Diane Murray - Assistant Director Clinical ImprovementAngela Cunningham Head of Midwifery and Childrens Services
AttitudesValues   Culture      Behaviours           Beliefs
What is a culture of safety andhow will I know if I have it ?  ―Safety Culture is how the organisation  behaves when no on...
Evolution of a Culture of Safety andReliability                                                      Generative           ...
Safety Culture - The problem is; • Organisations often state that safety is their highest   priority, but fail to live up ...
Inherent Human Limitations
Skilled Humans Will Make MistakesDo you know what the rules are ifyou make a mistake?Do you always feel safe reporting a...
Perspectives on Human Error- DekkerOld View                                New ViewHuman error is a cause of trouble      ...
Knowing the Rules It is the actions of Management and not their words that have a significant                            e...
The Deliberate Harm Test                    The Physical/Mental HealthWas the intent was to cause                 TestPhys...
The Importance of Culture“When something goes wrong it is how the organization acts thatredefines and reshapes the culture...
Stress Working                         JobConditions                   Satisfaction                Teamwork   Management  ...
Culture Risk Score
AMU Overall Performance by Domain                  Average Percent Positive
Goal: NO blood stream infections for 5 consecutivemonths in the next 12 months by implementing achecklist for central line...
Why Communication? Why Teamwork?    The overwhelming majority of untoward     events involve communication failure    Wr...
Being a Jerk is Not OK – It’s          Dangerous© 2010 Pascal Metrics
Secondary Driver    Aim           Primary Driver                                                     (from debrief process...
Moving to Action
Organising for Improvement                        Key senior clinical and                          leadership input Matern...
Recipe for improvement     Maternity SPSP                                 PASCAL METRICS ( Cultural     Maternity CQI’s   ...
Moving to Action -How does it feel?                                      Driver                                    diagram...
Aim          Primary Driver                            Secondary Driver                                         All women ...
.•I           Aim                Primary Driver                          Secondary Driver                                 ...
Next Steps             • Embed             • Support and grow             • Communicate and               educate
“Our lives begin to end the day we become  silent about the things that matter”                            Martin Luther K...
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Parallel Session 2.3.1 What's Your Problem? Lessons on How to Solve National and Local Challenges

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Parallel Session 2.3.1 What's Your Problem? Lessons on How to Solve National and Local Challenges

  1. 1. Diane Murray - Assistant Director Clinical ImprovementAngela Cunningham Head of Midwifery and Childrens Services
  2. 2. AttitudesValues Culture Behaviours Beliefs
  3. 3. What is a culture of safety andhow 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. 4. Evolution of a Culture of Safety andReliability 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. 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
  6. 6. Inherent Human Limitations
  7. 7. Skilled Humans Will Make MistakesDo you know what the rules are ifyou make a mistake?Do you always feel safe reporting anerror?How do we differentiate individualproblems for good people working inunsafe systems? Pascal Metrics 2011
  8. 8. Perspectives on Human Error- DekkerOld View New ViewHuman error is a cause of trouble Human error is a symptom of deeper system troubleYou need to find people’s mistakes, Instead, understand how theirbad judgments and inaccurate assessments and actions made sense atassessments the time - contextComplex systems are basically safe Complex systems are basically unsafeUnreliable, erratic humans undermine Complex systems are tradeoffs betweensystem safety competing goals – safety v. efficiencyMake systems safer by restricting the People must create safety throughhuman contribution practice at all levels
  9. 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 LearningAs 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. 10. The Deliberate Harm Test The Physical/Mental HealthWas the intent was to cause TestPhysical or emotional harm. If intent has been discounted, theThe Deliberate Harm Test asks Physical/Mental Health Test helpsquestions to help identify or to identify whether the individualseliminate this possibility at the (not the patients) ill health orearliest possible stage. substance abuse caused or contributed to the patient safety incident. Incident Decision ToolThe Substitution Test The Foresight Testif protocols were not in place or If intent to harm and incapacityproved ineffective, the Substitution have been discounted, theTest helps to assess how a peer Foresight Test examines whetherwould have been likely to deal protocols and safe workingwith the situation. practices were adhered to. NPSA - Reason
  11. 11. The Importance of Culture“When something goes wrong it is how the organization acts thatredefines and reshapes the culture.”Jeanette Clough, President & Chief Executive OfficerMount Auburn Hospital, Boston, MA, USA
  12. 12. Stress Working JobConditions Satisfaction Teamwork Management Safety Culture
  13. 13. Culture Risk Score
  14. 14. AMU Overall Performance by Domain Average Percent Positive
  15. 15. Goal: NO blood stream infections for 5 consecutivemonths in the next 12 months by implementing achecklist 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. 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
  17. 17. Being a Jerk is Not OK – It’s Dangerous© 2010 Pascal Metrics
  18. 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 unitMaternity care for patient and Develop systems that clearly identify and maximise thedemonstrating staff benefit roles of the Multidisciplinary team50% 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 byJanuary 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 staffImprovement 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 mannerCulture Survey To improvescores 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
  19. 19. Moving to Action
  20. 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. 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. 22. Moving to Action -How does it feel? Driver diagrams Care Bundles Measurement Sustainable Improvement
  23. 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 scoreReliability of all times performed prior to admission.Induction oflabour inprolonged The unit will follow NICE Guidance. Any deviation must bepregnancy Develop and clearly documented and should include discussion41+0 - 42+0 provide safe reliable with the woman.(NICE care bundles for the The guideline will include a fetal monitoring regime and aGuideline administration of prescription for pain relief2008) will be Prostaglandin Woman reporting uterine activity will be assessed by animproved for appropriately competent professional.all womenby Dec Develop and2012 *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. 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. 25. Next Steps • Embed • Support and grow • Communicate and educate
  26. 26. “Our lives begin to end the day we become silent about the things that matter” Martin Luther King

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