Learning from the Environment of care culture of the past .

Florence Nightingale FoundationAnnual Conference

February 2014

leadership Putting patients first Complaints handling Professional regulation of fitness to practice Regulating healthcare systems Standards Collection of real time data to measure quality Performance Management Promotion of NHS Constitution values Openness , transparency and candour Universal culture

Mid Staffordshire Public Inquiry -Recommendations Key Themes

“The trouble with culture is everyone blames it when things go wrong but no-one really knows what it is or how to change it” - Prof John Glasby

Its “how we do things round here” - Prof Charles Vincent

“What are we going to work for today ?” – Prof Sir Ian Kennedy

“Organisational culture is informed by the nature of its leadership” – Robert Francis QC

“It’s what people do when no one is looking” – comment about bankers

Descriptions of culture

“ We are undoing 30 years of culture” – Anthony Jenkins

Barclays Bank

“The Francis report is a powerful reminder that we need a renewed focus on hearing and understanding what patients are saying”. Ruth Thorlby , senior fellow Nuffield Trust

Evidence of poor care in a range of settings

◦ Bristol Royal Infirmary – 1984 – 95 . Report 2001◦ Allitt 1991 . Report 1994◦ Shipman 1998. Report 2000◦ Climbe 1999 – 2000 . Report 2003◦ Alder Hey - 2001◦ Mid Staffordshire NHS Foundation Trust – 2005 -08 Public Inquiry

report 2013◦ Baby P – 2006 – 07 . Report March 2009◦ Maidstone and Tunbridge Wells 2007. Report Oct 2007◦ Ombudsman Report – elderly care 2001◦ Patients Association Reports 2011 / 2012 ◦ Winterbourne View – 2011. Report Dec 2012

Background

Whilst there must be individual accountability for breaches of standards , the reality is that in most instances of poor care and avoidable harm arise from a much more complex set of circumstances. Systems and processes, pressure of work, quality of leadership and the cultural mind-set of the organisation are crucial factors .

Factors that influence poor care

Patients fear of upsetting staff Forceful style of management Target driven priorities Lack of appreciation of risks for patients Clinician dissengement from management Low staff moral Isolation – lack of strong associations Lack of openness Acceptance of poor standards of conduct / behaviour Reliance on external assessments Denial / defensiveness

NB. Echoes of cultural issues throughout healthcare not just Mid Staffs

Robert Francis findings re culture in Mid Staffordshire Trust

Research demonstrates a number of key factors which are necessary to maximise staff commitment , engagement and productivity and linked to 4 themes ; * resources to deliver *support to do the job *a job that offers chance to develop *the opportunity to improve team working Ipsos Mori 2008 What matters to staff in the NHS

Factors that influence staff behaviour

“It is especially important that organisations do more to ensure the engagement and health and well being of their staff”. Professor Michael West – lead author

BMJ Quality and Safety study – published Sept 2013

“The results reinforce the need for a much greater focus on staff management and engagement – we know there is a clear correlation between a passive staff experience and better health outcomes“. HPMA President

Chartered Institute of Personnel and Development and the Healthcare Management Association – Survey of 1,021 staff

“You need to light fires inside people not under people” - South Tees Hospitals NHS FT

Staff Care – How to engage staff in the NHS and why it matters – The

Point of Care Foundation 2014

The environment of care is broader than the notions of patient or person centred care . Staff too need an enriched environment to create the same for patients .

The Care Environment

“The NHS reflects the society around it”. Royal Commission on the NHS – 1979 Commissioned

by Barbara Castle

“We need to look beyond the NHS and examine the values we hold as a society”. Ann

Clwyd Feb 2013

Common set of values and standards shared throughout the system

Committed leadership at all levels to the values A system that recognises and applies values of

transparency , honesty and candour. Freely available , useful full information on

attainments of values and standards The use of a tool or methodology to measure

the cultural health of all parts of the system Organisational stability

- ----Mid Staffordshire Public Inquiry Report.

Drivers for a positive Universal culture;

Acceptance that patients needs come before ones own

Recognition of the need to empathise with patients and other service users

Willingness to provide patients with the assistance one would want for oneself or refer to someone who can help

Willingness to listen to patients to discover what they want for themselves

Willingness to work together for the benefit of patients

A commitment to draw attention about safety and welfare to those who can address them – Mid

Staffordshire Public Inquiry Report

Ingredients of a culture of caring

Develop a clear vision for quality care Embed key values / behaviours that could make a

difference Encourage use of data to drive quality and safety Find simple measures to address consistency, and

complacency Ensure a recognition of human factors Act as Role models / Champions / Mentors Don’t assume others will act – misplaced trust Strong leadership

Creating a Safe and Compassionate Culture of Care

Responsible for developing a patient safety culture - Assurance - Duty of candour - Human factors – NQB Concordat www.england.nhs.uk/ourwork/part-rel/nqb/ - Leadership

The Boards role

Effectiveness and outcomes Patient safety Patient experience

3 Facets of Quality The Healthy NHS Board 2013

Principles for good governance - NHS Leadership Academy

Trusts should embed early warning systems Have people with expertise to scrutinise

data Real time feedback Patients and Clinicians more involved in

inspections Skill mix reflects acuity Harness the ideas of students

Keogh Reviews of 14 Trusts - 2013

“Maintaining a safety culture indeed any kind of culture , requires leadership and on-going work and commitment from everyone concerned” – Prof Charles Vincent in evidence to the Mid Staffordshire Public Inquiry

Leadership

43 % of senior managers and leaders said that organisational culture was the biggest obstacle to improving care. Kings Fund Leadership Review. 2013

Patient Centred leadership : Rediscovering our purpose

A promise to learn - a commitment to act

Improving the safety of Patients in England

National Advisory Group on the Safety of Patients in England . August

2013

Courage for change Abandon blame Transparency at all levels Functions relating to safety and

improvement are vested clearly and simply Give people in the NHS top to bottom –

career long help to learn Make sure pride and joy in work, not fear ,

infuse the NHS.

Donald M Berwick - key Points

Looking is not seeing. Listening is not hearing. It is possible to miss so much that is right in front of us if we lack the categories and skills to notice . The greatest of these skills is, perhaps, to put aside our expectations, and to stay open to the actual.” Donald M Berwick.

Principles for good governance

“Don’t just do something , stand there”. – Alice in Wonderland

Reflection