Organisational working cultures in the NHS may differ considerably depending on which area of clinical practice the health professional is working in and this has important patient safety implications. In a hospital, the working culture may be different on the dialysis unit compared with that of the maternity unit or A&E. This diversity of culture can be found in all types of organisations. In terms of culture development and execution, organisations are wholly dependent on the staff they employ to properly carry out their functions and to translate their corporate mission statements into practice. These may often be bold, highly refined, ambitious, organisational mission statements.
The role of patient safety reports in organisational culture
Patient safety reports have a key role in helping staff maintain and develop good organisational cultures. They are a rich source of real-time information showing how nurses and doctors can better work in organisations and how best to reduce the risks of adverse health events occurring. They can reveal common trends, errors and ways of dealing with acute patient safety issues. They can function as good education and training tools, providing a baseline of good professional practice.
In reading patient safety reports and using them for training and education courses it is important to think beyond the specialty that they relate to. Healthcare delivery does not take place in conceptual or isolated clinical silos. Care is often delivered by more than one person in teams. Teams can also vary and involve different clinical specialties. Care is also given in an organisational context with various management hierarchies, systems, matrices and protocols. There may be set ways of doing things and staff may work within different organisation frameworks and cultures, but common themes can still emerge.
Many patient safety adverse events across the NHS are caused by common causes that exist regardless of clinical specialty. Failures in communication (between staff themselves and with patients), poor record keeping, not keeping up to date with changes in the care area, poor clinical techniques, poor staffing levels, not being aware of and adapting to new changing care environments. These are all common patient safety failings.
This commonality of cause means that patient reports from various clinical areas can have an NHS-wide value, relevance and application. It will usually be possible to extrapolate from them generally applicable patient safety themes that can apply in any healthcare context, and to help develop common and positive patient safety cultures.
HSIB report
The recent report by the Healthcare Safety Investigation Branch (HSIB) (2020) looking at delays to intrapartum intervention once fetal compromise is suspected is a prime example. Even though the focus of the report is on a maternity investigation, the errors found and the framework, methodology and observations used in the report can have a more general application across various care settings in the NHS.
There have been several previous reports into the issues investigated in this report:
‘There are recurring themes in the reports, such as loss of situation awareness (an awareness and understanding by staff of everything that is going on around them and its potential effects) and the importance of teamworking and multidisciplinary training.’
The report states that approximately 650 000 babies are born each year in England. The vast majority are delivered safely, but compared with other high-income countries there are higher numbers that are stillborn or who die soon after birth.
HSIB points out that national reports over the last 5 years have identified delay in intrapartum intervention once fetal compromise is suspected as a patient safety issue. The reports have made many recommendations to deal with the problems identified but systemic problems seem to still persist. The HSIB took a systems approach in order to identify aspects of ‘organisational resilience’.
Safety-I and Safety-II
The report has a discussion of investigative approaches: ‘Safety-I’ and ‘Safety-II’ are two different approaches that can be used to analyse the safety of systems. The explanation of these approaches, drawing on the work of Hollnagel (2015) and others, gives a useful insight into what can be termed ‘patient safety science’.
The Safety-I approach is the one most used in the NHS. This focuses on incidents and adverse outcomes that are believed to have happened because something goes wrong. The focus is on seeking to retrospectively see what happened and to rectify. Training policies, compliance and proper procedure adoption are key aspects of this approach.
Safety-II, on the other hand, does not concentrate on the minority of times when things go wrong, but seeks to understand how normal or routine performance results in safe outcomes generally:
‘Safety-II views safe outcomes and adverse outcomes as emerging from a same basis—that is, both types of outcome stem from everyday performance adjustments. Incidents are considered to arise from “unexpected combinations of everyday performance variability” rather than being a result of “distinct failures and malfunctions”.’
As HSIB explains, the focus is on day-to-day performance and how things generally go right, and understanding this:
‘The emphasis is on improving a system's capability to make sure things always go right, referred to as an organisation's resilience. A key feature of a system's potential for resilient performance is its “ability to adjust how it functions”.’
Both approaches have value in investigating patient safety incidents and they do not replace each other—there are differences in application and focus. The HSIB adopted a Safety-11 approach:
‘To identify systemic and contextual elements that appear to support resilient performance and factors that will erode it …’
The factors identified as supportive of resilience are not new, as HSIB points out; they include teamworking, situation awareness, multidisciplinary training and simulation.
Considerations for units
Based on its investigations, the HSIB asks maternity units to consider several questions, which include:
A key value of this report is the introduction of the different patient safety science approaches within the well-known clinical context of maternity care. The approaches discussed can be seen to have a broader, more general application as positive patient safety culture development tools.
CQC inspection report
HSIB reports are excellent patient safety education aids and tools. Care Quality Commission (CQC) reports of inspections of healthcare providers are equally valuable. Both series of reports provide a rich seam of easily accessible analysis and understanding of key patient safety issues and can work to develop ingrained patient safety cultures in the NHS.
A focused inspection took place at Walsall Manor Hospital on 8-9 September, as a result of concerns surrounding safety and governance (CQC, 2020). There are a lot of positives in the report in terms of care but it highlights some matters that require attention.
The key question that will always remain from these types of reports is whether the care quality and patient safety lessons will be learnt and maintained within the various trusts inspected and farther afield in other trusts. The NHS is notably bad at sharing and learning the lessons that emerge from adverse healthcare incidents.
Urgent and emergency services
During their inspection the CQC inspectors found some gaps in patient records.
‘For four paediatric patients out of the 11 records we looked at showed that the sepsis pathway was not followed correctly. Out of the 11 adult patient records we looked at three patients either had no national early warning score (NEWS) completed or no NEWS calculated; three patients did not have sepsis scores/bundles completed where this would have been appropriate; two patients did not have falls paperwork completed; two patients did not have venous thromboembolism (VTE) assessments completed; one patient had no observations recorded and one patient did not have a pressure ulcer assessment completed.’
The amount of detail presented is immensely valuable for teaching and learning purposes and for positive culture development. A real-time context is given on the importance of proper record keeping. Other issues noted in the report include that leaders and teams did not always manage performance effectively. They did not always identify and escalate relevant risks and issues. Also, they did not always identify actions to reduce their impact. They did, however, have plans to cope with unexpected events.
Conclusion
Healthcare delivery does not take place in silos and this includes the discipline of patient safety. In a teaching and learning context staff can learn about patient safety issues from a variety of reports relating to various clinical areas. Even though cultures will differ depending on the organisation and clinical specialty, patient safety reports can provide a baseline of good and proper practice, which education and training courses can then build on to consolidate learning.
The difficulty lies in the danger of information overload and the volume of reports that are produced nationally and globally. Patient safety is now a big professional service industry with many global and national stakeholders regularly producing detailed and useful information. It has now become increasingly difficult for nurses and doctors to properly sift the information, to know what is authoritative and relevant. As the new NHS Patient Safety Strategy develops (NHS England and NHS Improvement, 2019) hopefully positive steps will be taken to help staff in this regard.