A positive culture in the NHS

The case for a positive culture

Improving patient safety in the UK requires change in many different areas, including a change in the culture within the NHS.   A positive safety culture is where staff within an organisation have a constant and active awareness of the potential for things to go wrong, they can share information openly and freely, and are treated fairly when an incident happens. This is vital for both the safety of patients and the well-being of those who provide their care.

The culture of an organisation is the way people behave; their beliefs, values, attitudes, norms, and unspoken assumptions and working practices together with entrenched processes that shape how people behave and work together. It is a very powerful force and something that can remain even when teams change and individual staff move on.

An organisation with a safety culture us one where patient safety is at the forefront of everyone’s minds; not only when delivering healthcare but also when setting objectives, developing processes and procedures, purchasing new products and equipment, and redesigning clinics, wards, departments and hospitals. It influences the overall vision, mission and goals of an organisation.  That is, it influences everything you do.

Why is a positive safety culture important?

There is evidence that when open reporting and an even-handed response when things go wrong are encouraged this can have a positive and quantifiable impact on the performance of an organisation.

A positive safety culture will help NHS organisations to achieve improvements across the board.  This requires changes at all levels of the NHS. It is vital that all those who work in and use the NHS; clinicians, managers, accountants, porters, receptionists, allied healthcare practitioners, patients, families and carers – ask themselves how they can help to improve the safety of patient care.

To create a positive safety culture we need to dispel two key myths:

  • The perfection myth: if people try hard enough, they will not make any errors.  A difficult but essential aspect of a safety culture is the need to accept the fact that people, processes and equipment will fail. By doing this organisations can focus on change and develop defences and contingency plans to cope with these failures. Finding out about systems failures in an incident, in addition to the actions of individuals, will help organisations learn lessons and potentially stop the same incidents recurring.
  • The punishment myth: if we punish people when they make errors, they will make fewer of them; that remedial and disciplinary action will lead to improvement by channelling or increasing motivation.  The vast majority of staff in the NHS want to do a good job, to reduce suffering and to be proud of the work they do. However, as Lucian Leape has famously said, ‘some of the best people can make the worst mistakes’. They mainly fail because of the underlying conditions in which they work; the design of the system, care pathways and environment together with human factors such as distraction, stress, teamwork, hierarchical structures and workload that lead to error and harm. Don Berwick stated in his report ‘A promise to learn, a commitment to act; improving patient safety in the England NHS’, fear is toxic to both safety and improvement. When staff are fearful of repercussions and blame it hinders them from sharing their concerns and speaking up when things go wrong. This in turn means that mistakes can be hidden, issues can be buried and lessons go unlearned.

A positive safety culture does not mean an absence of accountability. It is essential in a public service like the NHS that our actions are explained and that responsibility is accepted. Along with increased public awareness of patient safety issues, there is increasing public interest in the performance of the health service and therefore rightly an increased expectation around accountability. The many different forms of accountability influence the decisions healthcare staff make on a daily basis.

What can health providers do?

  • Understand the existing culture
  • Provide clear and visible leadership about what is expected in terms of values and behaviours
  • Address NHS Disciplinary Policies and Procedures
  • Understand how our natural bias influences decisions about patient safety incidents
  • Provide feedback about learning
  • Promote the right balance of accountability

Organisations need to understand their existing culture before they can change it.  There are many tools that can be used to measure an organisation, department or team culture. Changes in attitudes and behaviour can take time to develop and they require an understanding and willingness to adjust. Organisations therefore need to raise the level of understanding around patient safety and the systems approach to error and incidents.

The leadership of any organisation is central to setting the values and beliefs of an organisation’s culture. The chief executive, the board and directors therefore have a vital role to play in building a safety culture that is open and fair. They need to establish an environment where the whole organisation learns from safety incidents. In addition senior managers and clinicians can set the tone for their departments and teams by promoting and shifting the change in culture. They can ensure that incidents are dealt with fairly and that the appropriate learning and action takes place.

Being open and fair highlights a need for local NHS disciplinary policies and procedures that clearly describe how organisations will promote the just culture for safety and support staff involved in human error, incidents, complaints and claims to ensure that they are not detrimental to improving patient safety.  As Don Berwick went on to say; ‘All incentives should point in the same direction. In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.’

Incidents should be reviewed and investigated fairly, free from bias over the outcome of the incident or from hindsight. Disciplinary action tends to relate to the result of the incident (outcome) or based on ‘what we know now, rather than what was known then’ (hindsight). If the outcome is serious for the patient, the individuals involved are more likely to be disciplined than if the incident caused no harm to the patient.

Organisations should also ensure that staff receive feedback and are informed of what action has been taken as a result of an incident being reported. Staff are more likely to foster an open attitude if they feel they have been listened to and that by reporting an incident they have made a positive difference to patient safety.

Accountability for patient safety means being open with patients and the public, saying sorry, explaining the actions taken and providing assurance that lessons will be learned. NHS organisations need to demonstrate the right balance between positive support, fairness accountability and openness.