17 September 2020 marks the second annual World Patient Safety Day. The theme this year is 'Health Worker Safety: A Priority for Patient Safety'.
In the run up to this special event, Patient Safety Learning are publishing a series of interviews with staff from across the health and care system to highlight key issues in staff safety and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe.
In this interview, Patient Safety Learning's Content and Engagement Manager, Steph O'Donohue, speaks to Nick Kelly, Co-founder and CEO of the Axela Group, who specialise in health and social care services.
A transcript of the interview is available below.
Questions & Answers
Steph: Today, I’m very happy to be joined by Nick Kelly, who is the CEO of Axela. Nick, do you want to tell us a bit more about Axela and what you do, and what the link is with patient safety is?
Nick: Axela is a parent group of four companies; two care agencies that look after people when they’re in homes. We also go into care homes and assisted living facilities. We also have a training and consulting company, which supports individuals that are working within care and want to train up. So we do health and safety training… we do first aid training… And we’ve got Axela Innovations, which is our technology arm. We’re creating technology that supports healthy living but also supports individuals to live better safer lives in their own home.
Steph: In your experience, why do you think staff safety is so important and what do you think it looks like?
Nick: We’ve got staff in the office and those that go into homes, but we’ve also got a lot of staff in the community in care work. The one thing we’ve always tried to do is make our staff feel safe, make our staff feel valued and make them realise that they are key.
And we’ve done anything we can over the years to put things in place. We’ve got, on our care worker app, the app’s got an emergency button that pings out if they feel like they’re being threatened. It has a button that they click and it records their location and audio output… Any care worker working after 9 o’ clock has to be [part of a pair of two] care workers to make sure they’re both safe. In the office, more recently as well… we’ve given hand sanitiser on everyone’s desk. There are cleaning products on everyone’s desks, we’ve got air conditioning… we’ve got a lot of things in place to make sure our staff are safe.
At the end of the day…. the business is built on staff, and you have to make sure our staff feel safe. You’ve got to make them feel that that isn’t something they need to worry about… They’re here to deliver their job; they’re not here to worry about ‘Is this clean?’, ‘Am I going to be safe?’, ‘Has someone done a risk assessment where I’m going here?’, ‘Are the stairs going to fall apart?’ And I think people forget that the staff are the backbone of any business and is why your business is in place. So you have to put them in a safe environment; you have to make them feel that you are doing everything you can to protect their safety.
And I think, even when you look at equipment… We test all of our equipment… We check it as much as we can… As soon as we get a new bit of equipment, we might not know how to use that… so we work with those people who have created that piece of equipment to make sure everyone is trained because safety isn’t just about making sure you’re OK; it’s down to every last piece of kit you interact with.
Steph: It’s really interesting because you talk about the physical things, in terms of the hand sanitisation and making sure the equipment’s working. And then you talk about staff being valued, and the feeling of being valued and not having to worry about those things. So you’ve touched on the psychological side of it as well.
Nick: From December to January, and I think we went into a bit of February, all the senior managers and about 20 members of staff were offered mental health… training. And, off the back of that, we created a health group, we worked with a mindfulness coach and a fitness coach… Again, safety isn’t just a physical thing you can touch… You have to try and support the whole person. It’s not just about making sure you don’t trip; that’s quite basic. ‘I’m trying to support you’, ‘I’m trying to make sure that this environment is the safest possible [place] for you to work’. Safety isn’t just physical; there is that mental side to it. So is there something that everyone should be aware of that might be creating an unsafe environment…? Let’s all make sure we’re on the same page. Let’s all make sure we’re working towards that same goal…
And is there anything from a training perspective, where you feel that we can support you… [that you] don’t feel confident doing? So how do we support that as well. And that’s why we’ve gone down that route as well. So we’re trying to support not just the physical but that whole… 360 view [of] that person. If you are working for us, at any point in your working environment, how do I support you as a whole?
Steph: And what’s the feedback been like from staff?
Nick: Feedback has been really good. I think the big assessment for us; our turnover rate is less than 7%. For staff in an industry where you’re pushing upwards of 26%, 27%, we’re around that 7% mark. And the reason why is because we put our staff first and… We put all those initiatives in place – and, yes, there are costs to them – but the knock-on effect is I don’t have to constantly keep training new staff; I don’t have to worry about this new person coming in. I’ve still got the same… staff we started with 13, 15 years ago. So I think the overall feedback has been really good.
And because we build the technology ourselves, and we’ve been building it for a while, anything that needs to be changed or adjusted, we’re able to do that. So we’re not having to go back to a supplier and say ‘this doesn’t work’ or ‘can we add this feature in?’ It’s very much… we’ve got it… we test it, we build it, we release it. But we’re also testing with those people who have asked for that thing, so it’s not ‘go off, test with a bunch of developers’…. [we say to staff] ‘you said this was a problem – can you check and tell me if this works for you?’
Steph: You’ve got quite a unique position, haven’t you? With creating the technology and having the users right on your doorstep who are your staff who you’re quite close to and some of them have been there for 13, 14 years. They’re going to be quite honest with you! It sounds like quite a unique setup.
Nick: I’m always going to try and [be innovative] when you think about safety, but… safety doesn’t have to cost a huge amount of money. There are very simple things you can do… to deliver safety, that actually allows you to support the whole person… For me, it’s all about using the tools that you have in front of you and to deliver the best. And it’s not that technology is the answer, and it’s not that I don’t need technology to do this, it’s… ‘How do I create a safe environment and how do I make sure that environment stays safe?’
But then also, how do I monitor that? How are you monitoring that safe environment and then making continuous improvements?... If you’re putting things in and you’re looking at it once a year, so many things [can] then happen. If [you put] your safety plan [in place] in, say, February, that safety plan went out the window within six weeks… If you only review it once a year, that whole safety plan would have changed five or six or seven times. If you haven’t got that process in place to have that continuous improvement and that continuous process, [you’ll be] trying to catch up with yourself…. You have to look at it as a continuous part of the everyday business.
Steph: If staff don’t feel safe physically or mentally, what’s the impact that you’ve seen on patients? Maybe not in your organisation, but what do you think that would mean for patient safety?
Nick: I think right now… you can really see the cause and effect of that. Normally, it’s quite hard and it’s quite granular. But, right now, if that member of staff isn’t feeling safe… you can understand that they’re not getting the equipment or the training that they need. That is going to have a knock-on effect on how they deliver that level of care and how they interact with individuals receiving care. And that then is going to have an impact because if… someone walks in and they’re not wearing the right equipment or they don’t look happy or they’re not what you perceive as they should be, that’s going to have a knock-on effect on your confidence [as a patient]… And if someone is delivering health or care to you, you don’t want to question ‘Is that person feeling safe?’, ‘Is that person well trained?’, ‘Is that person the right person right now to deliver that?’ Because it makes you then feel anxious and that anxiety will then feed onto them… even if they were or weren’t feeling that.. You start creating that… cycle, where you’re anxious and they then feed onto that which makes them anxious which makes you feed on that… and you’re just in this circle.
So the best thing you can do is try and nip that really early; to try and support everyone as much as possible… You have to be explaining to people what you’re doing to try and make that interaction safe. And it’s not just a ‘Let’s go off and do things’ or ‘Let’s put these really nice peripheral things in place’… It’s everything you’re doing. So the equipment you’re using, we sanitise it… This is our cleaning schedule everyday… This is where we get our equipment from…. If a piece of equipment falls on the floor, this is our process; we throw it away.
And I heard a horror story a couple weeks ago about a surgeon… bringing his own equipment into surgery, and he wouldn’t use the hospital equipment… And at the end of it, he’d clean it and re-use it. If I found out a surgeon that was cutting me open was bringing his own equipment in, I’d be shocked! And that would make me very anxious, and that would make me not want to go to hospital…. So it has to go through that whole process, you have to signpost it, so everyone feels safe and everyone feels aware of it, and it has to be that transparent. The transparency is what’s going to allow people to feel relaxed. The transparency is what’s going to allow people to feel safe. The transparency’s going to allow staff to continue delivering their job in the best way.
Steph: It’s interesting that you use the example about the surgeon because we had an anonymous blog written by somebody for the hub and it was about somebody who had been in a surgical theatre as a scrub nurse and the surgeon had dropped an instrument on the floor and run it under the tap and had re-used it. And that member of staff had raised this as a concern and found that her shifts had been reduced or cancelled afterwards. That leads me onto the question for you guys about staff safety and speaking up, if they have any concerns about safety or ideas about safety. Do you find staff coming forward with ideas?
Nick: Yes, they do. We’re not the only ones that do this. I’m on a lot of calls with providers of other companies and they all have… I think the big thing I can say is that we probably didn’t have it right, and we probably don’t have it 100% right. But we are very much pursuing, we’re opening to listening to our staff but we’re also open to learning from other companies. Because no one company has it right. And I think you also have to somewhat cherry pick the best bits for you to create what is going to inevitably be your safety…
For us, we’ve got a suggestion box in the office, we have an anonymous email account, all staff have my phone number… If you tell me something, I will investigate that. The other members of the leadership team will investigate as much as they can and keep that person anonymous…. We want to make sure that that person stays anonymous… but we also don’t want staff to feel like they’re being victimised… You have to create that open and safe environment for your staff to feel like they can explain things to you; that they can feel like they’re not going to be victimised. Because, at the end of the day, we’re all working towards the greater good…
With that example of the scrub nurse, it felt very much like they wanted to protect the surgeon and the hospital, not the scrub nurse. Now what you’ve done is you’ve protected that surgeon; he’s going to go off and do that again. He’s going to continue doing that. And now because everyone knows that they can’t speak up, everyone’s going to go ‘I’m not going to say anything because I can’t lose my job’… which means the actual problem there is that the individual who is now receiving that care isn’t getting the best level of care.. And then you run the risk of something going wrong and you then having to react to it… The best thing you can do is create that openness and honesty and be safe. And, when things are brought to you that aren’t safe, be very hard on it and show what you’ve done to mitigate it.
Steph: What advice would you give to other organisations? I know you said that you work very collaboratively. Is there anything that you’ve learned along the way… the key things that you would advise other organisations to do?
Nick: What we did is to try and have advocates on each level, sitting together… and create a Safety Board… and make sure that there are actions that come out of that and they are actually being delivered on. So, from our perspective, bring a care worker, bring a HCA, bring a senior manager, bring a director… Then ask ‘What do we need to do? These are the things that are wrong… this is how we make that safe’… You go into that meeting, you make it tangible and you put it into process. You don’t just go in… have an hour meeting and nothing happens… Because then we’d go back to not having that trust or that authenticity. So you have to create that; you have to have that environment where people feel that if they speak up and things are said, they can see that being done. And the more they speak up, the more things are being delivered, the more things are getting safer.
We had an incident where… we were giving vinyl gloves to our staff and what they were finding was when they were putting vinyl gloves on, they would always break… So we scrapped it and said we’re not using vinyl gloves anymore; we’ll only be using nitrile gloves… And we then sent out a notification saying that because of the problems everyone had with vinyl gloves, we’ll only be using nitrile gloves. And we went out and spent; the difference in pricing, it’s pretty much close to double the cost of a vinyl glove. But we knew that there was a problem. We knew that staff didn’t feel safe using vinyl gloves, and they didn’t feel like the barrier the vinyl glove created was able to allow them to feel safe delivering care. So we went out and bought the nitrile gloves. And we did the same thing with shoe covers…. So it’s about understanding what the problem is and really delivering on that.
If your staff don’t feel safe and happy, that will start causing problems… And staff do talk. When one person leaves, they all tell their colleagues why they’re leaving… And then all of a sudden, you’ve got other people looking for that same problem for their justification for leaving… So, for example, with us, if we’d [not listened], all of our staff would have left [saying] ‘they didn’t care about us’… And if you say ‘the gloves aren’t safe’ then ‘Well, what other practices are they doing that aren’t safe?’… And all you [the company] can do now is react. And if you have to be defensive without evidence to back it up… you’ll always look a bit guilty. You should try and be as proactive as you can… If you’re creating all these things and you’re signposting to them, people then feel reassured, people feel safe…
And there are other industries that are doing it better as well. Yes, we’re in healthcare but is there a company that’s in, say, pharmaceuticals, or a company in logistics… Has a supermarket got it better than us? What are other people doing? What can we learn from everyone else to create the best environment?... You have to realise that you might not have it right. You have to learn from others that are potentially doing it… better than you. So learn what they’re doing, improve on it. The next person will learn from what you’re doing, improve it. And all you’re doing is laddering up each time we learn.
Steph: And would you give staff any advice of how to keep themselves safe or how they can contribute to keeping everyone safe in a health and social care environment?
Nick: What I try and do for everyone is [encourage them] to have a conversation between [themselves]… If you see something that you think is being done unsafely; you think someone can do it better – speak up, raise your hand and do it. And put it into practise. If you feel like a surface hasn’t been cleaned, don’t wait for somebody else to do it. And I appreciate, in hospitals, certainly you might have professional cleaners. But if that cleaning regime is done every two hours and it’s dirty now, there are enough cleaning products for you to… clean it, and then write a note to say ‘I cleaned this by hand at [x]’. Own up to that so everyone’s aware of it.
I think staff should really be able to feel that they are able to have that conversation; that they don’t feel that they are unsafe. But if you do feel unsafe, speak up. You need to feel safe in your work environment, because you probably spend more waking hours at work than you do at home. So, actually, that is your space. That should be a really comfortable space for you. So you should make sure that space feels welcome and that you don’t dread going in because it’s not welcoming for you.
Steph: In terms of charities like us, Patient Safety Learning. We’ve been trying to support staff in raising awareness in some of the issues around psychological safety and around physical safety. And helping to understand how system-wide problems are as well, in terms of addressing patient safety issues and staff safety issues. What more do you think a charity like us could be doing?
Nick: What we normally talk about it one side of the story… At the beginning of Covid, all we were talking about was the bad side of Covid; these are the people dying, these are the problems. What we forgot was, there are a whole lot of people; doctors, nurses, police, ambulance, care workers…people working in supermarkets, logistics… that were having to go out. So if I’m waking up in the morning being told there are a thousand people dead, stay at home, stay safe… If that was the message you were being given and then you were going to work, you automatically didn’t feel safe. You’re being told that the safest thing to do is to stay home but then why am I going out? If that’s the safest thing for us all to do, why am I going in? So I think we tend to say one side of the story and forget that you have to say both sides. Yes, it might not be the best way to do it but if, right now, you were saying, ‘OK, all of these companies are being really good, really safe’, there’s going to be someone saying, ‘Well my company’s not safe; this doesn’t reflect my company’, and they’re going to completely ignore the rest of it…
So if we go back to that story about the scrub nurse who didn’t feel safe – stories like that need to be written and shown on par with stories of… ‘I’ve done an app for my staff’… ‘I’ve put signage in the office’… ‘there’s hand sanitiser and bleach on everyone’s desk’… You have to put those two stories together because then I will go ‘we’re doing things wrong, these guys are doing things right, I want to have a conversation about how we can do things better’. Not, ‘let’s all tell the good stories’. Because then you start getting people switching off…. [It’s the same as] if all you’re telling is bad stories, you’re just going to get trolled by people saying ‘you’re taking a very skewed view of this’.
So I think, from [Patient Safety Learning’s] perspective, showing that dual side. I think reaching out to the wider environment, so it’s not just health and social care. Could you reach out to other industries that potentially feed in or work within, because actually their knowledge, their understanding, the way that they’re looking at safety, is also pretty key and important as well.