COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is a new patient safety tool to help understand the impact of organisational culture on patient safety and is currently being trialled across 12 Trusts.
The tool has been developed by Chris McQuitty (Clinical Fellow) and Nicki Pusey (Maternity Investigation Team Leader) to provide a standardised process for Maternity and Newborn Safety Investigations (MNSI) staff to articulate, analyse and feedback observations about organisational safety culture.
It is based on work carried out by the Patient Experience Library who conducted a literature review of avoidable harm enquiries over 10 years, which included the reports on the maternity services at East Kent and Morecambe Bay. The work had been collated into a report called ‘Responding to Challenge’ which was published last week.
Commenting on the report and the new COMPASS tool, Sandy Lewis, Director of MNSI, said: “The report highlights the importance of an organisation’s culture towards patient safety. The response towards families and staff following a safety event can provide an indication of a systemic issue and reflects what we can see within our safety investigations.
“These issues can be subtle and difficult to describe. Within maternity and newborn services, they can have a significant impact and result in repetitive events occurring. Trusts that have a positive culture to patient safety and learning are able to demonstrate the improvements they are making and recognise where further work is required.
“Through our safety investigations it became clear that there is no consistent approach that supports us to objectively articulate the impact an organisation’s safety culture may have had on a patient safety incident occurring and the response. We developed our structured and evidence-based tool COMPASS to feedback on improvements that can be made.
“We believe the tool will help our investigations to reflect on a Trust's cultural approach to safety informing improvements in patient safety across maternity and newborn services.”
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. The programme was established in 2018 as part of the Healthcare Safety Investigation Branch (HSIB) and has been hosted by the Care Quality Commission (CQC) since October 2023.
- For further information visit: ‘Responding to Challenge’, Patient Safety Library: https://pexlib.net/?247061
- To find out more about COMPASS, visit: https://www.mnsi.org.uk/news/introducing-compass/
