3. What is a culture of safety and
how will I know if I have it ?
―Safety Culture is how the organisation
behaves when no one is watching‖
A knowledge and belief that you will not be
punished or humiliated for speaking up with
ideas, questions, concerns or mistakes.
4. Evolution of a Culture of Safety and
Reliability
Generative
SafetyBehavioural the way
is built into
we work and think
Proactive
We work on problems
that we still find
Calculative
Systematic
We have systems in place
to manage all hazards
Reactive
Safety is important we do lots
of it after every accident
Pathological
Fragmented
Who cares if we are not caught *Adapted from Safeskies 2001, ―Aviation
Safety Culture,‖ Patrick Hudson, Centre
for Safety Science, Leiden University
5. Safety Culture - The problem is;
• Organisations often state that safety is their highest
priority, but fail to live up to that maxim.
• The leadership may fail to live up to the words that they
speak about safety and culture.
• The staff also fail to play their part through a lack of
knowledge of the rules and commitment in completing
their actions.
• Financial pressure sometimes out-weighs safety to
protect the bottom line.
M Leonard 2012
7. Skilled Humans Will Make Mistakes
Do you know what the rules are if
you make a mistake?
Do you always feel safe reporting an
error?
How do we differentiate individual
problems for good people working in
unsafe systems?
Pascal Metrics 2011
8. Perspectives on Human Error
- Dekker
Old View New View
Human error is a cause of trouble Human error is a symptom of deeper
system trouble
You need to find people’s mistakes, Instead, understand how their
bad judgments and inaccurate assessments and actions made sense at
assessments the time - context
Complex systems are basically safe Complex systems are basically unsafe
Unreliable, erratic humans undermine Complex systems are tradeoffs between
system safety competing goals – safety v. efficiency
Make systems safer by restricting the People must create safety through
human contribution practice at all levels
9. Knowing the Rules
It is the actions of Management and not their words that have a significant
effect on the culture.
Safety Culture
Blame Just and No Blame
Learning
As in all things, extremes are never the right choice, yet as an organisation we
supported Blame for many years and more recently No Blame.
Neither work!
Improving safety culture
- Edwards
10. The Deliberate Harm Test The Physical/Mental Health
Was the intent was to cause Test
Physical or emotional harm.
If intent has been discounted, the
The Deliberate Harm Test asks
Physical/Mental Health Test helps
questions to help identify or
to identify whether the individual's
eliminate this possibility at the
(not the patient's) ill health or
earliest possible stage.
substance abuse caused or
contributed to the patient safety
incident.
Incident Decision Tool
The Substitution Test The Foresight Test
if protocols were not in place or If intent to harm and incapacity
proved ineffective, the Substitution have been discounted, the
Test helps to assess how a peer Foresight Test examines whether
would have been likely to deal protocols and safe working
with the situation. practices were adhered to.
NPSA - Reason
11. The Importance of Culture
“When something goes wrong it is how the organization acts that
redefines and reshapes the culture.”
Jeanette Clough, President & Chief Executive Officer
Mount Auburn Hospital, Boston, MA, USA
12. Stress
Working Job
Conditions Satisfaction
Teamwork
Management Safety
Culture
15. Goal: NO blood stream infections for 5 consecutive
months in the next 12 months by implementing a
checklist for central lines insertions?.
High
Medium Team work
Team Work 44%
Low
Team Work 31%
21%
How many ICU’s in each group
achieved the goal?
16. Why Communication? Why Teamwork?
The overwhelming majority of untoward
events involve communication failure
Wrong site surgery — somebody
knows there’s a problem but can’t get
everyone in the same movie
The clinical environment has evolved
beyond the limitations of individual
human performance
Pascal Metrics 2011
18. Secondary Driver
Aim Primary Driver
(from debrief process)
To Improve the To Improve Team Create and adopt the vision of ―one team‖
Quality of Work wherever staff work in the unit
Maternity care for patient and Develop systems that clearly identify and maximise the
demonstrating staff benefit roles of the Multidisciplinary team
50% reduction To Improve Safety
Develop safe clinical processes and care bundles that
in Adverse and Reliability of The Unit is flexible, mobile and supportive.
improve outcomes for mothers and babies and ensure
events Care staff can make safe decisions and are supported to do so
by
January 2013 To improve the Identify and implement clear values, rules and behaviours
and culture within the
Maternity unit for Ensure mutual respect is a core value and ―conflict
20% management‖ is managed
patients and staff
Improvement
Develop Management processes that give clarity
in Care
regarding staff numbers and deployment in the unit and
Experience To improve involve staff in the discussion and planning of staff
by Leadership and changes/rotations.
January 2013 Management
and Effectiveness Reduce stress and fatigue and build informal relationships
by development of a reliable process to ensure breaks are
Improve taken in timeous and appropriate manner
Culture Survey To improve
scores by 10% effectiveness Develop and implement clear learning and educational
by January through learning strategy and conduct multidisciplinary drills across the unit
2013 and education
20. Organising for Improvement
Key senior clinical and
leadership input
Maternity Quality
Effective improvement
Improvement Team support – Improvement
Advisor, Clinical Improvement
Aligned to the Practitioners
Quality Strategy
Involvement of staff at all
levels
21. Recipe for improvement
Maternity SPSP
PASCAL METRICS ( Cultural
Maternity CQI’s
Survey)
Maternity Quality
Improvement
Team
Complaints Learning and Significant Adverse Event
Improvement Learning and Improvement
22. Moving to Action -
How does it feel?
Driver
diagrams
Care Bundles
Measurement
Sustainable Improvement
23. Aim Primary Driver Secondary Driver
All women will be informed about the risks associated with
Improve the criteria pregnancies longer than 42/52.
for safe selection of All women will be informed of the choices available to them.
The Safety women for induction All women will be informed of where and when induction will
of labour ensuring be carried out and have access to pain relief.
and
informed choice at All women will have a membrane sweep and bishop score
Reliability of all times performed prior to admission.
Induction of
labour in
prolonged
The unit will follow NICE Guidance. Any deviation must be
pregnancy Develop and clearly documented and should include discussion
41+0 - 42+0 provide safe reliable with the woman.
(NICE care bundles for the The guideline will include a fetal monitoring regime and a
Guideline administration of prescription for pain relief
2008) will be Prostaglandin
Woman reporting uterine activity will be assessed by an
improved for appropriately competent professional.
all women
by Dec Develop and
2012 *All women will have a syntocinon regime prescribed
provide, safe and
appropriate to their parity.
reliable care
Any deviations from the protocol must be clearly documented
bundles for the
and a rational provided.
administration of
Women should be informed induced labour can be more
syntocinon
painful and have access to appropriate analgesia.
24. .
•I
Aim Primary Driver Secondary Driver
•
• Planning groups to identify change concepts and
Increase the identify specific training needs
• Back to Basic training sessions for both acute
number of Provision of evidence based hospital and community midwives
women who give care and use of pathways and • Prevention of transfer to obstetric/labour suite
birth naturally • Develop and implement care bundles for 2nd stage
care bundles labour when no descent with active pushing
within the • Utilise pathway for maternity care as defined in
Midwifery Suite maternity standards
(MWS) at
Ayrshire
Increased confidence of midwives in normality skills
Maternity Unit by •Education in normality skills
10% by Hormones & labour
November 2012. Latent phase of labour
Promotion of normal childbirth Recognition and management of behaviours
during labour
Operational for women using the social Nutrition & hydration
Definition of model of care. Labouring positions
Natural childbirth Perineal protection
Mechanisms of labour and relation to practice
is women who Affirmation of labour and birth
deliver vaginally
with either
amniotomy •Continuous risk assessment
and/or the Provision of person centred •Increase awareness of aims of Keeping Childbirth
administration of Natural and Dynamic programme
care through informed choice
•Joined working relationships between community and
diamorphine or and informed decision hospital staff
entinox. making. •Appropriate antenatal education of women in relation
to pain management and positioning techniques in
labour.
25. Next Steps
• Embed
• Support and grow
• Communicate and
educate
26. “Our lives begin to end the day we become
silent about the things that matter”
Martin Luther King
Editor's Notes
What does that mean in the workplace?Individual & Group = personally and together.Values = principles held dear such as integrity, or living up to your word.Beliefs = what you have faith and/or understanding in. Attitudes = the mental approach you/we take towards work.Behaviours =- the physical approach you/we take towards work.
Utilised the skills and knowledge of the Organisations Quality Improvement Team.Member of the team, non midwife, working closely with us.Drop in sessions to acquaint staff with the terminology.Assurances this is not about measuring for the sake of it ! it is about outcomes for Mothers and Babies.Aligned to the Quality Strategy, safe, effective, person centred.Appointed a Midwife as a Quality Improvement Advisor to work with the existing Organisational Team.Staff ownership of the process
Introduced Driver Diagrams:Peri operative Care Bundle-surgical pause, WHO check list.Syntocinon Bundle- safe selection, Prostin, syntocinon regime.Utilised the model for improvement.Commenced PDSA cycles, producing run charts( new terminology and steep learning curve)
The unit should follow NICE guidelines/local policy. Any deviations must be clearly documented and should include discussion with the womanThe guideline should include a Fetal monitoring regime and a prescription for pain relief.Women reporting uterine activity will be assessed by an appropriately trained professional.
Embed this into the cultureEnsure we continue to grow grass roots ownershipKeep our champions enthused and supported in time and trainingCommunicate, Communicate, Communicate
