organisation for the first time, I think they would very quickly notice that the solutions lie at the front line rather than senior management. That’s a culture that we’ve very firmly embedded. We are not at all risk averse. Our approach is: don’t seek permission – seek forgiveness afterwards. If you’ve got an idea and you want to try it, do a PDSA [plan, do, study, act] analysis and then go ahead. And if it works, make sure you share the learning.

Our journey as a trust started in 2001, when chief executive David Dalton joined. He pulled a team around him and increased performance. Many of the senior management have been there a long time, and I’m sure stability helps – but only if it’s the right team. Developing our 2008 quality improvement strategy was key. It heralded a cultural shift towards paying absolute attention to quality and safety.

How do you go about formally measuring your safety culture?

We measure using a whole host of indicators including patient and staff experience, reliability, experience and harm. In 2008, we set out to save 1,000 lives in three years – and we managed to save 953. We’re currently aiming to become the safest organisation in the NHS.

How did you establish such a strong safety culture?

We developed four core values (patient and customer focus, continuous improvement, respect and accountability) and the staff developed a framework of behaviours within those categories. So, staff are held to account against the standards that they themselves set.

Our performance framework includes incentives and consequences. That sounds punitive, but good staff don’t mind being held to account for their actions. As a trust, we are willing to deal with poor performance. But we also provide a supportive environment that provides the tools staff need to do the job well. And we aren’t only interested in goals and objectives – staff are also assessed on how they deliver; values and behaviours have equal weight to outputs.

In what areas are you still trying to improve?

We’ve still got masses to do! We’re at the beginning of a journey, and I don’t think we’ll ever get there, because we just keep raising the bar. Next year, one area of focus will be on reducing readmissions, because we consider readmission to cause harm to a patient.

Has your approach been influenced by any other industries?

In 2007 I spent time at the Institute of Health Improvement, along with our finance director and chief executive, and that’s where we had our ‘road to Damascus’ experience that led to our first quality improvement strategy. Many of the approaches we were introduced to draw on international best practice within many industries.

We are currently developing a safety approach to teamwork that uses the language ‘Stop the line!’ This is clearly production-line speak. What it means is if you spot that something’s going awry, don’t press ahead regardless.

What advice would you offer to a trust wanting to develop a strong safety culture?

It can be helpful to start thinking about the national drive for safety as an enablement to move towards a safety culture, rather than a series of targets. When national messages come out about safety-related targets, we try to convert them into a different language that helps us think of them less as targets to aim for, and more as standards for meaningful improvement.

But for me, the top priority is to seek engagement and collaboration across the organisation. I believe it’s important to engage from the bottom up, but with a highly visible leadership in the organisation that puts safety first.

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