Dawn Stott

This blog from Pentland Medical and Dawn Stott Associates highlights the findings from their report ‘Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests’.[2] The aim of the work is to look at patient harm from surgical airway securement in critical care environments and, ultimately, to underscore the importance of continuous learning, a culture of transparency and collaboration across disciplines to sustain improvements in patient safety. Background Securing an airway device is a critical component of patient safety, particularly in situations where airway management is essential to life support, such as during surgery, emergency care or critical illness. The airway device, typically an endotracheal tube or laryngeal mask airway, ensures that a patient’s airway remains open for adequate oxygenation and ventilation. The WHO Guidelines for Safe Surgery states that “Securing the airway of a patient undergoing general anaesthesia is the single most critical event during induction.”[1] As all healthcare professionals working in the anaesthetic environment will know, properly securing the device is paramount as any displacement or dislodgement can lead to life-threatening complications like hypoxia, aspiration or airway obstruction. Ensuring that the airway stays in place for the time needed is an equally important part of this process. Currently, this is often done with the use of off-label materials, such as tape and ties, which can cause facial damage ranging from minor redness to severe tissue damage. This tape can also pose an infection risk, but, perhaps more pertinently, any off-label methods are not fit for purpose. Although they are embedded in healthcare practice and are used world over, tape and ties were never designed to perform airway securement. Consultation on airway device securement Following an inaugural round table discussion meeting led by Dawn Stott Associates, a ‘cross sector’ Short Life Working Group (SLWG) was formed to consult on the way an airway device is currently secured when a patient is undergoing a surgical intervention. The group’s goals were to identify systemic barriers to the standardisation of airway management and to develop guidance to support a more robust and consistent way of securing the airway device. The group’s mission was to: review current policy, guidance and legislation to help interpret and apply them to daily anaesthetic practice to support healthcare facilities and personnel with materials and resources on airway device securement and management to help ensure compliance with policy to establish an environment where standardisation of approach is accepted to make guidance available to support healthcare professionals ensure that the patient is safe. The group also reviewed the broader issues around patient safety and the cultural challenges around change management in securing an airway device with tapes. Current guidance What has been astonishing for the SLWG is that no guidance exists from any recognised bodies in the UK on securing an airway device. The Difficult Airway Society (DAS) is generally regarded as the leading authority on anything airway related, not just in the UK but also internationally. However, while the DAS guidance states that healthcare professionals should secure the airway device, it does not go beyond this to advise on best techniques or materials that should be used. This absence of national guidance has resulted in an inconsistent approach to securing an airway device within UK hospitals, and with it the risk of facial harm, infections and more serious incidents that are entirely preventable. Until now there has not been any solution designed and risk-assessed to secure an airway device in the theatre environment, leaving a vacuum where healthcare professionals worldwide are forced to improvise by developing their own techniques and by using off-label generic materials such as tape and ties. There are also a huge number of varying circumstances encountered involving the use of different airway products and surgical positions that further complicates matters when it comes to a standardised approach to airway device securement. It is the opinion of the SLWG that the report we have produced provides compelling evidence for an urgent review of the existing practices for airway securement and for guidelines to be established, which include the requirement for dedicated medical devices to perform airway device securement. The study We used three approaches to gather information: A survey for healthcare practitioners was developed to explore whether there is a standardised approach to securing an airway device in their hospital. The intention was to use the findings to support ongoing work around safer patient care and better clinical outcomes. Focus groups were held to provide insight into how things are currently being done. Freedom of Information (FOI) requests were sent to NHS Foundation Trusts. The information requested was for the period between the 1 January 2020 to 31 December 2023. The FOI requests were designed to define how patient safety is delineated around securing an airway device and how standardisation can be improved to ensure the reduction of current incidents of failure and infection to patients. What we found The responses from the FOI requests show that a substantial number of trusts have experienced inadequate patient outcomes because of poor airway management (see the tables below). It also highlighted that many trusts do not report these patient safety incidents. This is sometimes due to the normalisation of the process and that the incidents are so ‘small’ it is not felt necessary to report them. Feedback from one Trust suggested that many professionals involved in the management of airway did not want to change their practices. Several Trusts stated that they did not routinely record this type of information and would therefore only be able to fulfil the FOI request if they were paid to do so under Section 12 of the FOI Act, underlining the lack of normal visibility of this data. Total responses to the FOI questions Five hospitals were unable to provide the information in the format requested but responded as follows: Key findings from the survey 23% of the people surveyed were aware of incidents of poor patient care resulting from their airway securement techniques. How people currently secured an airway: - 57% used tapes and ties - 20.16 % used elastoplast or similar - 4.3% used a fit for purpose device (not specified) - 8.7% used a mixture of methods depending on procedure - 9.4% didn’t respond. 56.5% of the respondents were aware of the infection risks associated with using tapes. However, they continued to use this as a method of securing the airway device even though it is an unlicenced and unhygienic way of managing the securement. 95.7% of the respondents were aware that the airway may migrate during the intervention and could cause serious harm to the patient but continued to use the same methods of securement. During the focus groups we asked about communication. The responses below showed that there wasn’t always an open and honest culture within the operating department. Infection Prevention and Control guidance The National Infection Prevention and Control Manual, Chapter one, Standard Infection Control Precautions (SICPs) states that care equipment can be easily contaminated with blood and other bodily fluids and infectious agents.[3] They classify care equipment as either: Single use – equipment which is used once on a single patient then discarded. Must never be reused even on the same patient. Single patient use – equipment which can be reused on the same patient. Reusable invasive equipment – used once then decontaminated e.g. surgical instruments. Reusable non-invasive equipment (often referred to as communal equipment) – reused on more than one patient following decontamination e.g. commode, patient transfer trolley. Multi-patient rolls of tape are, by definition, classified as ‘non-invasive re-usable equipment’, which by reason of the SICPs above, must be decontaminated to adhere to the National Infection Control Standards. As findings from our surveys/focus groups made clear, this is not happening because rolls of tape by their structure cannot be decontaminated. Education Ongoing education is one of the most crucial elements of managing the securement of the patient airway. Many organisations have integrated crisis management training, including human factors education into their anaesthesia and airway management programmes.[4] Simulated learning offers a dynamic and risk-free environment where learners can apply theoretical knowledge to practical scenarios, enhancing understanding and retention. By mimicking real-world situations, it allows individuals to develop critical skills, problem-solving abilities and confidence without the consequences of real-life errors. Encouraging innovation and change There is a continuing desire to make airway management safer. Innovations and new equipment continue to be developed to support safer anaesthetic practices; however, if healthcare professionals were to put forward the suggestions of tapes and ties to the regulatory bodies that manage new innovations, they would not pass the scrutiny and rigor and endure the processes in place to get the product to market. This speaks volumes about the archaic way of securing an airway device – but how do we encourage change within an environment that is entrenched in history and a ‘this is the way we have always done it’ mentality? New regulatory systems and sometimes political unawareness can cause pressures on the industry due to their often single-minded need to cut headline costs. Only recently, the Association for British Healthcare Industries announced that £50k worth of registration projects have been withdrawn due to the costs associated with compliance. This will have a catastrophic impact on much needed healthcare innovation and products that are designed to support patient safety.[5] How collaboration can make things happen This project has highlighted the importance of a team approach when trying to develop a standardised approach to different parts of the critical care environment. Another issue the project group discussed was how standardisation of certain practices made things much easier. However, it was thought that all approaches for standardisation should be backed up by rationale and be evidence based. Those involved in the discussions felt that training of new members of the team would be much easier if certain ways of working were standardised. Conclusion Effective airway device securement is a critical component of patient safety in clinical settings. Proper securement techniques reduce the risk of unplanned extubation, displacement, infection risks, facial tissue harm and compromising the airway, which can lead to life-threatening complications. Healthcare providers must be well-trained in securing airway devices and remain vigilant in monitoring their stability throughout patient care. Standardised protocols, high-quality materials and evidence-based practices are essential for ensuring the reliability of airway device securement. Regular assessments, interdisciplinary collaboration and the use of checklists further enhance safety by promoting consistency and reducing errors. In their WHA 72.6 Resolution (2019), WHO Health Ministers mandated for the global patient safety action plan 2021-2030 to be implemented.[6] Within the resolution at 5.3 they suggest they will make available guidance on how to create cultures that operate transparently and encourage speaking up.[7] Unfortunately, through the research we have undertaken and discussions we have had with individuals throughout this project, we have witnessed a damaging culture that exists within the healthcare environment. We believe that this is leading to a nation of healthcare professions who feel let down, devalued and unable to speak up and speak out to support better patient results. We did meet and talk to some professionals who worked in an environment of support and nurture, but sadly the majority of individuals felt unheard in a massive environment of ‘noise’. It has become evident that trusts generally only change their practices following an incident which is costing them more than it would have done to use a product that is designed for purpose. Failure to see the impact of such obstinacy on the patient and their wellbeing is a very blinkered approach to improvement and innovation. By prioritising proper securement practices, healthcare teams can improve patient outcomes, prevent adverse events and reinforce a culture of safety in airway management. Ongoing research and innovation in device design and securement techniques will continue to advance this critical aspect of patient care. Despite its contributions, this study is not without limitations and future research is needed with larger and more diverse samples, refining methodology and exploring additional variables. However, the outputs do highlight the issue that the project is championing for change. We are pleased to report that our work has garnered international interest, prompting efforts to replicate the exercise in both the USA and Europe. This global recognition underscores the significance of our findings and highlights the potential for broader applications in enhancing safety standards worldwide. These strategies, combined with continuous education and integration of innovative technologies, demonstrate the potential for significant improvement in patient safety related to airway device management. References World Health Organization. Guidelines for Safe Surgery 2009. Safe Surgery Saves Lives, 2009. Pentland Medical and Dawn Stott Associates. Surgical airway securement: A report analysing responses to a survey, focus groups and freedom of information requests, November 2024. NIPCM. National Infection Prevention and Control Manual, Chapter one; Standard Infection Control Precautions (SICPs). Tankard K, Sharifpour M, Chang MG, Bittner EA. Design and Implementation of Airway Response Teams to Improve Patient Safety. J Clin Med 2022; 11(21): 6336. https://doi.org/10.3390/jcm11216336. Fick M. Insight: Medical device makers drop products as EU law sows chaos. Reuters, 19 December 2022. World Health Organization. WHO Global Patient Safety Action Plan 2021 – 2030. Towards eliminating available harm in healthcare, 3 August 2021. World Health Organization. Consensus statement: Role of policy-makers and health care leaders in implementation of the Global Patient Safety Action Plan 2021–2030, 13 July 2022. You can read the full report of this study here or by scanning the QR code below: Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

Normalisation of patient care refers to the process of standardising healthcare practices to ensure consistent, high-quality care for all patients, regardless of their background or condition. This concept is vital in today’s healthcare systems, where variability in care can lead to disparities in outcomes. By normalising care, healthcare providers aim to reduce these disparities, improve patient outcomes and enhance the overall efficiency of healthcare delivery. However, if poor care becomes normalised; i.e., treated as routine, it can have detrimental effects on patients and their outcomes. In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia.  Consistency in care delivery One of the primary goals of normalisation is to ensure that every patient receives the same standard of care. This means that the treatment a patient receives should not depend on the time of day, the healthcare provider’s experience or the facility where they are treated. Standard protocols and guidelines help to minimise variations and ensure that all patients receive evidence-based care. When care is standardised, it often leads to better health outcomes. For instance, standard protocols for managing chronic diseases like diabetes or hypertension ensure that all patients receive the most effective treatments, reducing the risk of complications and improving long-term health. Normalisation also enhances the efficiency of healthcare delivery. Standardised protocols streamline processes, reduce the need for unnecessary tests or treatments, and make it easier for healthcare providers to coordinate care. This, in turn, can reduce costs and improve the overall functioning of healthcare provision. An example of a change to a standardised way of working is the securement of an intravenous (IV) cannula. Many articles have been written on the subject of IV securement, which essentially broke down the silos and made it clear, based on evidence, that after insertion of the cannula, the next most significant consideration was the securement of the device.[1][2] Historically securement was achieved with tapes, ties or sutures. Adhesive securement devices became the preferred method over sutures because they offered securement without additional skin punctures. The introduction of the IV dressing for cannula securement was revolutionary and is now a custom practice internationally. Developing global guidance on securing an airway In a recent survey, and following several professional focus groups, our project team have found that inflammatory damage to a patient’s skin following anaesthesia was a ‘real’ problem because of the way the airway was secured. There is a risk of these practices becoming normalised and therefore not being reported as a patient incident. As a result of a freedom of information study undertaken by the project team, the information gained suggests that many hospitals do not measure poor airway management outcomes and there does not appear to be any central database to support this either. There is a risk of damage to a patient’s skin when tapes are used to secure the airway. However, this is often not reported because it is ‘just the tape’ causing the harm. As a result of this type of practice happening quite often, it has become accepted and engrained into healthcare practice, similar to how it used to be with an IV cannula, and is another example of where normalisation of a practice is detrimental to a patient’s care. To improve this, a group of individuals have come together to work on developing global guidance on securing an airway and delivering anaesthesia safely in the pursuit of precision and vigilance. The idea was that as a project team we could, together, envision a future where anaesthesia safety is not just an aspiration but a standard of care that we exceed every single time.[2] Our goal is to standardise securing an airway to eliminate harm to a patient’s skin, airway displacement and infection risks. Although the project team appreciate that anaesthetics is deemed to be one of the safest areas of healthcare practice, our project’s aim is to provide evidence that current practices in airway securement are unsafe and are leading to patient harm, and that a better, licenced and regulated, solution is needed. Tapes and ties are still the mainstay for securing an airway in operating theatres and these methods are unlicensed with varying adhesive capabilities, which could cause inadequate safety to the patients. With this evidence we hope to influence nationally recognised bodies to establish clear guidelines and recommendations to support safer patient outcomes through education and learning. Strategies for effective normalisation of care Healthcare providers may resist the implementation of standardised protocols, particularly if they feel that these protocols limit their clinical judgment. Overcoming this resistance requires effective communication and education about the benefits of normalisation, including: Developing and implementing clinical guidelines, which should be evidence-based with regular updates. These guidelines will serve as the foundation for standardisation of procedures across different settings and providers. Ongoing training and education, which are crucial to ensuring that providers understand and can effectively implement standardised protocols. The education should form the basis for induction as well as continuous professional development. Continuous monitoring and evaluation, which are essential to ensure that normalised efforts are effective. This will involve tracking outcomes, gathering feedback from both patients and providers, and adjusting care protocols as required. Moving forward, healthcare systems must continue to develop and refine strategies for normalising care, balancing the need for standardisation with the importance of individualised, patient-centred treatment. By doing so, a more equitable and effective healthcare system can be provided for all. Conclusion This year’s World Patient Safety Day slogan is ‘Get it right, make it safe’. Our project is all about getting it right and making the securing of an airway safe for the patient. The team are aiming to highlight the importance of prioritising patient safety over financial constraints. As healthcare professionals it is important to raise awareness of the value it will have to the patient; i.e., the quantity of harm to the patient to promote the value of the quality outcomes for the patient versus the cost of the product. Healthcare is a high-risk industry and professionals should follow guidance developed from the best available evidence (NICE guidance) rather than any traditional or ritualistic practice. As practitioners we are accountable for our actions and safety is everyone’s responsibility. References Barton A. Universal Adhesive Vascular Access Securement with GripLok Devices. BJN, 2020. https://doi.org/10.12968/bjon.2020.29.8.S28 Docherty V. The Importance of Airway Training. CSJ, 2024.

In a new series of blogs, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), discusses how coaching and developing teams can support patient safety and its outcomes.  In part one and part two, Dawn looked at the strategies and coaching methodologies that can be used to develop individuals and to support patient safety, and discusses the indicators of improvement, prosocial behaviours and the importance of good communication to improve culture and, ultimately, patient safety. In the final blog of the series, Dawn discusses the importance of reflective practice and how it encourages  learning and growth, and helps us to identify and address challenges. Reflective practice is the process that you can go through to engage in thoughtful and purposeful consideration of the experiences you have had, the actions you have taken and the outcomes of those actions. It involves a conscious effort to gain insights, learn from experiences and enhance your professional and personal development. Reflective practice is used in various fields but is used a lot by healthcare professionals to analyse patient interactions, clinical decisions and the overall delivery of healthcare interventions. To be able to engage in reflective practice it is important to understand your own thoughts, feelings and reactions to different situations. An open and honest mindset is key to achieving this. The ability and willingness to consider different perspectives is important – to challenge assumptions, your own and those of others. Your coach should encourage you to analyse and evaluate experiences, actions and decisions to identify strengths, weaknesses and areas for improvement. Part of the reflective learning process is viewing experiences as opportunities for learning and growth and actively seeking ways to expand your knowledge and improve your skills. During my tenure at AfPP a colleague introduced me to a book called ‘The Three Minute Diary’. The diary provides you with an opportunity to reflect on your day and document experiences that in turn facilitates the reflection process. It asks what has been good in your day, what has been bad, what you were grateful for, etc. I found it invaluable, and I still dip into it when my pathway has become a little blurred and I need clarity. From experience I know that it is very easy to walk away from a fiery or difficult situation and think about what you should have said. I call this the ‘if only’ scenario. If only I had said that. In the heat of the moment, we often forget to breath which in turn stops us thinking and behaving effectively. Reflection isn’t only about thinking about what we should have said but also about enhancing our ability to identify and address challenges through thoughtful and clear analysis of the situation, which often provides you with alternative solutions. It can deepen our awareness of personal values, beliefs and strengths and also our areas of improvement. This will support our ongoing learning and development, which contributes to our professional competence and effectiveness; resulting in heightened empathy and understanding of the perspectives of others, which can lead to improved interpersonal relationships both at work and at home. We all want to be good decision makers and reflective practice can encourage us to review the decisions we have made and, in the future, consider the potential consequences and ethical implications of the choices you make. Reflection supports continuous improvement in work or practice by identifying and addressing areas that can be refined. It aids personal growth, self-discovery and achieving any life goals you have set for yourself. Reflective practice is dynamic and an ongoing process that contributes to continuous learning and improvement, fostering a mindset of curiosity, openness and adaptability. The bottom line is that with coaching, people can become better at what they do and in a healthcare setting that is so very important to the safety of the patients. Coaching is a very undervalued business tool that can be important to any professional no matter where they are in their career. Great athletes at the top of their game have a coach. Brilliant singers have voice coaches to keep them hitting the right note. We all reach our limits and are unable to improve because of the complexity of things going on around us – an external pair of eyes can help us focus on the blurred edges and help us to continue seeing the bigger picture. However, we do have to feel safe in our environment to be able to speak openly and offer support and guidance to people who don’t always want it. Psychological safety is a shared belief that the environment is safe for interpersonal risk taking. It’s tough at the top and it’s tough to be a patient – so you should invest in yourself to ensure patients are kept safe. It’s not about how good you are right now, it is about how good you can be, or are going to be that really matters. Any improvement, big or small, can impact greatly on patient safety and healthcare outcomes. Further blogs from Dawn: To coach or not to coach? Part 1 To coach or not to coach? Part 2 Developing cultural change in healthcare: Part 1 Developing cultural change in healthcare: Part 2

In a new series of blogs for the hub, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), discusses how coaching and developing teams can support patient safety and its outcomes. In part one, Dawn looks at strategies and coaching methodologies that can be used to develop individuals to be the best they can be. We all develop at different rates; having an external view point that supports your progress is something to grab with both hands. It is not about about how good you are right now; it is about how good you can be. To coach or not to coach? Well, that really is a good question. Just because we are at the top of our tree, ahead of our game (or any other idiom you wish to quote), it doesn’t mean that we have everything covered. We might think that we are doing a great job but sometimes the analysis from an outside person gives us the truth that we need to improve our own skills and those of others. However, people have to be receptive to the process to achieve the best results. Coaching Methodology is the systematic approach or set of principles that coaches use to help individuals or groups of individuals achieve their goals, improve performance and enhance their overall wellbeing. If a person’s wellbeing is high then, through a process similar to osmosis, it passes through our pores and out through our skin layers to those around us. Different coaches may use various methodologies based on their training philosophies and the needs of the client. Below are some key elements commonly found in coaching methodologies – finding an effective method for you is paramount. It is very important to note that coaching methodologies can vary, and coaches may integrate elements from different models and approaches based on their expertise and the unique needs of their clients. The effectiveness of coaching often depends on the quality of the coaching relationship, the coaches’ skills and the person being coached commitment to the process. There is absolutely no point forcing a member of your team to undergo coaching, unless, of course, patient safety is at risk because of them not doing so. If someone is given an ultimatum, then they probably will not benefit from the coaching experience. However, by using the personal development route it may be better received. Coaching methodologies to support patient safety Now, let’s look at how these coaching methodologies and strategies can support patient safety. The infographic below provides another methodology to support patient safety. It is an essential aspect of healthcare management and professional development. Patient safety is about preventing errors, ensuring a safe environment for patients and continuously improving healthcare practices. Let's look at the different elements of the methodology: Continuous training and education Provide regular training sessions on patient safety protocols and best practices. Keep healthcare professionals updated on the latest advancements in safety initiatives. Encourage ongoing education to enhance the skills and knowledge of healthcare professionals. Promote a culture of safety Foster an organisational culture that prioritises patient safety and demonstrates that it is taken seriously. Encourage open communication about safety concerns without fear of retribution – this links to psychological safety which is a topic that supports all elements of healthcare provision. Recognise and reward individuals or teams for promoting a safe environment. Simulation and role-playing Conduct simulation exercises to mimic real-life scenarios and identify potential risks. Use role-playing to help healthcare professionals practice effective communication during critical situations. Feedback and coaching sessions Provide constructive feedback on performance related to patient safety – make it a part of everyday practice within the healthcare environment. Conduct regular coaching sessions to discuss improvement areas and celebrate successes. Establish a mentorship programme to support less experienced members of the team. Root cause analysis Teach and implement root cause analysis techniques to identify the underlying causes of errors and near misses. This isn’t just a senior management role, everyone should review their performance and behaviours following any patient safety incidents. Ensure that the information gathered is used to implement preventative measures and improvement strategies. Team collaboration Emphasise the importance of teamwork and effective communications. Encourage interdisciplinary collaboration to address safety issues from multiple perspectives. Educate patients on their role in their own safety. Encourage patients to ask questions, communicate concerns and actively participate in their care. It is important that regular audits and assessments take place to review processes and procedures and identify potential risks. It would be advisable to use data-driven assessments to track performance and measure improvements over time. Encouraging a culture that is ‘just’ and recognises the difference between human error and reckless behaviour is key. It is important to have clear standards and goals for performance; that way when things are not going as they should and someone is not meeting the required benchmark, the failings can be addressed based on the task rather than it being personalised. Skills and behaviours should be separated, and poor behaviour should not be normalised. Establish fair and consistent consequences for safety breaches while promoting a culture of learning and improvement. By incorporating these coaching strategies, healthcare organisations can create a safer and more supportive environment for both patients and healthcare professionals. In part two, Dawn discusses prosocial behaviours, reflective learning and how coaching can support individuals no matter where they are in their career pathway. Further blogs from Dawn: Developing cultural change in healthcare: Part 1 Developing cultural change in healthcare: Part 2

In a two-part blog for the hub, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), talks about the strategies that can help you develop cultural change in your organisation. In part one, Dawn set out the steps to develop a programme of change to support you to achieve good solutions. In part two, Dawn gives you tips on how to assess the culture of your organisation and establish a programme of standardisation. Establishing cultural change To establish cultural change, it is important to firstly assess the culture within the service, particularly in response to incidents. It can sometimes be difficult to establish whether the current culture enables open and honest discussions at all levels among hospital teams and patients. Test this through open communication and internal audit and observation. A cultural assessment can be an internal process whereby organisations evaluate their workplace culture. There are many tools available to support this type of evaluation; for example, Insights Discovery, My Team Radar, etc. It is statistically proven that the right behaviours within an organisation can enhance performance and wellbeing within a team. Cultural assessments generally analyse both the implicit and explicit beliefs and attitudes held by an organisation and by everyone involved. The outputs from the analysis should help leaders make informed decision about the current culture and determine if actions are necessary to strengthen the organisation and those who work within. If a culture of openness currently exists, then to establish a programme of standardisation will be easier to achieve. However, if there is a lack of psychological safety within a team, then there will be barriers to change, and the programme of learning and education may take longer to achieve. It will be important to consider the relationship between team members to determine if these enable them to work collaboratively, share responsibility and resolve conflict promptly and constructively – without blame. Standardisation When we talk about standardisation of a process, it essentially means that people working for that organisation have an established process to use. If standardisation is done well then it can decrease ambiguity about patient care and guarantee quality, boost productivity and support positive morale within a team. By standardising a process it will eliminate the need for guesswork or extra work. Every task within any organisation, regardless of how often it is carried out, requires guidelines/rules that define the methodology that needs to be followed. If these rules are not standardised, then you can’t assess whether you are undertaking jobs effectively and ensuring a quality outcome. Standardisation also supports the reduction of human error. A standardised way of doing any task within the perioperative environment should be documented and used as a training tool for new employees. An example of standardisation of care and change, without a mandate or guideline to follow, is the securing of a cannula. Before the most common way of securing a cannula – generally using a product similar to the 3M Tagaderm dressing – most practitioners would secure the cannula using tape and/or bandages. The driver to this change may have been around infection control issues relating to the use of tapes, which may have significantly transformed the change into an acceptable and standardised way of working. Rules in the workplace are not only driven by policies and procedures. In many organisations, and particularly within healthcare, ‘rules’ are also established by patterns of behaviour or the ‘unwritten rules’. The ‘this is how we do it here’, type of approach can influence behaviour and expectations, often referred to as custom and practice. In healthcare unwritten rules and ways of working can become deeply ingrained into the workplace culture and, if not managed effectively, can consequently seriously endanger patient outcomes. Sphere of influence As healthcare professionals you have a ‘sphere of influence’ in everything that you do. The example below shows a sphere of influence for airway management. Essentially a clinician’s core sphere of influence is the care given to a patient allowing patients to make informed choices and support health equality. The WHO checklist is a great example of a core sphere of influence in that there is an obligation to act meaningfully to ensure the patient pathway through theatres is safe – it should not just be a ‘tick box exercise’. Healthcare organisations have obligations to patients; however, these are not the same as those between patients and clinicians. Organisations have an obligation to provide structures that support healthcare practitioners to create a culture of integrity. By not upholding the organisation’s values they are compromising the integrity of the organisation and the long-term effectiveness. If initiatives are implemented, they should be followed up and measured to ensure patients are getting the best possible care and employees are nurtured and reimbursed effectively for the work they undertake. My advice would be don’t cut corners just because others say it is ok. Don’t watch others cut corners because then you are condoning poor practice and not working effectively within your sphere of influence. Ask yourself ‘what are the driving factors to cutting corners’, is it about time, saving money or something else? Work on ways to change things so patient safety is not compromised. Change is always difficult to achieve because people become entrenched in their ways and their mindset is often ‘if it aint broke, don’t try and fix it’. However, if a product can be substituted that leads to better patient outcomes, then it should certainly be seriously considered. NHS England says that: "Patient Safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare. We support providers to minimise patient safety incidents and drive improvements in safety and quality. Patients should be treated in a safe environment and protected from avoidable harm." If you can drive forward on a patient safety initiative that supports better patient outcomes, then do so. Who knows, you may become a patient safety champion who advocates for better patient results. Also, remember, you or a member of your family may one day be a patient and you wouldn’t want somebody to be cutting corners or compromising your safety because it’s quicker and easier to do so.

If we are to continue improving healthcare services, then developing cultural change in healthcare is crucial. Improving the quality of care, reducing medical errors and, ultimately, enhancing patient outcomes is essential for the future. Transforming the culture within healthcare organisations requires a comprehensive approach that involves leadership commitment, employee engagement, continuous education and a focus on patient-centred care.  In a two-part blog for the hub, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), talks about the strategies that can help you develop cultural change in your organisation. In part one, Dawn sets out the steps to develop a programme of change to support you to achieve good solutions. There have been many incidents in healthcare that have led to employees feeling less than empowered and frightened to speak up and speak out. Ongoing scandals and behaviours will forever challenge all of those who work within the healthcare environment, particularly if cultural issues are not addressed. Working towards cultural change in healthcare will take time and persistence. It involves not only implementing new policies and procedures but also changing mindsets and behaviours. Consistent effort, leadership support and a commitment to patient safety will be key to your success, no matter who you are or at what level you work. It will take a sensitive and pragmatic, evidence-based approach to challenge culture and practice within any speciality. Corporate culture and corporate memory are manifested in how decisions are made and the results of those decisions; i.e., the actions taken to support better outcomes. It is also about how we engage with individuals to encourage them to give of their best, support best practice and not be maligned for speaking up if things are not as they should be. Across the healthcare sector, organisations will endeavour to provide a safe and sustainable service that improves outcomes for patients and their families. To develop a programme of change the following steps may support you to achieve good solutions: Leadership commitment Engage leaders: gain commitment from top-level executives, administrators and department heads. Leaders must champion the cultural change and lead by example. The enormity of this may seem daunting; however, it is achievable if you have a structured plan and a strong vision. It takes one person to stand out in the crowd to ensure they have followers. There is a great video on YouTube that shows how important followers are to anyone in a leadership position. Assessment and awareness Assess current culture: carry out a thorough assessment of the current organisational culture. Identify areas that need improvement, especially related to patient safety (see point below about cultural assessment). Awareness building: raise awareness about the importance of patient safety and its impact on overall healthcare quality among all staff members and the patients they support. Define cultural values Establish core values: define and communicate core values relating to patient safety, such as transparency, open communication, accountability and a commitment to continuous improvement. Communication and training Training programmes: develop comprehensive training programmes for health teams at all levels. This should include training on patient safety, communication skills, teamwork and conflict resolution. Effective communication: Promote open and effective communication among healthcare teams. Encourage staff to voice concerns and report errors without fear of reprisal. This isn’t about putting your colleagues into the spotlight if they are underperforming, it is about improving standards and reducing blame. Patient-centred care Patient involvement: involve patients in their decisions, making them active partners in the healthcare process. Empathy and compassion: emphasise empathy and compassion in patient interactions. Practitioners should understand and respect the unique needs and preferences of each patient. Data and metrics Collect data: implement data collection systems to track patient safety metrics and outcomes. Feedback loops: establish feedback loops that allows colleagues to review and learn from incidents and near misses. Accountability and reporting Accountability measures: define clear lines of accountability for patient safety at all levels of the organisation. Reporting systems: create systems for reporting adverse events, near-misses and safety concerns. Encourage a culture of reporting rather than blame. Encouragement can come through using corporate governance structures to ensure greater transparency and accountability. Continuous improvement Quality improvement teams: form multidisciplinary quality improvement teams to identify areas for improvement and to implement evidence-based practice. These may already be in place in many organisations; however, sadly they may not or may not be fully utilised. Regular audits: conduct regular audits and reviews to ensure compliance with patient safety protocols. Recognition and rewards Recognise achievements: acknowledge and celebrate successes and improvements related to patient safety. Raise awareness of your organisation and put yourselves up for national awards such as the annual HSJ awards. We often work in an environment and don’t realise we are doing great things that should be celebrated. Sustainability Embed into the organisations culture: patient safety and a culture of continuous improvement should become ingrained in the organisational ethos and not just be a temporary initiative. Sustainability is key on achieving success. External benchmarking Benchmark against industry standards: compare your organisation’s patient safety practices with industry benchmarks and best practices. Seek external guidance and certification if possible. (The Association for Perioperative Practice offer an Audit and Accreditation Programme to support the NHS and private sector.) Feedback and adaptation Regular feedback: continuously seek feedback from patients, families and staff to adapt and refine your patient safety initiatives. In part two, Dawn will give you tips on how to assess the culture of your organisation and establish a programme of standardisation.