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NHS England define a positive safety culture as one where the environment is collaboratively crafted, created, and nurtured so that everybody can flourish to ensure brilliant, safe care.

Please explore the resources in this padlet: Patient Safety Cultures: https://padlet.com/c_magnusson/patient-safety-cultures-4m29a0t6iuhi

Consider below questions and upload your answers to Surreylearn discussion board:

1) What are the key ingredients of a good safety culture according to the literature? Add one reference.

2) Describe one approach to measure safety cultures, its strengths and limitations. Add one reference.

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Safety culture in healthcare: a review of concepts, dimensions, measures and progress

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Safety culture in healthcare: a review of concepts, dimensions, measures and progress

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Michelle Halligan, Aleksandra Zecevic

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Safety culture context within the NHS patient safety strategy

1. We define a positive safety culture as one where the environment is collaboratively crafted, created, and nurtured so that everybody (individual staff, teams, patients, service users, families, and carers) can flourish to ensure brilliant, safe care by:

1. Continuous learning and improvement of safety risks

2. Supportive, psychologically safe teamwork

3. Enabling and empowering speaking up by all

2. Trying to understand, measure and improve safety culture can appear to be nebulous goal. However, it is one of the two key foundations of the NHS Patient Safety Strategy, so in 2019, we set out to understand more about what makes an organisation outstanding for patient safety culture.

3. Only a handful of trusts are rated outstanding by the Care Quality Commission (CQC) and previous analysis by NHS Improvement in 2018 showed that on average most trusts are rated lower for the Safe domain. We recognise that the CQC rating is only one measure of safety and safety culture; however, in order to have a simple, consistent and recognisable approach, we chose to ask organisations that were CQC-rated Outstanding/Good for the safe domain to participate in this review.

4. Using a Safety-II inspired approach to learn from every day work ( Hollnagel et al., (2015) From Safety-I to Safety-II: A White Paper), we identified organisations that were CQC rated as good/outstanding in Safe. In 2019 and 2021 we undertook a series of focus groups with Executive and quality leads across acute, specialist, mental health, community, and primary care organisations to understand what their safety culture looked and felt like and what we could learn.

5. We understand that organisations are at different stages of their safety culture development and that one size does not fit all. The ideas shared here can be explored via a variety of approaches such as coaching. Within safety culture, context is everything and improving safety culture is not just about what interventions happen, it is also abouthow these interventions happen ie how change is implemented ( Context for Successful Quality Improvement, Health Foundation (2015)).

6. Here we share the insights from these discussions and some ideas of good practice that may be helpful relating to the language, tools, and interventions that these organisations have used to help improve their patient safety culture. It should be noted that these ideas have not been formally reviewed and this report is not proposing formal recommendations or requirements. It is intended to inspire and support local safety culture improvement activity and to inform further national work on safety culture improvement.

7. Six themes were identified from the discussions and the good practice ideas identified are summarised in the boxes below, alongside a brief introduction.

1. Leadership

1. Leadership was identified as a fundamental part of safety culture within our discussions. The King's Fund's blog on NHS leadership and culture, states that: "Collaborative, inclusive and compassionate leadership is essential to deliver the highest quality care for patients and tackle deep-seated cultural issues in the NHS, including unacceptable levels of work-related stress, bullying and discrimination." Thus, leadership is a key influencer of safety culture and was certainly mentioned within these safety culture discussions.

2. Leaders should have values and behaviours that inspire understanding and trust, build inclusion and reduce inequalities as described in " Our shared ambition for compassionate, inclusive leadership" (NHS England and NHS Improvement, 2021). This is further supported in: " What is compassionate leadership? (The King's Fund, 2022), which highlights the evidence that compassionate leadership ultimately results in high-quality care.

3. The Leadership for a collaborative and inclusive future report (2022) noted "the very real difference that first-rate leadership can make in health and social care, with many outstanding examples contributing directly to better service". This clearly aligns with the Next steps for integrating primary care: Fuller Stocktake report (2022) that identified that "what truly drives change is a leadership culture that promotes an enabling and psychologically safe environment, and the capacity, time and skills for people to learn and experiment."

Leadership good practice ideas from trusts rated 'good' or 'outstanding' in safe care by the CQC:

Vision

Create a clear relevant vision, underpinned by key values, compassion, creativity, and community which aligns with Long term plan and People plan.

Focus on one safety priority for the organisation's quality account to drive improvements and clearly communicate the vision.

Recruitment

Start emphasising at the interview stage that recognising, and reporting incidents leads to learning.

Use values-based recruitment to ensure a good fit with the organisation.

Create a senior patient safety role (eg patient safety specialist), which could be at director level.

Appoint experienced clinicians into senior corporate roles so they can directly influence the operational teams.

Invest in leaders for patient safety alongside those for quality improvement.

Focus on quality, and specifically patient safety, makes it easier to retain good staff including clinicians.

Behaviours

Give people permission to have time for safety when it gets busy.

Undertake monthly Non-executive director walkarounds that are conversations, rather than tick box exercises.

Lead by example and embed culture in practice such as encouraging people to raise no/low harm incidents.

Involve everyone in patient safety from the maintenance team to senior clinicians.

Show commitment and invest time by senior leaders, especially the CEO.

Leaders need and seek peer support, and value fresh eyes from colleagues in other organisations.

Role-model, 'living' values and calling out poor behaviour are important, from the CEO onwards.

Governance

2. Continuous learning and improvement

1. As James Reason stated: "Safety is a continually emerging property of a complex system." (Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, UK: Ashgate Publishing Limited.) Thus continuous learning leads to continuous improvements in patient safety and is very much supported by the science of improvement.

2. Within the focus groups, discussions centred on firmly linking safety and quality improvement into a cohesive system where co-production was highlighted as best practice.

Continuous learning and improvement good practice ideas from trusts rated 'good' or 'outstanding' in safe care by the CQC:

Quality improvement

Focus safety activity via a dedicated central safety team.

Set up a research and quality improvement academy including projects on safety and improvement.

Ensure quality improvement teams support and enable frontline clinicians, who own and lead the improvement work themselves.

View improvement of safety and wider quality as a journey with an identifiable starting point.

Understand that an improvement journey is hard, with barriers including funding, staffing levels and service pressures.

Recognise and share positive practice and achievements as a common activity.

Make an unflinching commitment to ensure progress and unity, founded on an "emotional connection" to patient safety at board-level. This includes the development of confidence and belief amongst frontline staff - which can be grown via focused, evidence-based quality improvement programmes.

Improvement actions

Shift the focus from blame to learning by reviewing the actions from previous incident investigations and identifying effective learning and actions and use these as future examples of good practice.

Push to apply quality improvement methodology to action planning (eg using the PSIRF safety action development guide) across all governance: incidents, complaints, audits etc.

Make action plans smaller - eg 5 things maximum and also identify the impact that these actions will make.

Consider the use of the SWARM approach (Swarm: a quick and efficient response to patient safety incidents | Nursing Times) for incident response (note further information on incident response is available as part of the new Patient Safety Incident Response Framework).

Prompt feedback after incidents and the actions that are taken.

Create a culture of pursuing ideas and making changes.

Understand that there is no overall 'end point'. Constant honesty, curiosity and energy are necessary to continue driving continuous improvement.

Co-production

Undertake incremental changes, via co-production.

Use patient feedback to generate improvement priorities.

Create direct escalation mechanisms for patients or relatives to raise concerns with doctors, outreach teams, or on-call nurses.

Priority setting for improvements

Ensure alignment of quality improvement with patient safety systems and strategy.

Enable priority-setting to incorporate both central and departmental priorities, promoting frontline ownership to ensure relevance.

3. Measurement and systems

1. It is not easy to measure safety culture, as many changes beyond those you are introducing may indirectly contribute to improvements in culture. However, an initial assessment can enable you to capture a baseline understanding of your safety culture, and where collectively you can prioritise your efforts. Being able to measure your safety culture will help to identify changes that work and to celebrate success.

Measurement and system good practice ideas from trusts rated 'good' or 'outstanding' in safe care by the CQC:

Measurement

Use staff survey Question 16 (ie My organisation treats staff who are involved in an error, near miss or incident fairly) to understand whether staff feel valued and able to speak up.

Use data to reveal trends, use these to trigger deep conversations which can lead to change.

Use staff measures, such as staff retention and feedback.

Use patient-assessed measures such as compassionate care and pain control as key revealing metrics.

Look at 'soft intelligence' or the 'feel' of a clinical space eg The Fifteen Steps Challenge (2017), as well as surveys such as GMC, staff and area-specific culture surveys.

Systems

Aim to implement well-designed patient safety information systems to increase automatic data capture.

Build engagement tools to share patient safety improvement information with wards and community teams.

Provide data/information that is more meaningful to teams and individuals.

Recruit a business intelligence analyst in patient safety to link incidents, learning from deaths and complaints to identify patient voices that can be used as examples and stories.

Ensure that access to useful, high-quality data is proactive and addresses areas of outlying concern

Focus on work as done and observed, rather than work as imagined.

4. Teamwork and communication

1. Teamworking is fundamental to delivering safe, high quality care, whether that is in the labour ward, ICU, an ambulance or in general practice. Making teams function effectively is a complex task where collaboration and good communication are fundamental. Communication should be open, respectful, honest, two-way, and inclusive across disciplines and professional groups.

2. Professor Amy Edmondson has studied what "good" looks like when people come together to work as a team, and calls this "teaming". She describes a four part approach to increase the chances of success in Extreme Teaming (2019). The Kings Fund published " How to build effective teams in general practice" (2020) that brings together insights from research and policy.

Teamwork and communication good practice ideas from trusts rated 'good' or 'outstanding' in safe care by the CQC:

Messaging

Teaming

Use a What matters to you? (WMTY) philosophy and work with clinicians and communities and staff group.

Promote team building through the use of protected team-time, and expectations that senior leaders should build strong relationships with frontline staff.

Pay attention to skill mix, with creative deployment of experienced staff to support colleagues.

Networking

Establish clear links across pathways, with focus on transitions of care in the whole system ie integrated care system (ICS)

Set-up twice yearly organisation-wide safety meetings, with all (clinical and non-clinical) staff invited and encouraged to attend.

Have regular, inclusive engagement and community-building safety huddles (in person/virtual).

Language

Use patient safety incident response-style language to move from Serious incident investigation/significant events to learning response, learning events, safety studies etc.

Use Easy as 123 SEE = Safety Experience Effectiveness.

Tailor messages to articulate and emphasise the relevance to different staff groups.

5. Psychological safety

1. Psychological safety is defined as " a shared belief held by members of a team that the team is safe for interpersonal risk-taking." ( Managing the risk of learning: Psychological safety in work teams (2002). It is about being open, willing to admit mistakes and feeling supported to speak up. Psychological safety is not just being nice to people, nor is it protecting people by wrapping them up in cotton wool; it is about creating an environment of rewarded vulnerability. The premise of psychological safety is not measured by how warm and fuzzy people feel, but by how bold and brave they are at pushing the margins of the system.

2. Unfortunately, in healthcare there can be a culture of blame and fear, from the mistaken belief that patient safety is about individual effort, rather than the interactions of usual human behaviour and systems, both of which can easily fail. Challenges to enabling psychological safety were discussed in the focus groups and some approaches identified.

Psychological safety good practice ideas from trusts rated 'good' or 'outstanding' in safe care by CQC:

Civility

Appreciation

6. Inclusion, diversity and narrowing healthcare inequalities

1. The first principle in the NHS Constitution for England (2015) is that the NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. We need to ensure that the service is designed to improve, prevent, diagnose, and treat both physical and mental health problems with equal regard. We have a duty to each and every individual that the NHS serves, and we must respect their human rights. At the same time, the NHS has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

2. During the Covid-19 pandemic healthcare inequalities have become more apparent and significant work is now underway across all aspects of healthcare to narrow inequalities for both patients and staff.

3. The 2022 NHS Race and Health Observatory's Ethnic Inequalities in Healthcare report highlights areas that require attention including: mental health, maternal and neonatal health, digital inclusion, genomics and precision medicine, and the health and care workforce. The report also provides overwhelming evidence of ethnic health inequality through the lens of racism and expects leaders to hold themselves and their organisations to account to implement change. For example, studies found that Black children were 10 times more likely to be referred to CAMHS (child and adolescent mental health service) via social services (rather than through the GP), relative to White British children.

4. One of the report's recommendations is to: "Work to build trust with ethnic minority groups and key voluntary, community and social enterprise (VCSE) organisations". This level of trust and interaction can be enhanced by co-production with patients, families and carers and is well demonstrated in case study 3, from Solent NHS Trust.

Inequalities good practice ideas from trusts rated 'good' or 'outstanding' in safe care by the CQC:

Co-production

Highlight the expectation for services and teams to include co-production with service users/carers as part of all projects.

Support an active patient participation group.

Engage with Healthwatch, who have helped general practices identify and work with local patients.

Focus on patient populations' needs, rather than on external assessments.

Empowerment

Work on what is Strong, not what is Wrong.

Work alongside communities and groups who face healthcare inequalities to enable relationships. and empower partnership engagement.

Enable carers to contribute as 'care partners' for patients.

We are grateful to the following organisations for their time and contributions to this review:

Central and North West London NHS Foundation Trust

Dorset Healthcare University NHS Foundation Trust

East London NHS Foundation Trust

Frimley Health NHS Foundation Trust

GP federation Hartlepool & Stockton Health

Harleston Medical Practice

Herefordshire and Worcestershire Health and Care NHS Trust

Hertfordshire Partnership University NHS Foundation Trust

Kent and Medway NHS and Social Care Partnership Trust

Kingston Hospital NHS Foundation Trust

Lincolnshire Partnership NHS Foundation Trust

Liverpool Heart and Chest Hospital NHS Foundation Trust

Marden Medical Practice

Newcastle Upon Tyne Hospitals NHS Foundation Trust

Norfolk Community Health and Care NHS Trust

Royal Marsden NHS Foundation Trust

Royal Papworth Hospital NHS Foundation Trust

Salford Royal NHS Foundation Trust

Solent NHS Trust

St Helens and Knowsley Teaching Hospitals NHS Trust

Stanmore House Surgery

West Kent ICP

Western Sussex Hospitals NHS Foundation Trust

Case studies

All case studies are available for download on our FutureNHS platform: Learning from best practice - NHS Patient Safety - FutureNHS Collaboration Platform - this platform requires you to log in.

Case study 1: Leadership Promise and Behaviour framework dictionary, Norfolk Community Health and Care NHS Trust

Norfolk Community Health and Care worked with their staff to develop their behaviour framework in 2019 to improve the quality of people's lives in their homes and community through the best in integrated health and social care. They identified a ten-point leadership promise that each leader signs up to, committing to deliver the best patient care.

View the Leadership promise and behaviour framework dictionary on the FutureNHS platform.

Case study 2: Safety Strategy and SCARF, Central and North West London NHS Foundation Trust

Central and North West London NHS Foundation Trust created their 2021-2024 safety strategy focussed on improving safety, reducing harm. Their strategy provides a "call to action" for all staff to reflect on what is important in their particular service to improve safety for their patients, and safety for their staff. This includes staff signing up to pledge their commitment to a safety initiative.

Alongside this, they have set in place the safe, compassionate and reflective, fair (SCRF) approach. It is about their patients and staff and has been introduced because staff have said that change is needed to develop a climate of openness and psychological safety.

View the Central and North West London NHS Foundation Trust safety strategy and SCARF on the FutureNHS platform.

Case study 3: Alongside communities, Solent NHS Trust

Alongside communities: The Solent approach to engagement and inclusion was developed in 2020. This was developed in partnership with local people to improve health and reduce inequalities in their local community.

View the Solent NHS Trust 'alongside communities' document on the FutureNHS platform.

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NHS England » Safety culture: learning from best practice

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1. We define a positive safety culture as one where the environment is collaboratively crafted, created, and nurtured so that everybody (individual staff, teams, patients, service users, families, and carers) can flourish to ensure brilliant, safe care by:

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Strategies for improving patient safety cultures

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Strategies for improving patient safety cultures

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safety culture in hospitals:

a systematic review

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Change

Toolbox

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NHS England: Improving patient safety culture - a practical guide

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NHS England: Improving patient safety culture - a practical guide

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Foreword

Safety culture can appear nebulous and it can be unclear how to improve it or indeed how the shift occurs. This has led to a broad number of approaches which are associated with improvements in safety culture but are not always successful when they are used in similar or different contexts.
In considering the safety culture of where we work we often separate out 'what' work we do from 'how' we work. This can lead to a disconnect and lead to 'how' we work not transferring into the 'what' we do.

By considering the 'what' and the 'how' as two intertwined threads where each is necessary to provide a strong team, we can see that unless we give them equal attention the overall strength of it will weaken.

We hope that this 'toolkit' will give teams an understanding of how to craft, create and nurture a positive safety culture and provide a theoretical underpinning to how to shift the culture.

This is the first in a series of safety culture toolkit pieces. We are still learning how to do this, and we invite you to share your experiences of using the toolkit and share what has or hasn't worked, but most importantly share the 'how' of what has made a difference in your teams. This will shape the future work.

We want to work with you to shape this 'toolkit' and to learn together to understand how we can make positive changes to our NHS culture.

Dr Matt Hill, National Clinical Advisor, NHS England.

Preface

Changing culture takes concerted effort and time and we all need a bit of help along the way. The Improving Patient Safety Culture toolkit provides us with that help. No matter what your job or role is in healthcare this toolkit applies to you.

The toolkit is not a recipe, rather a menu of ingredients and a toolbox to help the reader create a personalised strategy. Like any recipe there are some ingredients that provide the foundation for the rest; a positive approach to safety, a restorative just culture, psychological safety, inclusivity and civility.

Each of these while important on their own when combined can help build the momentum we are seeking, and to spread a positive patient safety culture throughout the NHS.

This toolkit will help you get on the front foot, learn from what works and what doesn't, and be far more proactive. Desmond Tutu is quoted as saying 'there comes a point where we need to stop just pulling people out of the river. Some of us need to go upstream and find out why they are falling in'. This toolkit will help you do just that.

Professor Suzette Woodward.

Introduction

Safety culture has been a key and recurring theme in reports where there has been poor care ( Francis Report; Morecambe Bay; East Kent; and Ockenden Report) and its importance highlighted in responses ( Berwick Review; Response to Winterbourne View).

Its ubiquity has hampered our understanding of what it is, and it has become apparent that it means different things to different people, and at different hierarchical levels. Without a common understanding of what we perceive safety culture to be, it is difficult to understand how to create a positive shift.

The nebulous nature of culture and focusing on where the culture is less positive have not allowed us to consider what we are trying to achieve in focusing on it.

"A positive safety culture is one where the environment is collaboratively crafted, created and nurtured so that everybody (individuals, teams, patients, service users, families and carers) can flourish to ensure brilliant safe care."

Prof Seligman on PERMA - YouTube

The NHS Patient Safety Strategy starts to explore how culture is crafted where the "importance of individuals day-to-day behaviour" and how we interact with each other in the moment is increasingly recognised as creating the local culture. These local relational interactions are complex and we do not routinely consider how we are working alongside what work we are doing. Understanding the complexity in these interactions and considering culture as a dynamic social construct can give us useful insight into how interventions which are associated with improvement in culture have their effect, and why they may not work in different contexts.

How does culture shift?

Seeing culture as a dynamic social construct focuses our attention on to our interactions with those in our team and other teams. This emphasises the importance of how we create the space to optimise the relational aspects of the work. In structured parts of work we have traditionally focused on, and measured, process metrics e.g. that teams are meeting, who is there and how long it takes, and not considered the quality of how we work together. It is often only when outcomes are poor or relationships break down that we try to understand how a team is working together.

When we consider how we can influence these social interactions and amplify the relational opportunities there are three elements:

Space/time: We need to create time for teams to come together. These may be structured parts of the working day (eg briefings, huddles, ward rounds) or more informal (e.g. coffee room, corridor conversations, cafe).

What we talk about: We will pay attention to the aspects of work that we talk about and in doing so, what we value becomes explicit. By focusing on the balance between how we ensure brilliant and safe care and what the individuals and team need to flourish allows teams to consider how work is sustainable. There is a ripple effect from these conversations into others as teams make sense of their work.

How we talk and work together: The "values based enactment" of how we speak and behave towards each other is crucial in crafting the conditions where we can all flourish and ensure brilliant care. To do this, we need to routinely reflect as a team on how we are working together, and invite and value the perspectives of others within the team to understand how each of us feels and the impact that our behaviour has on others. In doing so we can create the conditions where we all feel included, invited to contribute, safe to speak up and that our contributions will be explicitly valued and appreciated.

Recent research by Dr Nicola Mackintosh et al found that the:

"Fidelity of function of interventions is linked as much to the supporting social structures as the form of the intervention itself."

This focuses our thoughts on the social connectedness, peer learning and the importance of the relations between members.

As you use the tools within this toolkit we encourage you to focus on 'how' the practices and interventions are done and consider the relational elements of the work and the extent to which they embody positive values, alongside the practices and interventions that you use in your teams.

What are the key elements of positive safety culture?

All of these are valuable approaches to shifting the culture but we are starting the toolkit with those in bold.

We explore how we can craft, create and nurture the conditions (in alignment with the People Promise) to support the key elements of a positive safety culture:

Individuals and team flourishing

Brilliant, safe care and experience

Continuous learning and improvement

Safety I and Safety II

Learning from excellence

National Patient Safety Improvement Programmes

Appreciative inquiry

Patient centred collaboration

Teamwork and communication

What is it?

Teamwork in healthcare can be thought of as two or more people interacting to deliver safe, high quality care, wherever that is be it in primary care, social care, mental health or acute hospitals. Good communication is essential to this. It should be open, respectful, honest, two-way and inclusive across disciplines and professional groups. Good communication is also about curiosity and seeking to understand the perspectives of others.

Why is it important?

A breakdown in communication between healthcare staff has been identified as the most common cause of safety problems. When communication in teams is poor, it's easy to feel your colleagues are being uncooperative, that your voice isn't being heard, and that you aren't being valued. But when teamwork and communication is good, you feel that you're listened to and that concerns you raise about safety are quickly dealt with. Team members feel motivated and empowered to put forward safety ideas to the team and get them sorted.

What does good look like?

Professor Amy Edmondson has studied what "good" looks like when people come together to work as a team, often for the first time. She calls this 'teaming' and describes four steps to do it well (see Top Tips below), which are particularly helpful if you're working in constantly changing teams. The approach helps break down silos and creates opportunities to develop new solutions for complex problems.

Top tips:

Working together as a team

Adapted from Extreme Teaming: How to Deliver Integrated Care

Aim high: set a clear, ambitious, compelling, meaningful vision which inspires people by focusing on the things that matter to the team

Team up: value the diversity of the team as this will lead to a greater ability to achieve breakthroughs

Fail well: identify opportunities for intelligent failures that provide information on how to improve approaches and systems next time round

Learn fast: maximise learning from mistakes - apply focus, discipline and structure when reviewing them.

Safety culture discussion cards

Having informal conversations with colleagues about safety and risk within services is a great place to start. The NHS Scotland safety culture discussion cards, originally developed by Steven Shorrock, are a great resource.

Remember, receiving feedback is hard for anyone if it feels negative. Taking a positive approach to giving feedback to colleagues, delivered empathetically, helps to reduce anxiety and contributes to a continuous learning cycle.

Taking a structured approach to the communication of safety-critical information (tools such as SBAR - the Situation, Background, Assessment, Recommendation) in specific circumstances can be helpful, but imposing a structure in all circumstances may not always be the right approach.

Approaches like safety huddles - regularly scheduled, short meetings to discuss safety - can be an effective way to communicate key information, improve cohesion, build relationships and reinforce shared values and purpose.

Case study: Huddling up for safer healthcare - Yorkshire and Humber AHSN

Yorkshire and Humber Patient Safety Collaborative's ' Huddle Up for Safer Healthcare ' (HUSH) programme supports and coaches frontline teams to implement safety huddles and deliver sustained improvements in care.

A safety huddle is a short, multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. Effective safety huddles involve agreed actions, are informed by visual feedback of data and provide the opportunity to celebrate success in reducing harm.

The original HUSH focus was falls prevention, and has stopped more than 6,000 falls happening, equating to an estimated £15 million in avoided healthcare costs.

From its work helping teams address their safety priorities, the Patient Safety Collaborative now has evidence of effectiveness in addressing pressure ulcers, deteriorating patients, nutrition and hydration; and for mental health teams, seclusion, self-harm and violence and aggression.

Hear more about safety huddles in Yorkshire and Humber on the Improvement Acadamy YouTube channel.

Top tips:

Conducting safety huddles

Taken from the Culture Change Toolbox:

Start by explaining the purpose of the huddle. Consider how we optimise care by discussing safety concerns of the past, present and future and examples of excellent care as well. Emphasise that it's about learning and improving safety, not about blame.

Think about some example issues to bring up at the first huddle. At first, it might not be clear to everyone what sort of topics they can talk about.

Keep it short. Five minutes is reasonable.

Thank everyone for their participation and be clear about next steps. Will someone follow up on the issues raised? Will there be another huddle? What changes can we make to the structure of the huddle to make it more effective?

Adjust the structure of the huddle using this first group, then expand to have them more often or with more staff. Aim to include all team members eventually and determine how often you would like to hold safety huddles in your work area.

Be transparent with follow-up. Share the outcomes of the huddle using email, meetings, posters or personal conversations. Acting on the information shared during safety huddles sends a powerful message that safety matters.

Invite other team members to host them once the huddles happen regularly, so that they can take place without requiring the original facilitator.

Use structured feedback

Space/time: This can be done throughout our work and can be very quick to do, and have a big effect. Especially if it is positive feedback that is being shared.

What: Feedback is a key ingredient of the learning cycle. Give each other positive feedback, and the reasons why. Use a structured approach to giving constructive feedback, such as the Situation, Behaviour, Impact (SBI) approach: eg Situation: 'When you were with that patient/relative/colleague in the...' This needs to be a specific context. Behaviour: 'I noticed that you did... ' This needs to describe what you observed without being judgemental. Impact: 'It had a real impact on me and made me feel... ' 'I noticed how the patient/relative/colleague responded to you and I noticed that they did... '

How: Think kindly about the other person and, with respect and care, give them a clear description of what you observed at each stage of the feedback.

Teach or treat: This is from the Each Baby Counts group

Space/time: These learning conversations can occur at any time when clinical concerns are escalated or another opinion is sought.

What: When a concern about a patient/service user is raised the response from the senior member of staff is framed as either Teach or Treat. If the senior member of staff is happy with the current management then they can respectfully explain their rationale so that each is clear about the other's perceptions. If they believe that new treatment is required then this can be taken in a timely fashion.

How: This encourages staff to have a 'respectful, learning conversation' at times of escalation. This flattens the hierarchy and supports team members to feel that they have been heard and their contribution valued. This helps to support learning and mutual trust through enhanced relationships.

Initiate safety huddles

Use resources including the "Yorkshire Safety Huddles Manual" to initiate safety huddles, starting with a single team.

Space: Create a time in the day when safety huddles can occur.

What: Any aspect that affects safety can be discussed. Consider the importance of the conversation in developing the social relationships between team members, as well as what is discussed.

How: Starting with everyone introducing themselves (even if we think we know everyone) flattens the social hierarchy and makes it more likely that everyone will feel able to speak later and contribute to the huddle and allow all forms of expertise to be valued and heard.

Read about the Innovation Agency's Coaching for Culture programme, which included accredited coaching training for team leaders, use of a team culture diagnostic, and use of practical quality improvement (QI) skills to support the development of safe, high-quality, and compassionate services in the North West.

Just and restorative culture

What is it?

A just culture is about creating a culture of fairness, transparency and learning. It recognises that success or mistakes are the product of many factors and focuses on changing systems and processes to make it easier for people to do their jobs safely. It is about ensuring everyone is confident they will be treated fairly when something goes wrong.

Why is it important?

NHS Resolution develop this idea further by saying that " What we need is a restorative just culture (Dekker, 2018) that is about repairing and building trust and relationships when things have not gone as planned. This means we need to develop working practices that move people away from fear and blame, including tackling incivility and bullying, and addressing the health and wellbeing needs for staff to help them work safely. Ensure everyone's needs are met, no matter who they are. Treat everyone fairly, no matter what their background is, and help them speak up." ( Being Fair, NHS Resolution)

Sydney Dekker described a restorative culture as one that looks to the future by exploring what needs to be done and who should do it. There are three questions:

1. Who is hurt?

2. What do they need?

3. Whose obligation is that?

"A just and learning culture is the balance of fairness, justice, learning - and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong. It is also not about an absence of responsibility and accountability."

Being Fair, NHS Resolution

Underpinning this approach are the practical applications taken in Being Open and the subsequent Duty of Candour publications.

Shifting to this approach is not just about using the NHS Just Culture Guide but is a wholesale shift of approach, supported by the Patient Safety Incident Response Framework (PSIRF) - "a system designed for safety and learning rather than performance management".

Importantly it is recognised in PSIRF that the NHS Just Culture Guide is:

Used only when there is reason to believe the deliberately malicious, negligent or incompetent actions or decisions of an individual contributed to an incident, and not routinely whenever an incident is reported or a Patient Safety Incident Investigation is conducted.

Managed completely separately from any activity to examine an incident for the purposes of learning and improvement.

The use of the NHS Just Culture Guide in these situations will also help to "reduce the role of unconscious bias when making decisions and will help ensure all individuals are treated equally and fairly no matter what their staff group, profession or background. This has similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black, Asian and minority ethnic staff.

Case study: Duty of candour community of practice - Health Innovation Network South London

Duty of candour is a statutory requirement in the NHS when a patient experiences harm while receiving healthcare. It ensures patients and staff understand how things may have gone wrong and reassures everyone involved that lessons have been learned.

The Health Innovation Network South London created a community of practice (CoP) to support staff to share and learn best practice when dealing with difficult situations. The community brings clinicians, managers and patient groups together. It has created a set of generic training materials that are used across the area, promoting consistency and tackling difficult aspects of Duty of Candour, such as how practitioners say sorry to patients when things go wrong.

The CoP is still going strong and has proved an effective forum for sharing concerns and making decisions. There is a genuine passion from the professionals who attend about sharing their experiences and effecting positive change within their organisations.

Find out more information on the Health Innovation Network South London website.

Case study: Supporting team health: A simple framework and a tale of three teams

Jo Davidson, Associate Director Organisational Effectiveness and Learning and Melissa Holt, Strategic Organisational Effectiveness Lead.

Overview

More than two years responding to COVID has reinforced the significance that great teamwork has on both staff wellbeing and the safety, quality and experience of care they provide. NHS organisations are full of people caring for others but what happens when those teams, become stuck in conflict, toxicity or resistance to change? These sorts of comments are not common to any one organisation, the experiences by these teams are all to common across the health service.

This piece tells the story of three such teams, brought back to health with the use of a simple tool - The Mersey Care "Team Canvas", and how that tool has been used to facilitate team health and culture across the Trust. It includes how it has been designed and implemented to integrate with our clinical assessment, improvement and accreditation processes which enables us to track and measure improvement and demonstrate the impact not just to our colleagues, but importantly to our patients.

This excerpt provides detail in relation to just one of the OD interventions that have been designed and developed to support a Restorative, Just and Learning Culture at Mersey Care NHSFT, all of which are described within the recent publication of ' Restorative, Just Culture in Practice '.

"Managers don't trust us, we're closest to the patients and yet when we put ideas forward, no one listens, we're the bottom of the pile" Team A

"In this team I've lost my confidence and any sense of feeling valuable or valued" Team B

"Changes are not discussed. They are dictated, regimented and we are told - not asked" Team C

1. Consider how to adapt and use the Just and Learning Culture Charter in NHS Resolution 'Being Fair':

Space/time: Use a team meeting to discuss what a just and learning culture means to your team, and what their experiences have been. The shift to a just and learning culture requires a continuous approach that is anchored in the elements of a Just and Learning Culture Charter. The key purposes of transparency, fairness, learning are underpinned by the principle that patients and families involved in a patient safety incident need to be looked after and have their questions answered.

What: In the discussion ask what the people's experiences have been when things have gone wrong and how they felt and how they thought it was for the patient and families. There is a need for a shift in the language that we use and the approach to incidents that focus on the learning - what happened not who was involved.

How: Consider how to involve everyone in the discussion so that all the perspectives are heard and the process supports the principles of openness, honesty and transparency.

2. Recognise staff as the victims of unsafe systems too:

Staff who are involved in an unanticipated adverse patient event, caused by systemic issues, including human factors, can be traumatised by the event.

Resources to support second victims are available through the Improvement Academy's dedicated Second Victim Support website.

3. Use the NHS Just Culture Guide:

This is a way to ensure that everyone is treated fairly in the event of an incident of harm. The NHS Just Culture Guide is a tool to support individuals to treat staff fairly, consistently and constructively if they have been involved in a patient safety incident and to help to prevent unconscious biases.

Psychological safety

Psychological safety was first described by Amy Edmondson who defined it as:

"A shared belief held by members of a team that the team is safe for interpersonal risk taking."

It describes the ability of members of a group to feel free to speak up, ask questions, report errors, raise concerns and ask for feedback without fearing the consequences and being judged. We learn early in life about making mistakes and the feelings of embarrassment and awkwardness it provokes. As adults we naturally avoid these awkward situations. When discussing safety, it's important to create conditions in which we feel safe to take what can feel like personal risk, saying for example, "I made a mistake" or 'this didn't go as planned", without fear of judgement.

Psychological safety in a team does not happen by chance - it needs to be actively created and nurtured. The feeling of inclusivity and trust are key to crafting the conditions where diversity of thought in ethnicity, gender and age is welcomed and valued as it leads to a more complete picture and better care.

It does not mean that we will always agree and that teams will be free from conflict, but that by feeling valued we can all contribute our ideas to a find a better solution.

In the book The Four Stages of Psychological Safety, Timothy Clarke describes how teams move through each stage:

Stage 1 Inclusion Safety: Team members, whatever their age, sexuality, ethnicity or race, feel that they are included and valued and that they are appreciated by the team.

Stage 2 Learner Safety: Team members are able to admit that they don't know things and are able to ask questions and start to try new things.

Stage 3 Contributor Safety: Team members are able to voice their own ideas without fear of being ridiculed or embarrassed. Stage 4 Challenger Safety: Team members are able to question the thoughts of others in the team including those with power.

In 'The Fearless Organisation', Amy Edmondson describes three ways to help to create psychological safety in healthcare.

Set the stage

Leadership tasks

Frame the work
Set expectations about failure, uncertainty and interdependence to clarify the need for voice

Emphasise purpose

Identify what's at stake

Why it matters

For whom it matters

Accomplishes
Shared expectations and meaning

Inviting participation

Leadership tasks

Demonstrate situational humility

Practice inquiry

Ask good questions

Model intense listening

Set up structures and processes

Create forums for input

Provide guidelines for discussion

Accomplishes
Confidence that voice is welcome

Responding productively

Leadership tasks

Express appreciation

Destigmatise failure

Look forward

Offer help

Discuss, consider and brainstorm next steps

Sanction clear violations

Accomplishes
Orientation toward continuous learning

1. Try using a survey to measure psychological safety in your team to understand and then discuss the different perceptions within the team.

2. Leaders and team members sharing their stories about when things went wrong for them, and what they learnt.

3. National Staff Survey and National Quarterly Pulse Survey results are available on the Model Health System - start a discussion about the team's results.

Consider using the King's Fund ABC (Autonomy, Belonging and Contribution) Framework which links the questions to these topics. This is a good way to start a conversation about the results.

Psychological Safety Survey

1. If you make a mistake in this team, it is often held against you.

2. Members of this team are able to bring up problems and tough issues.

3. People on this team sometimes reject others for being different.

4. It is safe to take a risk on this team.

5. It is difficult to ask other members of this team for help.

6. No one on this team would deliberately act in a way that undermines my efforts.

7. Working with members of this team, my unique skills and talents are valued and utilised.

Amy Edmondson. The Fearless Organization. Wiley, 2019

What is it?

The NHS People Plan states that:

"The NHS was established on the principles of social justice and equity. In many ways, it is the nation's social conscience, but the treatment of our colleagues from minority groups falls short far too often.
Not addressing this limits our collective potential. It prevents the NHS from achieving excellence in healthcare, from identifying and using our best talent, from closing the gap on health inequalities, and from achieving the service changes that are needed to improve population health."

Inclusion is the degree to which a person perceives that they are an esteemed member of the work group through experiencing treatment that satisfies their needs for belongingness and uniqueness. Team
environments that promote inclusivity and psychological safety of their members usually achieve the best patient safety outcomes. Such teams model behaviours characterised by civility, inclusivity, trust, respect and professional courtesy. They offer team members the chance to thrive and be themselves and foster diversity, equality and fairness. Such environments value and encourage continuous input from patients,
carers and families into the design and delivery of their services.

Why is it important?

There is strong evidence that where an NHS workforce is representative of the community that it serves, patient care and the overall patient experience is more personalised and improves. Yet it is also clear that in some parts of the NHS, the way a patient or member of staff looks can determine how they are
treated. Undermining, humiliating and discriminating behaviours increase fear and decrease team psychological safety and learning. Celebrating difference and diversity in all forms stimulates learning
and creativity, if harnessed in the right way. Civility between health and care staff in the work environment matters because it reduces errors and stress and fosters excellence.

Patients, carers and families are in a unique position to provide new ideas and insights and to identify safety and care quality concerns that insiders may have ceased to notice long ago. They may also spot team issues and behaviours that are unsafe.

What does good look like?

Inclusive teams recognise and celebrate diversity and difference both for team members and their patients. Inclusive teams promote equity and fairness for everyone, no matter your ethnicity, age, gender, sexuality, religion or power.

They hunt the good stuff - the things that unite and energise you and which give you shared common purpose.

Diversity of thought is paramount.

Encourage patients, carers and families in all their diversity to be at the centre of your plans and involved in co-creating them.

Three change ideas to try:

Support staff wellbeing and joy in work

The Institute for Healthcare Improvement (IHI) has developed a range of resources, including a
Conversation and Action Guide to support staff wellbeing and joy in work after the COVID-19 pandemic.

Reverse mentoring

It can be difficult to understand how it feels to be different members in a team. By partnering with a
more junior member of a team from a different diverse background, a leader can spend time with them
to understand the different perceptions that they have and understand 'work as done' rather than 'work
as imagined"'.

Always events

Implement the Always Event methodology - aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the system - as a means of consistently putting patients at the heart of the care provided.

Case study

Seema Srivastava is a geriatrician and Associate Medical Director at North Bristol NHS Trust. Here she discusses how responding to the COVID-19 pandemic provided an opportunity to engage with Black,
Asian and Minority Ethnic staff at the hospital.

One of the most worrying findings in the research and reviews into COVID-19 is how it has disproportionately affected some groups more than others in our society, particularly people from ethnic minority backgrounds. In April, during the height of the pandemic, we realised there was an urgent need to find out how this was affecting staff at North Bristol NHS Trust, particularly those from ethnic minorities.

We wanted to understand how people were feeling at this time and what we could do to create a space that felt safe, where people felt cared for, and which would build on a safety culture that recognised and addressed this inequality.

Supported by Jackie Marshall, the Trust's Director of People, we arranged a series of virtual listening events to hear from staff from ethnic minorities, listen to their lived experiences and ask what meaningful actions we could take. They were held as open forums for any member of staff, regardless of their role or
level in the trust.

We knew that not everyone would be able to attend virtual meetings, so we also ran face-to-face sessions in a large marquee with social distancing in place. Between April and June, we held 11 events in total and around 240 staff attended, giving rich insight into the issues they were facing. Some staff had been unwell with COVID-19 themselves; others knew friends or family members who had sadly died.

Themes emerging from these events included worries about PPE and access to health risk assessments. This led to immediate improvements, with some of the attendees co-designing an updated risk assessment process, to enable better safety and better conversations between managers and staff.

These sessions also coincided with the Black Lives Matter movement, and they became a platform for people to share their feelings and experiences about the impact of racial injustice in their daily lives.
While the trust had held staff engagement events before, it had never attempted something on this scale. As the hospital employs over 9,000 people, they are really important to create safe spaces for listening.

The existing BAME network has also increased its membership, and we are contributing to conversations about wellbeing as part of the trust's 'People Strategy'.

We found COVID-19 has brought many existing issues to the surface, but it's also given us the time and permission to address them in a way we haven't before. I hope we can maintain this momentum and build on the framework we've created to ensure a safer culture for staff in future.

Civility

Civility is essential for individuals and teams to fulfil their potential and "civil work environments matter
because they reduce errors, reduce stress and foster excellence." It "creates that sense of safety and is a key ingredient of great teams."

The Civility Saves Lives campaign promotes the importance of respect, professional courtesy and valuing
each other. The campaign aims to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours. Patients, carers and families notice incivility between team members, which can lead to increased feelings of fear and vulnerability, and a poorer patient experience. The campaign includes examples of how teams have sought to make patients active participants in fostering a positive safety culture.

There is also a NHS England Civility and Respect Toolkit with a number of resources within it to support teams.

Space/time: Add the topic of civility to a team meeting.

What: Use the infographics to start a discussion or watch a video. Discuss what team members experiences of civility and incivility are and how they have felt when these have occurred.

How: Discuss what clear standards and expectations the team have and role model respect and care for
others to enable meaningful and respectful connection and participation.

Acknowledgements

The following people contributed to this practical guide, and we would like to express our gratitude to them:

Joanna Pendray, Susanne Smith, Suzette Woodward, John Illingworth, Matt Hill, Paul Wastell, Bernard Allen, Lee Gridley, Sarah Papworth-Heidel, Sarah Tilford, Hester Wain, Heather Pritchard, Chloe Morales-Oyarce, Caroline Angel, Peter Jeffries, Nathalie Delaney, Phil Duncan, Sarah Speck, James Nicholls, Jane Reid, Alison Lovatt, Seema Srivastava, Joanne Crawford, all of the NHS and AHSN teams who kindly shared their work in the case studies and throughout the guide, and the National Patient Safety Team at NHS England.

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Improving patient safety culture - a practical guide

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Safety culture can appear nebulous and it can be unclear how to improve it or indeed how the shift occurs. This has led to a broad number of approaches which are associated with improvements in safety culture but are not always successful when they are used in similar or different contexts.In considering the safety culture of where we work we often separate out 'what' work we do from 'how' we work.

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Measuring patient safety climate: a review of surveys

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Measuring patient safety climate: a review of surveys

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Reis, C.T., Paiva, S.G. and Sousa, P., 2018. The patient safety culture: a systematic review by characteristics of hospital survey on patient safety culture dimensions. International Journal for Quality in Health Care, 30(9), pp.660-677.

# data[].attributes.subject
Reis, C.T., Paiva, S.G. and Sousa, P., 2018. The patient safety culture: a systematic review by characteristics of hospital survey on patient safety culture dimensions. International Journal for Quality in Health Care, 30(9), pp.660-677.

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What is Patient Safety Culture? A Review of the Literature

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What is Patient Safety Culture? A Review of the Literature

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CQC Rapid Literature Review: Safety Culture

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CQC Rapid Literature Review: Safety Culture

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Safety culture assessment: a tool for improving patient safetyin healthcare organizations

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Safety culture assessment: a tool for improving patient safetyin healthcare organizations