The importance of culture in patient safety

When things go wrong it’s often easier to focus on the particular processes, people or equipment that failed, and ignore underlying cultural issues. But large-scale failings like Mid Staffs demonstrate that there’s often something deeper wrong with the way the organisation thinks and behaves when it comes to safety issues.

A focus on culture

This month we get an inside view on Mid Staffs. Sir Stephen Moss, previously chair of the Trust, talks candidly about what was wrong with the organisational culture, and why it’s been such a struggle to put it right. At the other end of the spectrum we talk to Elaine Inglesby from Salford Royal NHS Foundation Trust, a trust that has transformed itself over the last ten years from a poorly performing organisation, to one of England’s best hospitals with a reputation for safety. They claim to have done this by changing the culture and placing a ‘relentless focus on safety and quality’.

Tebussum Rashid’s story reminds us of the devastating human impact of safety failures. She describes what happened to her sister-in-law, and how much she feels the issues can be traced back to problems inherent in the organisation’s attitude to both safety and diversity.

It’s widely expected that the Francis report (the public inquiry into failures of care at Mid Staffordshire NHS Foundation Trust due to report early 2013) will focus heavily on recommendations around regulation. But will this alone be enough to improve approaches to patient safety in the NHS?

The Health Foundation is convinced that specific work to improve organisational safety culture leads to both better outcomes for patients and higher levels of satisfaction for patients and staff. This is being demonstrated through their work on the Safer Clinical Systems programme and through evidence based reports such as Does improving safety culture affect patient outcomes?.

What is a positive safety culture?

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.

The scan reveals that high reliability organisations across multiple industries tend to have some consistent attributes. These include a continuous attitude to improvement, a learning culture, highly trained and rewarded staff, and the flexibility to deal with change. When describing a positive safety culture, the report also talks of a ‘collective mindfulness’ about safety issues, where leadership and frontline staff take a shared responsibility for ensuring care is delivered safely.

How to develop a safety culture?

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.

Regulation to drive culture change

So will increased government regulation help to bring about change? Hopefully it will help and will be used by trusts as Elaine Inglesby suggests, as ‘an enablement to move towards a safety culture, rather than a series of targets’.

Let’s also hope that the Francis report provokes an honest debate about prioritising safety which considers the importance of culture change and acknowledges how long that can take. As all the articles in this month’s issue show, regulation is just one part of the mix. For a safety culture to thrive, patient safety needs to be owned by the front line, backed up by effective and inspiring leadership and underpinned by good governance and robust regulation.