What next for the Francis culture of safety? Six steps to start

No-one would claim that changing culture is easy, but it is possible. And in light of Robert Francis’s latest report we know that there is still much to be done if we are to create the learning culture advocated by Don Berwick in A promise to learn – a commitment to act.

Over the years we have engaged with many organisations working towards a culture of safety. Often at the heart of the current culture isn’t a lack of will for care to be better. It's more a lack of awareness of the inherent risks associated with delivering complex care in multi-disciplinary settings, and a blindspot when it comes to the experience of patients along our care pathways.

Looking at what we have learned, as well as approaches tried and tested elsewhere, I would offer six actions that leaders can put into practice in order to start the journey of culture change.

Spend more time asking where things could go wrong than why things have gone wrong

Reviews of untoward incidents, complaints investigations, root cause analysis – these are commonly recognised practices. And of course it's important to learn when things go wrong. But looking into the causes of failure is a difficult thing to do without people feeling blamed, either implicitly or explicitly. It’s human nature to excuse and justify rather than learn.

Our Safer Clinical Systems programme teams took a different approach to looking at risk. Rather than asking ‘what went wrong?’ they asked ‘what could go wrong?’ Participants described feeling the burden of potential blame lifted, able to speak honestly and openly about the risks they saw around them. And things don’t always fail in the same way, so framing the question this way allowed teams to think about a broader spectrum of risks and hazards, and take pre-emptive steps to address them.

See through the patient's eyes

Those of us working in health care can forget how bewildering and complicated it appears to patients and their families. We know how it works – surely they do too? While the professional culture emphasises the importance of the care of the patient in front of you, clinicians are less likely to be preoccupied by what might happen to a patient at the next stage, and whether they are acting not just in the immediate best interests but also in the best interests over the course of the patient’s care.

As part of the Patient and Family Centred Care programme supported by the Health Foundation and The King’s Fund, the Point of Care Foundation worked with sites to help people see patient experience of care through the eyes of patients themselves. Standing in someone else’s shoes is a great way to build empathy and also to see opportunities to improve what you are doing.

Hold up a mirror within multi-disciplinary teams

I’m sure I’m not alone in suddenly finding that someone who I thought liked working with me actually found my style and approach capricious or undermining. I don’t think anyone genuinely wants to obstruct colleagues from working to their best potential. But, all too often, the silos that occur within multi-disciplinary teams mean that this is exactly what happens. Left unchallenged, poor teamwork becomes the norm and poor teamwork puts patients at risk.

The Yorkshire and Humber Improvement Academy has been using a survey tool to surface the difference in experience and perceptions of different professionals. While this is simply diagnosis rather than treatment, they repeatedly find that just helping people realise how colleagues feel about the way they work can be enough to nudge well-meaning people to re-evaluate their relationships and practice.

Create space for staff to reflect on the emotional challenge in their work

There can be few professions that place such an emotional burden on its workforce. Knowing that however hard you try, the outcome may be a tragedy for a relative or loved one. That however vigilant you are, the complexity of modern health care and the fallibility of human beings means that, even in the best systems, mistakes happen. That while you strive to do your best, you are often working in systems replete with defects, making your job harder not easier.

The Point of Care Foundation have been introducing Schwarz Rounds into the NHS. These are an important way of supporting staff to share the burden of the emotional challenge of their work, get support from peers and give them a safe place to share concerns. Increasingly we are recognising that the welfare of our teams has direct impact on the welfare of our patients. We need to create the time and space to provide our workforce with the emotional support it needs.

Boards need to ask ‘how safe are we?’ not simply ‘how many people have we harmed?’

The willingness of the NHS to talk about ‘avoidable harm’ was a turning point in the drive towards safer care, whether the failure to prevent deterioration, inadequate infection control or the prevalence of pressure ulcers. Seeing these events as harm that has the potential to be avoided through reliable care has generated significant will to make change.

However, while we should never lose sight of the need to root out avoidable harm, it cannot be our sole preoccupation. Looking at harm is like driving through the rear view mirror. It tells you here you have been, not where you are going.

Our work to develop a more comprehensive approach to measure and monitor safety provides another opportunity for teams to anticipate where things may go wrong – inadequate staffing levels, an unexpected rise in demand, poor handover systems – and to take steps to prevent this. Boards and teams need to be asking not simply what harm occurred last month/last year, but also asking ’are we safe today, will we be safe tomorrow and what are we learning for the future?’

You can find out more on practical steps for boards on measuring and monitoring safety by watching our webinar or downloading our practical guide.

Show visible leadership commitment to improving safety

One of the successful interventions from our Safer Patients Initiative was the introduction of Leadership Walkrounds – structured visits to clinical and non-clinical areas to talk with staff about their safety concerns. The visible presence and interest provided an important signal of how important safety was to the organisation’s leadership, and the rigorous follow-up on concerns showed a commitment to act.

More interestingly, I saw in my own trust that the conversation around the executive table changed. As directors, often remote from the business of the organisation, we started to see the challenges staff faced in keeping patients safe on a daily basis.

Sadly, as often happens with good ideas, their value gets lost in translation and in too many places as the technique was rolled out they defaulted to an ‘inspect and justify’ mindset, rather than one that ‘learns and acts’. I would urge everyone to go back to the original principles of Leadership Walkrounds. By taking staff concerns seriously and in a non-judgemental way you will be amazed what people feel able to share.

Changing culture is a long journey, possibly one without a final destination. But in the words of the Chinese proverb, every journey starts with a single step. I think these are six steps that the NHS could take tomorrow. Or actually, today.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF