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Learning from the Environment of care culture of the past. Florence Nightingale Foundation Annual Conference February 2014. Mid Staffordshire Public Inquiry - Recommendations Key Themes. leadership Putting patients first Complaints handling Professional regulation of fitness to practice

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Learning from the Environment of care culture of the past .

Florence Nightingale Foundation

Annual Conference

February 2014

Mid Staffordshire Public Inquiry -Recommendations Key Themes

  • leadership

  • Putting patients first

  • Complaints handling

  • Professional regulation of fitness to practice

  • Regulating healthcare systems

  • Standards

  • Collection of real time data to measure quality

  • Performance Management

  • Promotion of NHS Constitution values

  • Openness , transparency and candour

  • Universal culture

Descriptions of culture

  • “The trouble with culture is everyone blames it when things go wrong but no-one really knows what it is or how to change it” - Prof John Glasby

  • Its “how we do things round here” - Prof Charles Vincent

  • “What are we going to work for today ?” – Prof Sir Ian Kennedy

  • “Organisational culture is informed by the nature of its leadership” – Robert Francis QC

  • “It’s what people do when no one is looking” – comment about bankers

Barclays Bank

  • “ We are undoing 30 years of culture” – Anthony Jenkins

  • “The Francis report is a powerful reminder that we need a renewed focus on hearing and understanding what patients are saying”. Ruth Thorlby , senior fellow Nuffield Trust


  • Evidence of poor care in a range of settings

    • Bristol Royal Infirmary – 1984 – 95 . Report 2001

    • Allitt 1991 . Report 1994

    • Shipman 1998. Report 2000

    • Climbe 1999 – 2000 . Report 2003

    • Alder Hey - 2001

    • Mid Staffordshire NHS Foundation Trust – 2005 -08 Public Inquiry report 2013

    • Baby P – 2006 – 07 . Report March 2009

    • Maidstone and Tunbridge Wells 2007. Report Oct 2007

    • Ombudsman Report – elderly care 2001

    • Patients Association Reports 2011 / 2012

    • Winterbourne View – 2011. Report Dec 2012

Factors that influence poor care

  • Whilst there must be individual accountability for breaches of standards , the reality is that in most instances of poor care and avoidable harm arise from a much more complex set of circumstances. Systems and processes, pressure of work, quality of leadership and the cultural mind-set of the organisation are crucial factors .

Robert Francis findings re culture in Mid Staffordshire Trust

  • Patients fear of upsetting staff

  • Forceful style of management

  • Target driven priorities

  • Lack of appreciation of risks for patients

  • Clinician dissengement from management

  • Low staff moral

  • Isolation – lack of strong associations

  • Lack of openness

  • Acceptance of poor standards of conduct / behaviour

  • Reliance on external assessments

  • Denial / defensiveness

  • NB. Echoes of cultural issues throughout healthcare not just Mid Staffs

Factors that influence staff behaviour

  • Research demonstrates a number of key factors which are necessary to maximise staff commitment , engagement and productivity and linked to 4 themes ; * resources to deliver *support to do the job *a job that offers chance to develop *the opportunity to improve team working Ipsos Mori 2008 What matters to staff in the NHS

BMJ Quality and Safety study – published Sept 2013

  • “It is especially important that organisations do more to ensure the engagement and health and well being of their staff”. Professor Michael West – lead author

Chartered Institute of Personnel and Development and the Healthcare Management Association – Survey of 1,021 staff

  • “The results reinforce the need for a much greater focus on staff management and engagement – we know there is a clear correlation between a passive staff experience and better health outcomes“. HPMA President

Staff Care – How to engage staff in the NHS and why it matters – The Point of Care Foundation 2014

  • “You need to light fires inside people not under people” - South Tees Hospitals NHS FT

The Care Environment

  • The environment of care is broader than the notions of patient or person centred care . Staff too need an enriched environment to create the same for patients .

“The NHS reflects the society around it”. Royal Commission on the NHS – 1979 Commissioned by Barbara Castle “We need to look beyond the NHS and examine the values we hold as a society”. Ann Clwyd Feb 2013

Drivers for a positive Universal culture;

  • Common set of values and standards shared throughout the system

  • Committed leadership at all levels to the values

  • A system that recognises and applies values of transparency , honesty and candour.

  • Freely available , useful full information on attainments of values and standards

  • The use of a tool or methodology to measure the cultural health of all parts of the system

  • Organisational stability - ----Mid Staffordshire Public Inquiry Report.

Ingredients of a culture of caring

  • Acceptance that patients needs come before ones own

  • Recognition of the need to empathise with patients and other service users

  • Willingness to provide patients with the assistance one would want for oneself or refer to someone who can help

  • Willingness to listen to patients to discover what they want for themselves

  • Willingness to work together for the benefit of patients

  • A commitment to draw attention about safety and welfare to those who can address them – Mid Staffordshire Public Inquiry Report

Creating a Safe and Compassionate Culture of Care

  • Develop a clear vision for quality care

  • Embed key values / behaviours that could make a difference

  • Encourage use of data to drive quality and safety

  • Find simple measures to address consistency, and complacency

  • Ensure a recognition of human factors

  • Act as Role models / Champions / Mentors

  • Don’t assume others will act – misplaced trust

  • Strong leadership

The Boards role

  • Responsible for developing a patient safety culture - Assurance - Duty of candour - Human factors – NQB Concordat www.england.nhs.uk/ourwork/part-rel/nqb/ - Leadership

3 Facets of Quality The Healthy NHS Board 2013 Principles for good governance - NHS Leadership Academy

  • Effectiveness and outcomes

  • Patient safety

  • Patient experience

Keogh Reviews of 14 Trusts - 2013

  • Trusts should embed early warning systems

  • Have people with expertise to scrutinise data

  • Real time feedback

  • Patients and Clinicians more involved in inspections

  • Skill mix reflects acuity

  • Harness the ideas of students


  • “Maintaining a safety culture indeed any kind of culture , requires leadership and on-going work and commitment from everyone concerned” – Prof Charles Vincent in evidence to the Mid Staffordshire Public Inquiry

Patient Centred leadership : Rediscovering our purpose

  • 43 % of senior managers and leaders said that organisational culture was the biggest obstacle to improving care. Kings Fund Leadership Review. 2013

A promise to learn - a commitment to actImproving the safety of Patients in England National Advisory Group on the Safety of Patients in England . August 2013

Donald M Berwick - key Points

  • Courage for change

  • Abandon blame

  • Transparency at all levels

  • Functions relating to safety and improvement are vested clearly and simply

  • Give people in the NHS top to bottom – career long help to learn

  • Make sure pride and joy in work, not fear , infuse the NHS.

Principles for good governance

  • Looking is not seeing. Listening is not hearing. It is possible to miss so much that is right in front of us if we lack the categories and skills to notice . The greatest of these skills is, perhaps, to put aside our expectations, and to stay open to the actual.” Donald M Berwick.


  • “Don’t just do something , stand there”. – Alice in Wonderland

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