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Showing results for tags 'Just Culture'.
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Content ArticleHealthcare organisations have struggled to move from a culture of blame to a ‘just culture’, despite this being stated as a goal for several years. As a result of this cultural inertia, the original principles of a just culture require critical examination. A just culture is still seen primarily as a linear mechanism to apportion liability. Within our complex healthcare organisations, this approach is inadequate. In this article, Paul Stretton proposes a revised approach to creating a just culture, which enables learning from all events, irrespective of outcome. There should be a focus on learning, rather than liability, with a presumption of good intention until proven otherwise. This more compassionate and respectful approach can help to move healthcare organisations towards a just culture and create an atmosphere of trust.
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Content ArticleSKYbrary is an electronic repository of safety knowledge related to flight operations, air traffic management (ATM) and aviation safety in general. It is also a portal, a common entry point, that enables users to access the safety data made available on the websites of various aviation organisations – regulators, service providers, industry.
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Content ArticleIn September this year, as part of World Patient Safety Day, Patient Safety Learning asked people, via social media and the hub, to name three things staff most needed to be safe. We gathered your responses and are now pleased to present an image which shows the most common themes. According to the responses we received, the four themes that became most obvious – the four things you think staff most need to be safe – are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff from burnout.
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Content ArticleIn his latest blog, Steven Shorrock explores what humanistic values and human decency means in management and organisational behaviour. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleA rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic has been published by the AHSN Network. PSCs are just one part of the health and care system which responded quickly to the immediate crisis from COVID-19 in March. They reprioritised their day-to-day work and took on new programmes at speed, such as promoting safer tracheostomy care. The report has been published as part of the NHS Reset campaign and gives examples of how PSCs refocused their work ‘almost overnight’ to respond to the pandemic. It illustrates some of the creative ways AHSNs supported their local systems and how this experience will be built into future patient safety programmes.
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Community PostIt's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
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Content ArticleWhen things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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Content ArticleWhy is it hard for a highly trained professional to speak or report about mistakes made by him or her? Jean-Pierre Kahlmann, a retired Military and Airline Pilot, and now Co-owner and CEO of Yes Human Factors Ltd, believes that every staff member in an organisation should feel safe to use her or his voice to speak about safety issues, mistakes and how to learn and improve. In this TEDx presentation, Jean-Pierre takes you on a trip through his Airforce and civil aviation career to show the added value of Just Culture in high reliability organisations. He talks about his, initial, internal resistance against speaking about his mistakes and he sees the same resistance within the culture of health care professionals.
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Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Nigeria joined the rest of the world to celebrate World Patient Safety Day on 17 September 2020. This event was jointly organised this year in Nigeria by the Occupational Health and Safety Managers (OHSM), Medical and Health Workers Union of Nigeria (MHWUN), OSHAfrica, International Trade Union Congress (ITUC-Africa), Nigeria Labour Congress (NLC), Patient Safety Movement Foundation (PSMF) and the World Health Organization (WHO). -
Content Article
Mersey Care NHS Foundation Trust: Staff Charter
Patient Safety Learning posted an article in Good practice
At Mersey Care NHS Foundation Trust, care and compassion is at the heart of everything they do. Their ambition is to deliver perfect care to become the world’s leading organisation in holistic health and well being. They strive to work side by side with their colleagues, the people who use our services, carers and families, and the communities they serve. The Mersey Care Staff Charter has been updated collaboratively and it highlights what is expected of their staff in supporting our Just and Learning Culture and what their staff can expect from the Trust in return. -
Content ArticleThis survey, a collaboration between the International Society for Quality in Healthcare (ISQua) and the International Hospital Federation (IHF) was designed to frame the WHO Global Consultation on Patient Safety, which was held from 24-26 February 2020 to kick off the development of the Global Patient Safety Action Plan. Already then, the pandemic-to-be was affecting various regions, before striking health systems worldwide. The question of patient safety is a critical one in the discussion about COVID-19: hygiene and hospital-acquired infections, non-suitable hospital architecture, delayed surgeries and procedures, lack of personal protective equipment (PPE) and much more affected the safety of patients as well as of health workers, to whom the World Patient Safety Day 2020 is dedicated. In February 2020, the IHF disseminated a short survey on national safety plans to its Full Members, hospitals’ national/regional representatives. At the same time, ISQua disseminated their survey asking how well incident reporting is in place, and if the outcomes improve the 'no blame no shame' approach to their Individual and Institutional Members. The surveys were repeated in July 2020 to see if the onset of COVID-19 had made any positive or negative changes to the responses.
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Content ArticleAs highlighted by NHS England with the NHS People Plan[, healthcare organisations that prioritise workforce wellbeing will be better placed to put lessons learnt from the coronavirus pandemic into practice. Phil Taylor of RLDatix outlines the benefits of introducing a just culture not a blame culture and shares a methodology for positive change.
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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Content ArticleThe US-based Institute for Healthcare Improvement (IHI) reviewed available evidence for interventions that can help protect staff mental health in the face of extreme working conditions such as natural disasters, terrorist attacks, and previous pandemics. They synthesised this research into evidence-based “psychological PPE” recommendations for use by staff providing care during the COVID-19 pandemic.
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Content ArticleOn Thursday 30 July 2020, NHS England and NHS Improvement published the NHS People Plan for 2020/21. Building on the Interim NHS People Plan released in 2019, it describes itself as focusing on “how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care”. In this blog, Patient Safety Learning looks at the People Plan with specific reference to its approach to tackling the blame culture in the NHS, which is a significant factor in the safety of patients and staff. It highlights where we think the People Plan has not addressed these well-known concerns and what more needs to be done urgently.
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Amy Edmondson: The importance of psychological safety
PatientSafetyLearning Team posted an article in Staff safety
As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. -
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The challenge of culture change in the NHS
Claire Cox posted an article in Culture
Connection, inclusion and compassion are certain, unchanging, and provide a safe refuge to deal with what feels frightening and isolating for so many. The challenge set by the Francis Inquiry Report – to create a compassionate, inclusive organisational culture – is now amplified in the COVID-19 era, which the NHS entered with pre-existing record levels of staff stress and chronic excessive workloads. This workshop from the University of Manchester, explores the problems and opportunities associated with changing healthcare organisation cultures. -
Content ArticleMany mental health service providers around England are meeting complex challenges with exceptional innovation, energy and creativity. NHS Improvement has drawn on this experience, skill and expertise to develop a national model to support continuous improvement in service delivery. This practical resource offers experience from those that have travelled the journey already, in the hope of supporting and encouraging other mental health trusts or any healthcare provider wishing to improve its services. Chapter 7 looks specifically at safety, clinical audit and clinical governance. It shows that a structured approach to improvement supported by an open and just culture can make safer ways of working part of an organisation’s DNA. It recognises that organisations also need robust and transparent governance to keep services safe during major change.
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Community PostWay back in March I applied to re-join the NHS to help with COVID-19. I am a mental health nurse prescriber with an unblemished clinical record. I have had an unusual career which includes working in senior management before returning to clinical work in 2002. I have also helped deliver several projects that achieved nation recognition, including one that was highly commented by NICE in 2015, and one that was presented at the NICE Annual Conference in 2018. Several examples of my work can be found on the NICE Shared Learning resource pages. Since applying as an NHS returner. I have been interviewed online 6 times by 3 different organisations, all repeating the same questions. I was told that the area of work I felt best suited to working in - primary care/ community / mental health , specialising in prescribing and multi-morbidity - was in demand. A reference has been taken up and my DBS check eventually came through. I also received several (mostly duplicated) emails. On 29th June I received a call from the acute trust in Cornwall about returning. I explained that I had specified community / primary care as I have no recent acute hospital experience. The caller said they would pass me over to NHS Kernow, an organisation I had mentioned in my application. I have heard nothing since. I can only assume the backlisting I have suffered for speaking out for patients, is still in place. If this is true (and I am always open to being corrected) it is an appalling reflection on the NHS culture in my view. Here is my story: http://www.carerightnow.co.uk/i-dont-want-to-hear-anything-bad-whistleblowing-in-health-social-care/
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News Article
NHS staff to receive ‘air accident’ safety training to reduce patient harm
Patient Safety Learning posted a news article in News
Frontline NHS staff will be given specialist ‘air accident investigation’ style training to help improve the way the health service learns from patient safety incidents. Cranfield University, which has been training air, maritime and rail safety investigators for more than 40 years, is to launch the first intensive course for NHS staff responsible for investigating safety incidents in hospitals. It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture. Traditionally the NHS has focused on simpler investigations that too often miss systemic causes of mistakes and instead target individual nurses and doctors for blame. The new one week intensive course, run in partnership with the charity Baby Lifeline, will start in January and will give students a basic grounding in the science of investigation and using real-life actors and a maternity based scenario, show participants how to get to the real causes of what went wrong. Read full story Source: The Independent, 20 July 2020 -
Content Article
Podcast: Incident reporting
PatientSafetyLearning Team posted an article in Good practice
Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too. -
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The right – and duty – of NHS staff to speak up
Hugh Wilkins posted an article in Whistle blowing
A blog from hub topic lead Hugh Wilkins on the recent messages from NHS England and NHS Improvement leaders reminding everyone, including those at board level, of the duty and right of staff to speak up about anything which gets in the way of patient care and their own wellbeing. Hugh highlights the real risk of reprisals against some staff who have raised concerns in the public interest, and points out that much needs to change before NHS staff can be sure that it is safe for them to speak up.- Posted
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Content ArticleThe National Guardian's Office (NGO) published a summary of speaking up learning and actions in response to its review into the handling of speaking up cases at Whittington Health NHS Trust. The review, carried out at the end of last year, revealed encouraging areas of good practice. There were also areas of improvement recommended by the review that highlighted issues with the wording and application of the trust policy relating to speaking up, support and feedback to those who speak up, and the way in which the trust manages grievances. The review summary details the NGO’s findings and actions of the trust.
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Content ArticleReport from the Saudi Patient Safety Center on: 1. Hospital Survey on Patient Safety Culture National Recommendations Cycle 2: (2019), and 2. National Supplementary Recommendations related to COVID-19.
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Content ArticleA "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
