Much is made of the NHS Staff Survey and rightly so, and, although it tackles many broad areas of how it feels to work in an organisation, what really matters to clinicians is how to practise with patient safety at the heart of everything that we do, and how safe it feels to practise.
In late 2018 the Care Quality Commission (CQC) released its report Opening the Door to Change (CQC, 2018a), with the CQC's Chief Inspector of Hospitals, Professor Ted Baker, calling on the NHS to promote a change in safety culture:
‘Everyone can play a part in making patient safety a top priority. But there is a wider challenge for us all to effect the cultural change that we need, to have the humility to accept that we all can make errors—so we must plan everything we do with this in mind.’
The CQC review was based on evidence gathered by inspectors during visits to 18 NHS trusts and through group discussions with staff, patients, the public and experts from other safety-critical industries. Although the review found a strong commitment from NHS staff to the safety of patients, it also found the current patient safety system to be complex, with trusts receiving guidance from a number of bodies, leading to confusion and a lack of clarity on which external organisations can provide information and support. Added to this is the impact of increasing patient demand and staff shortages, which leave little time for staff to implement safety guidance effectively.
The CQC found that, although we accept that by its nature health care is ‘high risk’, increasing pressures within the NHS mean this is not consistently reflected in its culture and practice, in contrast to other safety-critical industries. The CQC considered that there was still much the NHS could learn from those industries to ensure risks are identified and managed proactively, with a greater understanding of team dynamics, situational awareness and human factors, and with safety protocols followed consistently.
In a new patient safety strategy, the recently merged NHS England and NHS Improvement (2019) dedicate a whole section to safety culture. The concept of ‘just cultures’ is often hampered by a culture of fear and blame. Blame can often be disguised within otherwise valid approaches to improvement such as training and reflection; these can be recommended for one individual only with an underlying assumption that this individual is the problem, which will not prevent future errors.
Sonya Wallbank, National Clinical Advisor to the Culture, Leadership and Engagement Project, describes the key features of a safety culture:
Another area highlighted is the importance of everyday behaviours, kindness and civility, described by Suzette Woodward (NHS England and NHS Improvement, 2019). She argues that civility may be seen as ‘nice, tame and safe’, but when it is missing, we start to see its importance, and safety is often compromised.
My chief medical officer and I have a joint objective to ‘improve the safety culture’ of our organisation. Among a number of interventions, we have been seeking how we might measure our safety culture beyond the related questions from the staff survey. Our NHS Improvement quality team suggested using the University of Texas Safety Attitudes Questionnaire (https://tinyurl.com/y32rx2vk). The developers, Sexton et al (2006), showed that the survey demonstrates good psychometric properties. Healthcare organisations can use it to measure caregiver attitudes about six patient safety-related domains, to compare themselves with other organisations, prompt interventions to improve safety attitudes and measure the effectiveness of these interventions.
We are currently piloting this questionnaire, which appears to have applicability across different services, with a view to embedding this as a key performance indicator for regular monitoring, and hope to track the improvement of our safety culture using this tool.