One of the areas that I find most challenging now is when a statement is made about the ‘culture’ of a service. Whether this is from a regulator or colleagues, it's a label that sticks, and can be positive or negative. In 2018 the Care Quality Commission (CQC) chief inspector of hospitals, Professor Ted Baker, called for a change in culture within the NHS that he said would reduce the number of patients who experience avoidable harm. With the 2018 report Opening the Door to Change, the CQC was calling on the NHS and its partners to promote a change in safety culture to give safety the priority it deserves.
‘Staff know that what they do carries risk, but the culture in which they work is one that views itself as essentially safe, where errors are considered exceptional, and where rigid hierarchical structures make it hard for staff to speak up about potential safety issues or raise concerns.’
Cameron (2018), writing following the CQC's suspension of announced inspections in 2018, reflected that this could deliver a welcome ‘maturity leap’ in quality regulation, but warned that ‘trusts need to ensure their safety culture is strong and robust’ and that ‘safety culture cannot be “regulated in”; ownership lies with the provider board’ suggesting it should be the highest priority to lead and reinforce such a culture.
The 2019 NHS Patient Safety Strategy echoed this, saying that:
‘Culture change cannot be mandated by strategy, but its role in determining safety cannot be ignored. ‘Just cultures’ in the NHS are too often thwarted by fear and blame.’
NHS England/NHS Improvement, 2019
The strategy recognised that tackling inappropriate blame with a systems approach is not the only consideration, however. Within it, Dr Sonya Wallbank described the features of a safety culture and reflected on the success factors for healthcare organisations that want to be safe.
Psychological safety for staff: To enable individuals to work at their best, Wallbank said those colleagues need to feel supported within a compassionate and inclusive environment. She noted that psychological safety operates at the level of the group not the individual, with individuals needing to feel safe in the knowledge that fairness and compassion will prevail in the event of something going wrong. This in turn leads to staff not feeling the need to defend, but the ability to be open and learn.
Diversity: Team psychological safety is characterised by inclusivity, trust, and respect. Valuing differences, Wallbank said, can stimulate learning and creativity.
Compelling vision: Wallbank cited the need for an explicit vision with long-term thinking with high aspirations for teams before leadership can be practised well.
Leadership and teamwork: Put simply, feeling part of a team protects individuals against the demands of the organisation they work for; if they have clarity about their role in the team, they are less likely to burn out and more likely to operate in a safe way.
Open to learning: An organisation that identifies, contains, and recovers from errors as quickly as possible will be alert to the possibilities of learning and continuous improvement.
Cameron (2018) reflected that although improving safety cultures takes a sustained effort, the improvement journeys of several trusts have shown that safety can be strongly enhanced by building a closer connection between senior leaders and frontline staff, in addition to empowering staff and involving patients in their care. She recommended three areas of focus to enhance safety culture:
- Highly visible senior management and leadership
- Encouraging vigilance, information sharing, collaboration, teamwork, and clear communication on safety performance
- Nurturing staff resilience by saying thanks, celebrating good outcomes, being kind when colleagues show signs of fatigue, creating moments and a space for time out, and encouraging self-care.
I think that proactive assessment of safety culture is my next focus. I was also interested to note that in the planned Patient Safety Strategy update (NHS England/NHS Improvement, 2021) there was a refresh on the actions to monitor and support the development of a safety culture in the NHS, and explicit commitments to:
- Establish the safety culture work programme to bring together data, research and practical support for safety culture improvement.
- Produce a safety culture guide to help organisations implement specific improvement activities. Activity will also expand to mental health, community, and primary care settings.
The development of a systematic national approach would be welcome and I look forward to participating in any opportunities to develop and understand assessing and developing patient safety culture.