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Using Appreciative Enquiry to Develop Safety Culture. NHS England 

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Using Appreciative Enquiry to Develop Safety Culture. NHS England 

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Open organisational culture: what does it entail? 

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Open organisational culture: what does it entail? 

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Open organisational culture: what does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique

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Objectives Open organisational culture in hospitals is important, yet it remains unclear what it entails other than its referral to ‘open communication’ in the context of patient safety. This study aims to identify the elements of an open hospital culture. Methods In this group consensus study with a Delphi technique, statements were constructed based on the existing patient safety literature and input of 11 healthcare professionals from different backgrounds. A final framework consisting of 36 statements was reviewed on inclusion and exclusion, in multiple rounds by 32 experts and professionals working in healthcare. The feedback was analysed and shared with the panel after the group reached consensus on statements (>70% agreement). Results The procedure resulted in 37 statements representing tangible (ie, leadership, organisational structures and processes, communication systems, employee attitudes, training and development, and patient orientation) and intangible themes (ie, psychological safety, open communication, cohesion, power, blame and shame, morals and ethics, and support and trust). The culture themes’ teamwork and commitment were not specific for an open culture, contradicting the patient safety literature. Thereby, an open mind was shown to be a novel characteristic. Conclusions Open culture entails an open mind-set and attitude of professionals beyond the scope of patient safety in which there is mutual awareness of each other’s (un)conscious biases, focus on team relationships and professional well-being and a transparent system with supervisors/leaders being role models and patients being involved. Although it is generally acknowledged that microlevel social processes necessary to enact patient safety deserve more attention, research has largely emphasised system-level structures and processes. This study provides practical enablers for addressing system and microlevel social processes to work towards an open culture in and across teams. Data are available upon reasonable request. Data on the development of the first statement set and the consensus procedure can be made available by request to the corresponding author.

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Watch Being fair – Webinar with Suzette Woodward

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Watch Being fair – Webinar with Suzette Woodward

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Watch Being fair - Webinar with Suzette Woodward - NHS Resolution

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Suzette Woodward, co-author of ’Being Fair, talks about supporting a just and learning culture for patients and staff following incidents in the NHS.

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Listening, learning, responding to concerns - Care Quality Commission

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Listening, learning, responding to concerns - Care Quality Commission

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Listening, learning, responding to concerns - Care Quality Commission

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In my role as Director of this review, maintaining a sense of openness and impartiality has remained my priority. An undertaking of this scale and focus is significant and has benefitted from the skill and knowledge of colleagues with a long history of working at CQC. It has also been vital to take on board the contemporary perspectives of the independent review board members and external experts who have helped me to get to the heart of the key issues raised. My position sits between these two groups. I had only been working at CQC for a fortnight when I was asked to undertake this report. I made a conscious effort to maintain a level of distance from the organisation during the writing process to strengthen its objectivity.

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Patient safety and safety culture in primary

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Patient safety and safety culture in primary

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health care: a systematic review

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Organisations should adopt this policy and add their own local information in the sections highlighted in yellow. Organisations should ensure that an updated policy is in place by 31 January 2024.

Published June 2022.

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Organisations should adopt this policy and add their own local information in the sections highlighted in yellow. Organisations should ensure that an updated policy is in place by 31 January 2024. Published June 2022.

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The National Guardian’s Office - Freedom to Speak Up

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Freedom to Speak Up Guardians support workers to speak up when they feel that they are unable to in other ways.

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Freedom to Speak Up in Healthcare in England programme

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Freedom to Speak Up in Healthcare in England programme

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This programme is in partnership with...

About the Freedom to Speak Up in Healthcare in England programme

This training is for everyone wherever they work in healthcare and explains in a clear and consistent way what speaking up is and its importance in creating an environment in which people are supported to deliver their best. It will help you understand the vital role you can play and the support available to encourage a healthy speaking up culture for the benefit of patients and workers.

The training is divided into three parts.

Speak Up: Core training is for all workers including volunteers, students and those in training, regardless of their contract terms and covers what speaking up is and why it matters. It will help learners understand how to speak up and what to expect when they do.

Listen Up: This training for all line and middle managers and is focussed more on listening up and the barriers that can get in the way of speaking up.

Follow Up: This training is aimed at all senior leaders including executive board members (and equivalents), Non-Executive Directors, and Governors to help them understand their role in setting the tone for a good speaking up culture and how speaking up can promote organisational learning and improvement.

More information

What is Freedom to Speak Up?

Speaking up protects patient safety and improves the lives of workers.

When things go wrong, we need to make sure that lessons are learnt and things are improved.

If we think something might go wrong, it's important that we all feel able to speak up so that potential harm is prevented.

Even when things are good, but could be even better, we should feel able to say something and should expect that our suggestion is listened to and used as an opportunity for improvement.

Freedom to Speak Up is about encouraging a positive culture where people feel they can speak up and their voices will be heard, and their suggestions acted upon.

What are Freedom to Speak Up Guardians?

What are Freedom to Speak Up Guardians?

Freedom to Speak Up Guardians support workers to speak up when they feel that they are unable to do so by other routes. They ensure that people who speak up are thanked, that the issues they raise are responded to, and make sure that the person speaking up receives feedback on the actions taken.

The role of Freedom to Speak Up Guardians and the National Guardian were established in 2016 following the events at Mid-Staffordshire NHS Foundation Trust and recommendations from Sir Robert Francis' Freedom to Speak Up Inquiry.

About the National Guardian's Office

About the National Guardian's Office

Dr Henrietta Hughes OBE was appointed as the National Guardian in July 2016. The National Guardian's Office works to make speaking up become business as usual to effect cultural change in the NHS.

The office leads, trains and supports a network of Freedom to Speak Up Guardians throughout health in England and conducts case reviews when it appears that speaking up has not been handled according to best practice.

The National Guardian's Office also provides challenge and learning to the healthcare system as a whole as part of its remit.
www.nationalguardian.org.uk

National Guardians Office - Speaking Up

An insight into speaking up: Two workers, Jillette and Hannah, tell us their stories of speaking up and what happened when they spoke up to a Freedom to Speak Up guardian.

National Guardians Office - Being A Freedom To Speak Up Guardian

Being a Freedom to Speak Up Guardian: Three Freedom to Speak Up Guardians share their insights on the challenges, and rewards of being a guardian.

Acknowledgements

We engaged with a wide range of groups when developing this training and would like to express our sincere thanks to all of those who provided helpful feedback.

How to access

In order to access the Freedom to Speak Up in Healthcare in England programme, you will need an elfh account. If you do not have one, then you can register by selecting the Register button below.
Register >
To view the Freedom to Speak Up in Healthcare in England programme, select the View button below. If you already have an account with elfh, you will also be able to login and enrol on the programme from the View button.
View >
Not an NHS organisation?

If you are not an NHS health or care organisation and therefore do not qualify for free access elfh Hub, you may be able to access the service by creating an OpenAthens account.

To check whether or not you qualify for free access via OpenAthens, you can view the eligibility criteria and register on the ' OpenAthens ' portal.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the Freedom to Speak Up in Healthcare in Englandprogramme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

More information

Please select the following link for more information on how to use the elfh Hub.

elfh is a NHS England programme in partnership with the NHS and professional bodies

© elearning for healthcare 2023

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Freedom to Speak Up - elearning for healthcare

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This programme is in partnership with... This training is for everyone wherever they work in healthcare and explains in a clear and consistent way what speaking up is and its importance in creating an environment in which people are supported to deliver their best.

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Raising concerns: Guidance for nurses, midwives and nursing associates - The Nursing and Midwifery Council

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How to raise a concern, nurses and midwives raising concerns, raising concerns guidance, download raising concerns

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Training

The National Guardian's Office, in association with Health Education England, has launched their Freedom to Speak Up e-learning package - 'Speak Up, Listen Up, Follow Up' - for anyone who works in healthcare. Divided into three modules, it helps learners understand the vital role they can play in a healthy speaking up culture which protects patient safety and enhances worker experience. The second module - Listen Up - is for managers at all levels to give them the tools to foster a speaking up culture in their teams by listening to and understanding the barriers to speaking up.

Guidance

Whistleblowing: list of prescribed people and bodies as outlined under section 43F of the Public Interest Disclosure Act (PIDA) 1998. This list outlines who staff can make a disclosure to if issues remain unresolved after raising them using internal processes, or where individuals do not feel able to raise the issue with their employer. It is important that all workers are clear on the routes available to them to raise concerns both internally and externally to ensure they are covered by PIDA. Employers are advised to include reference to this list within local policies and guidance.

Additional useful references

Guidance for clinical managers

Responding to concerns: a guide for doctors who manage staff - This BMA guidance aims to help managers of other healthcare professionals better manage concerns raised to them.

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Raising concerns - guidance for managers

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The National Guardian's Office, in association with Health Education England, has launched their Freedom to Speak Up e-learning package - 'Speak Up, Listen Up, Follow Up' - for anyone who works in healthcare. Divided into three modules, it helps learners understand the vital role they can play in a healthy speaking up culture which protects patient safety and enhances worker experience.

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Jones, A. (2016). The Role of Employee Whistleblowing and Raising Concerns in an Organizational Learning Culture–Elusive and Laudable?: Comment on" Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations". International journal of health policy and management, 5(1), 67.

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Attree, M. (2007). Factors influencing nurses’ decisions to raise concerns about care quality. Journal of Nursing Management, 15(4), 392-402.

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General Medical Council: Decision making tool

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General Medical Council: Decision making tool

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This decision making tool will help you know what to do if you have a concern about patient safety.

Our guidance says that all doctors have a duty to act when they believe patients' safety is at risk, or that patients' care or dignity is being compromised.

If you are faced with one of these situations, it's essential that you know what action to take and feel confident in doing so.

This tool guides you through the decision making process, from incidents you can tackle yourself to challenging situations where you may need to involve a regulator or other external body.

We've developed case studies with input from doctors who understand the challenges that you can face when raising concerns about patient safety.

Ready to start?

You'll be asked a series of yes or no questions. Each question and endpoint links on to either the relevant guidance or a case study for you to explore the situation in more detail.

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Raising and acting on concerns decision tool

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This decision making tool will help you know what to do if you have a concern about patient safety. Our guidance says that all doctors have a duty to act when they believe patients' safety is at risk, or that patients' care or dignity is being compromised.

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During this session you will critically explore the idea of open and fair cultures in the NHS. At the end of the session you will have an understanding of key policies and the importance of raising concerns about quality and safety of care. You will also have knowledge of tools that are available to assess an organisations readiness for staff to raise concerns. You will develop an understanding from the research literature of the factors that sometimes hinders open cultures.

1) Start by exploring the resources provided in this padlet. Make notes of key evidence and the topics that you want to explore further and may draw on when you complete the module assessment. There are additional resources under day 4 relating to Professor Maben's session.

2) Answer the following discussion question and upload your answer on Surrey learn before 20:00 (if you can) on the distance learning day for this topic. Question: What are the key components of your organisation's raising concern policy (you should be able to find this on your organisations intranet, or through the HR department)?Discuss one potential barrier to its implementation.

3) Complete the 'what have I learnt quiz?' on Surrey learn.

Happy Learning!

Page updated Dec 2025

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Raising a concern is not always easy but it is the right thing to do. It is about safeguarding and protecting, as well as learning from a situation and making improvements.

This guide is to help nurses, nursing associates, students and health care support workers based in the NHS and independent sector.

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Raising concerns | Royal College of Nursing

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The RCN believes all nursing staff should feel safe and supported when raising concerns about patient care.

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Video: Raising Concerns - Health Education England

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Video: Raising Concerns - Health Education England

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Mid Staffordshire NHS Foundation Trust Public Inquiry

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Staffordshire and Stoke on Trent Partnership NHS

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Countess of Chester Hospital NHS Foundation Trust

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Health Education England is at the forefront of the drive to improve safety in the NHS by training staff on how to speak up for patient safety. Events such as those that occurred at Mid Staffs showed that some staff do not have the knowledge and confidence to raise concerns about patient safety.