Evidencing the impact of culture on patient safety – a new tool from MNSI (a blog by Chris McQuitty)

Summary

In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool.

COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI.

This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child.

Content

Why was COMPASS developed?

COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹.

The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers.

Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety.

What are the aims of COMPASS?

We developed COMPASS for two key reasons:

• To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations.
• To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered.

There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events.

How is COMPASS being used?

COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May.

MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report.

The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas.

These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety.

What is next for COMPASS?

After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to:

• Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool.
• Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services.
• Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare.

If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety.

How can people find out more?

• Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety 
• MNSI has launched a new patient safety tool COMPASS 
• Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library

References

1.      The Patient Experience Library's Responding to Challenge report April 2025

Do you have a safety tool or project to share?

Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more. 

About the Author

Chris is GP trainee who is currently undertaking the Faculty of Medical Leadership and Management National Medical Directors Clinical Fellow programme and is on secondment for a year to MNSI and the Care Quality Commission (CQC). Chris has an interest in patient safety and deteriorating patient management.

Nicki Pusey who co-designed COMPASS, is a Maternity Investigations Team Leader with MNSI. She has direct personal experience of infant bereavement, clinical and strategic midwifery practice, and investigations within MNSI. Nicki is passionate about improving maternity safety for families and staff.