This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety.
About the Author
Stephen is a nurse by background and has spent his entire career in the NHS. Following a number of years in clinical practice he moved into a variety of nursing and general management roles, and has over thirty years’ experience in posts at board level, including Chief Nurse, Chief Executive, Non-Executive Director and Chairman.
In 1999 Stephen was appointed by the Secretary of State as a Commissioner on the initial NHS Quality regulator, the Commission for Health Improvement (CHI). He received a Knighthood in 2006 for services to the NHS and Healthcare, and has been awarded Honorary Doctorates from the University of Nottingham and the University of Derby.
Questions & Answers
Hi Stephen. Please can you tell us who you are and what you do?
I’m Stephen Moss and I’m a Trustee on the board of Patient Safety Learning. I’m a nurse by background and after many years in clinical practice I moved into nurse management and then general healthcare management. I was the turnaround Chair of Mid Staffordshire NHS Foundation Trust (Mid Staffs) from 2009 to 2012, following the Healthcare Commission’s first report that highlighted severe failings and was highly critical of care standards at the Trust.
How did you first become interested in patient safety?
‘Do no harm’ was very much ingrained into my DNA when I trained as a nurse, but there were two particular episodes in my career where patient safety came into sharper focus.
The first happened when I was Director of Nursing at Queen’s Medical Centre in Nottingham. There was a very sad incident in which a young patient was injected with the chemotherapy drug Vincristine intrathecally rather than intravenously. It was an extremely rare event—I’m not sure there has been another event like it in the UK since. It was a classic Swiss cheese model event—in hindsight it was clear to see how many individual factors led to the event happening. Witnessing the impact this one error had on the patient and his family had a significant impact on me.
The second thing was my time at Mid Staffs, where again I saw how much harm had been caused to patients and the wider community. There was this feeling that the Trust must be an awful place with awful staff. But when you got under the skin of what happened at Mid Staffs, it wasn’t like that at all. Of course, there were pockets of bad practice, but most of the staff were committed to doing a good job. The issue was that they were poorly led and not properly supported in their roles, and the impact that leadership has on patient safety became even clearer to me.
The reason I was in a position to help Mid Staffs was that I had been previously appointed by the Secretary of State for Health to the first NHS quality regulator, The Commission for Health Improvement. That experience really nurtured my passion for and interest in patient safety.
When you first arrived at Mid Staffs, what were the most important patient safety issues you identified?
I started as Chair at Mid Staffs alongside Antony Sumara as the new Chief Executive. It was clear that the community had lost confidence that Mid Staffs was a safe place to be cared for, so our starting point had to be with that local community.
Inside Mid Staffs, what we saw was a group of committed staff who were trying hard to do a good job, but the leadership was not providing them with the resources they needed. There were a high number of near misses that weren’t being reported as staff were fearful of raising their head above the parapet. There was no learning going on at all. The board hadn’t recognised that its key function is to make sure that staff on the frontline have what it takes to do what is expected of them, the most important aspect of which is to keep patients safe.
The Trust also had some serious financial problems and had made major cuts to the nursing staff budget, so there was a massive shortfall of nurses. No risk assessment had been undertaken to assess the impact of cutting the workforce, and the consequences for patient safety were huge. But the issues went beyond staffing levels—existing staff weren’t being supported in terms of education, training and professional development. They didn’t have the kit they needed and they weren’t being valued and rewarded when they did a good job.
These are just a few of the many issues Mid Staffs faced and we realised that we had to make inroads as quickly as we possibly could. However, we were also clear that it would take a very long time to transform the culture at the Trust, particularly in terms of patient safety.
What measures did you take to change that culture?
One of the first things we did as a board was to sit down with our staff, patients, members of the local community and our governors. We talked about the values and behavioural standards they expected from us in terms of creating an organisational culture that prioritised quality of care and improved patient safety. We agreed on a set of values and recognised that as a board we had to be living and breathing those values individually. When we said things like, “Patient safety is our top priority,” we had to demonstrate what we meant by that.
Both executive and non-executive directors spent lots of time in clinical areas, but these were not ‘royal visits’! We sat with staff and heard from them about their pressures, where they were doing well and where they needed support to improve. We used the values as part of the staff appraisal process and included both organisational and behavioural objectives.
The second thing that had a major impact on the organisational culture was a board commitment to being open and transparent. That included talking publicly at board meetings about difficult issues we were facing and being honest about where things had gone wrong. We used the board meetings to bring our concerns about patient safety standards out into the open.
Another step we took aimed to help staff feel safe to speak up. As a board, we put out a statement to all our staff outlining that when something went wrong, our aim would be to learn from it and put things in place to stop a similar incident from happening again. We were trying to create a Just Culture before the concept had been defined and labelled! Initially the staff were understandably sceptical, but we demonstrated that we really meant it. The number of incident reports went through the roof and we were in a much better position to understand and deal with patient safety issues.
We also recruited a large number of staff so that our workforce could do the job it was expected to do. We were fearful that we wouldn’t be able to recruit, but the number of people who wanted to come and help Mid Staffs improve was amazing.
I’d love to sit here and say that after my three years at Mid Staffs, the issues were resolved, but of course they weren’t. However, I believe that we repositioned the focus of the organisation and put patient safety and quality of care clearly on the agenda.
Sometimes media reports about patient safety scandals will say things like “nothing’s changed since Mid Staffs.” Do you think there has been learning since the Francis Report?
From where I sit, things have improved tremendously. Following Mid Staffs, patient safety suddenly became part of the political agenda, and that’s made a huge difference in ensuring it is a national priority. When I think about the sort of measures in place now to track and improve patient safety, we’re in a much better place.
However, there is still a mountain to climb. One area we must focus on is transparency and disclosure with patients and families. I continue to hear of patients and families having to fight to get the information they need following a patient safety incident. It’s a theme that continually comes out in reports. While some work has been done to try and improve the situation, we still have much to do to ensure we fulfil the Duty of Candour in a way that works for patients and their families.
Boards have improved the way that they work and I can see examples of how they have increasingly prioritised patient safety. Having said that, I still get frustrated when I read inquiry reports—I often feel I could have written them because the same issue comes up every time: the board’s lack of focus on patient safety. There is a lot of rhetoric that goes on and many chairs and board members tell me that patient safety is obviously a priority. But when I follow that up by asking how, the response is often disappointing. Boards and leaders need to better understand that their primary role is to provide staff on the frontline with everything they need to do their job well—and the most important part of that role is to keep patients safe.
How is Patient Safety Learning improving patient safety?
As a trustee, I’m honoured to be part of a group of board members and staff at Patient Safety Learning who are totally committed to driving forward improvements in patient safety.
One important thing Patient Safety Learning is doing is creating a safe space for people to share their experiences and ideas. I am particularly excited about the work we are doing to support managers to create a patient safety culture through the Patient Safety Management Network. Patient Safety Learning is helping leaders and managers to develop that culture that supports staff to learn, as well as using the hub to connect with people working on the frontline of patient safety,
If you could change one thing in the healthcare system right now to improve patient safety, what would it be?
As my recent experience has been mostly as a board member, that’s where lots of my frustrations sit! If I had a magic wand, I would want to be able to walk into any healthcare organisation in this country and be confident that when they say patient safety is their priority, they really mean it. I would be able to easily find evidence that it really is the case.
Are there things that you do outside of your role that have made you think differently about patient safety?
Recently, I’ve become involved in a small local charity set up by the parents of a young man who committed suicide at university. It’s made me more aware of the huge gaps in services that support young peoples’ mental health. We need to do more about those gaps very quickly. We need to be much better at keeping the most vulnerable people in our society safe.
Can you tell us something about yourself that might surprise us?
I was a championship ballroom dancer in my early 20s, and Strictly Come Dancing really gets my feet tapping. However, as my family will tell you, those days are over as I’m now more like Peter Kay on the dancefloor at family weddings!
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