Zero tolerance: NHS behavioural and procedural policies

9 December 2013

If the NHS wants to create a ‘zero-harm’ culture, then where should it start? Darren Whitehouse, healthcare manager at the Health & Safety Laboratory, looks at the key behavioural and procedural changes required to make a difficult transition.

There have been many reviews of the NHS over the last decade, focusing on how the system can be improved. Most recently, Professor Don Berwick's 'A promise to learn - a commitment to act: improving the safety of patients in England' emphasised the culture change needed to improve safety. Meanwhile, 'The Francis Report', although mainly focused on the failures at Mid-Staffordshire NHS Foundation Trust, also alluded to systemic problems in the healthcare landscape, from basic care through to regulation.

Prior to these, the 'Boorman Review NHS Health and Wellbeing' stated the clear link and financial business case between staff well-being and patient outcomes. That is, if you don't look after your staff, how can you expect them to look after patients? Even further back lies Sir Liam Donaldson's 'An Organisation with a Memory' from 2001, which argued for a systemic improvement in the NHS's ability to learn from incidents.

The good news is that the NHS isn't alone; every complex industry faces the same challenges when trying to improve safety performance. "We have worked with many organisations to improve their safety culture and performance in the offshore, nuclear, construction and healthcare sectors, and can be sure that the current issues faced by the NHS aren't unique," says Dr Andrew Curran, science director at the Health and Safety Laboratory.

People power

The common theme through all of the reports, and government responses to them, is people. Front-line staff, patients and their representatives, managers, leaders and politicians - people are at the heart of the system.

Berwick said that, for the NHS to truly provide quality care for patients, its people are key, and he's right. What is important, therefore, is to ensure that the system within which those key people work is designed to support them and to maximise their performance. The science of designing environments, tasks, processes, and jobs to ensure maximum human performance also goes by another, more commonly used name: human factors.

In seeking to improve safety performance, the very best employers don't try to fix one element at a time. Central to the effectiveness of safety management is the concept of safety culture.

Organisational culture has been described as the way we behave when no one is watching. Issues of safety culture fall under the broad 'human factors' umbrella, and culture emerges as a result of how individuals react and work within the system. If you want to change the culture, you have to also change the system. But the system is notoriously difficult to change. It gets comfortable, and doesn't like to be altered. Organisational culture and the status quo are familiar bedfellows but, if you address the systemic problems in a strategic way, you can begin to indirectly influence the culture in a positive way, which helps you become a high-reliability organisation.

So what is safety culture?

The Health Foundation, in a 2011 review of its impact on patient safety, referred to safety culture as "the way patient safety is thought about, structured and implemented in an organisation". The research indicated that there is a two-way relationship between safety culture, and patient and staff outcomes. That is, the prevailing safety culture does influence patient outcomes and staff behaviours, but that improvements in staff attitudes and behaviours can also positively influence the safety culture.

Therefore, safety culture not only has an obvious and direct effect on accident rates, it also impacts on productivity, reliability, competitiveness and even employee morale. An organisation's culture will influence human behaviour and human performance at work and vice versa.

Weak safety cultures have contributed to many major incidents and personal injuries. Indeed, the culture of an organisation is at least as influential on safety outcomes as the safety management system itself. Meanwhile, organisations from all sectors have realised that an effective and just safety culture brings positive and demonstrable results throughout their business.

Can safety culture be measured?

In short: yes it can. But safety culture is complex; at an individual level we respond in established ways to a situation, based on our attitudes, beliefs and values. These judgements that we hold about something - a person, place or situation - can be positive or negative.

A single healthcare organisation can contain thousands of individuals with their own beliefs and values, operating under complex policies and procedures in a dynamic environment. If we accept this, then safety culture can best be assessed by measuring the safety climate: the staff perception of the safety culture at a given point in time. This is typically gauged through questionnaires that explore individual attitudes and perceptions regarding safety. Put together, these build up a picture of an organisation's safety culture.

As an example, a tailored version of the Health and Safety Laboratory's safety climate tool was used during the preparations for London 2012, particularly among the co-ordinated contractors involved in the 'big build' of the Olympic Park. The workforce on the East London site peaked at 12,000 and a total of 30,000 people worked on the project.

The outcome of this project demonstrated the impact that the right culture can have. The accident frequency rate on site was just 0.16 per 100,000 hours worked - far lower than the building industry average of 0.55, and better than the all-industry average of 0.21. Even better, there were no work-related fatalities on the whole London 2012 construction programme.

How does safety culture help build reliability?

The NHS is unique in many ways; in terms of the incredible outcomes it achieves on a daily basis and also in the rate of change needed in order to keep pace with the demands made upon it.

High-reliability organisations (see Figure 1) have leaders who anticipate problems well, because they talk to their staff regularly and have systems in place that capture near misses as well as incidents. They encourage the sharing of bad news without fear of reprisal, and are mindful of the links between productivity and safety. This leadership is visible at all levels within the business and, when things do go wrong, decision-making is devolved to those who are best placed to solve the problem, wherever they sit in the organisation. And HROs are oriented towards learning - procedures are reviewed and updated based on experience and feedback, and staff competencies are developed to help address exceptional situations.

All organisations have a responsibility to manage their risks, and to ensure adequate and appropriate mitigation of those risks. The key to moving beyond safety compliance, to becoming an organisation where there is excellence and innovation in safety, is to recognise that no group acts in isolation - people interact with each other and with the organisational system.

Consider the model in Figure 2. People are the central spine of that runs through an organisation and interact with the system at several points. They interact physically with the organisation, and so ergonomic considerations become important (especially for medical devices). They will certainly be involved with the end product - in the case of the NHS, this will be the patients. How well this works depends on people's behaviour which, in turn, is partly governed by the formal processes but also very much by the culture within the place.

Striving for improved quality outcomes

Leaders are found everywhere in the NHS, and not just at board level. Anyone who through their knowledge, skills, attitude and behaviour influences other people is a leader. And any of those leaders can catalyse change. With that in mind, a simple model is outlined for becoming a successful high reliability organisation (see Figure 3).

The first two steps are about getting the basics right and understanding where you are now: take a good look at your safety management systems. Are they adequate? Are the appropriate policies and procedures in place? Are you able to integrate data from across your safety systems and see a clear line of sight to informed decision-making or are you lost in a sea of dashboards that have lost their meaning? Are you compliant with basic safety standards across the organisation?

The next step is to take a snapshot of the safety climate. Communicate with staff so that they know not just why you are measuring it, but what you are going to do with it once you have the results. Use the results to guide you in allocating scarce resources to those areas of most concern or where the biggest gains can be made.

Then take a breather. Take stock. You have a good understanding of your safety systems and you have some evidence on the current safety climate. Consider now what strategic improvements could be made and what resources are needed. These might be development of new KPI's (and removing old ones) or improving accident investigations or reporting procedures. If you have exhausted the easier challenges, consider implementing more human-factors-based behaviour change techniques if the organisation is ready for it.

If you can implement these steps in existing programmes of work, you will be well on your way to becoming a high-reliability organisation: a beacon of safety excellence in a high-risk environment.

Darren Whitehouse is healthcare sector lead for the Health and Safety Laboratory (HSL). The HSL has been providing scientific and technical expertise to the Health and Safety Executive for over forty years, assisting with the investigation of every major industrial accident and providing high quality scientific research.
Figure 3. A model for change.
Figure 2. Interactions between people and systems.
Figure 1: Becoming a high-reliability organisation.

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