The Independent reports today on the issues of safety in maternity units citing the CQC’s chief inspector of hospitals, Professor Ted Baker, who told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems. “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.”
You can find the article here: https://www.independent.co.uk/news/health/cqc-maternity-safety-inquiry-baby-deaths-shrewsbury-east-kent-b747195.html
Over the last two decades there has been a concerted effort to improve the safety of care in maternity units and we are learning all of the time. Most recently an article published by the quality and safety journal by the BMJ group; Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation – Liberati et al.
The researchers identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include:
(1) commitment to safety and improvement at all levels, with everyone involved
(2) technical competence, supported by formal training and informal learning
(3) teamwork, cooperation and positive working relationships
(4) constant reinforcing of safe, ethical and respectful behaviours
(5) multiple problem-sensing systems, used as basis of action
(6) systems and processes designed for safety, and regularly reviewed and optimised;
(7) effective coordination and ability to mobilise quickly
They state that these “features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification”.
You can find it here: https://qualitysafety.bmj.com/content/early/2020/09/25/bmjqs-2020-010988
The paper explains the ‘new plain-language framework’ developed by This Institute [an independent organisation with the aim of creating a world-leading scientific asset for the NHS about how to improve quality and safety in healthcare] – this can be found at: https://for-us-framework.carrd.co
In my experience at the heart of a safety culture is the way we behave. These can be couched in terms of theoretical concepts such as just culture, behavioural psychology, behavioural insights, psychological safety, incivility, safety I and safety II. The thread that winds its way through all of these is the way we behave towards each other. This includes relationships, the habits that have become ingrained, our ability to work as a team, the words we use, the tone we use when we talk to each other, and the way we listen and respond to each other.
Therefore if you want to change the culture in your organisation you can develop all the processes and rules you like but if you don’t focus on the people and the way they behave you won’t get very far. You can start by understanding and highlighting the behaviours that help and the behaviours that hinder.
helping behaviours include compassionate leadership, listening, respect, kindness and gratitude
hindering behaviours include incivility, bullying, ignoring, lack of respect and a lack of kindness
Working in healthcare is already tough enough without people being treated rudely or being bullied, belittled or humiliated. We heard of inspiring stories of people coming together during the spring and summer to support each other during one of the most stressful times of our lives. But it wasn’t perfect with everyone getting on like a house on fire – the behaviours that tend to emerge at times of stress include those we know inhibit the ability to work safely – rudeness, incivility and bullying. Therefore for me the aspects identified by the researchers above of teamwork, cooperation and positive working relationships together with constant reinforcing of safe, ethical and respectful behaviours are great places to start.
My final comment though is with respect of scrutiny. How many of us would survive the microscopic scrutiny of our actions? There is almost no human action or decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight. Focusing people on their shortcomings doesn’t enable learning; it impairs it. If we continue to spend our time identifying failure as we see it and giving people feedback about how to avoid it, we’ll languish in the business of adequacy. We need to urgently shift away from this way of looking at safety and towards a Safety II* approach:
- Listen to every side of the story; parents, family, staff
2. Strive to be non-judgemental in your mindset – seeking to learn before assuming what has happened
3. Study how people work everyday and how they adjust and adapt to make care safer – and whether the processes and policies are supporting or hindering this ability to adapt
4. Learn about how things ‘normally go’ in order to understand why they fail in certain instances
5. Learn from ‘how people work everyday and how things normally go’ to replicate good practice and strengthen the system – if it succeeds most of the time you want it to continue to succeed. If it fails occasionally and you make changes – you may actually impact on the way in which things succeed and lead to more failure – think before you change and base that change on a balanced view of safety (safety I and safety II)
*Reference: Read anything by Erik Hollnagel and you can’t go wrong