Patient Safety Culture Tools

1. Patient Safety Culture Tools

2. Bristol Royal Infirmary ReportFinal report • It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. • Many failed to communicate with each other, and to work together effectively for the interests of their patients. There was a lack of leadership, and of teamwork.

3. Bristol • The culture of the future must be a culture of safety and of quality; a culture of openness and of accountability; a culture of public service; a culture in which collaborative teamwork is prized; and a culture of flexibility in which innovation can flourish in response to patients’ needs.

4. Bristol • A culture of safety in which safety is everyone’s concern must be created. Safety requires constant vigilance. Given that errors happen, they must be analysed with a view to anticipate and avoid them. • A culture of safety crucially requires the creation of an open, free, non-punitive environment in which healthcare professionals can feel safe to report adverse events

5. What defines your Trust’s culture? “the total of inherited ideas, beliefs, values and knowledge which constitute the shared basis of social action”

6. "The feature that distinguishes the best health organisations is their culture." Liam Donaldson writing in BMJ 1998; 317:61-5.

7. What is a safety culture? • safety is considered in everything you do and there is a balanced approach when things go wrong - you ask why and how • constant vigilance - always alert to expect the unexpected • understand what they should do when things do go wrong • are open to and make, suggestions for change and improvement • believe their actions make a difference to themselves and to others

8. What is TCAM • The TCAM programme is made up of a questionnaire and a set of development sessions

9. How does it work? • The TCAM questionnaire measures team climate and teamwork, particularly team behaviours essential to the maintenance of patient safety and effective patient safety incident management in clinical settings. • The TCAM development sessions help teams work together to improve team climate.

10. How can TCAM help? • There is increasing evidence that the climate within a team has a major impact upon patient safety and care. The TCAM questionnaire enables teams to identify the areas of team climate that they can improve, and the TCAM development sessions provide the opportunity to work on these areas. • The TCAM questionnaire measures team organisation and team culture using 11 different Dimensions. Some of the Dimensions have Components that specifically relate to patient safety and effective patient safety incident management in clinical settings. The team’s responses to the questionnaire highlight where the team is doing well and where it can improve in terms of team working. • The TCAM development sessions provide the team with an opportunity to work on the areas where they can improve.

11. Team Co-ordinator • The team co-ordinator will • administer the TCAM questionnaire, • produce a report from the TCAM questionnaire • arrange and facilitate all sessions. • send a copy of the TCAM questionnaire responses and the co-ordinators log to Aston Organisation Development (info@astonod.com) to assist in the continued development of TCAM.

12. Team members • Team members need to • complete the TCAM questionnaire and return it promptly to the team co-ordinator. • attend the TCAM questionnaire feedback sessions • attend any TCAM development sessions the co-ordinator arranges.

13. What materials are available to run TCAM? • The Co-ordinators guide • TCAM theory • TCAM questionnaire • The Template for scoring TCAM • The Template for the TCAM report • The Team member resource book

14. Manchester Patient Safety Framework • Originally developed for use in primary care by Manchester University • Based on Ron Westrum’s (1993) theory of organisational safety – “organisational personality” • Tailored from a tool developed for the oil industry and used by Shell Plc • Now piloted and developed for use in acute, mental health, ambulance settings

15. 1 2 3 4 5 X 1. Commitment to Quality X 2. Priority given to Patient Safety X 3. Incident Reporting 4. Incident Investigation X 5. Learning from Patient Safety Incidents X 6. Communication About Patient Safety X 7. Personnel Management of Safety X 8. Safety Education and Risk Management X 9. Team working in Risk Management Board responses? Nurse responses? X X X X X X X X X X

16. Framework Document

17. Snapshot of whole tool (folded out)

18. Facilitator Guidance

19. Trust MaPSaF Toolkit • Hard copies of the tool relevant to your care setting • Copies of the Facilitators Handbook • Internet resources: slide presentation & speaker notes

20. What can MaPSaF be used for: • To facilitate self-reflection at various levels within an organisation • To promote patient safety as multidimensional concept • To stimulate discussion about cultural strengths and weakness • To highlight differences in perceptions of staff groups • To view how a mature safety culture might look. • To evaluate how interventions and change may have impacted on your safety culture

21. What MaPSaF is not: • A performance management tool for comparing or benchmarking Trusts • A way of apportioning blame if an organisations culture is perceived to be not sufficiently mature

22. Who can MaPSaF be used by ? Clinical Governance & Risk Committees Directorates & Specialties Trust Boards Primary care contractors Multi-disciplinary Teams Wards & Departments

23. Maturity Levels 5. Risk management is an integral part of everything that we do 4. We are always on the alert for risks that might emerge 3. We have systems in place to manage all identified risks 2. We do something when we have an incident 1. Why waste our time on safety?

24. Any Questions?