Changing cultures to improve safety

Effective team working was identified as one of the top priorities required to improve safer working practices by a number of speakers at the Patient Safety Congress 2009, yet a recent survey of 300,000 NHS employees, by the Healthcare Commission, showed that only 39% felt that they worked in wellstructured teams in which staff have clear objectives and worked closely together to meet these goals. Team working has been shown to be crucial to improving safety in other highrisk industries. However, congress speakers said that the hierarchical culture of the health service was a particular barrier to promoting effective team working – along with bullying, secrecy and a “culture of blame”. Anne Keen, the parliamentary under secretary for health services, pointed out that health hierarchies are very difficult to change, particularly in the perioperative environment, but must be addressed to ensure theatre staff are empowered to challenge unsafe practice. She said that it is important to ask: “What can we do differently?” and to move away from a blame culture. Lucian Leape, professor of health policy, Havard School of Public Health, and an international leader of the patient safety movement, acknowledged that it is not easy to create a non-punitive environment – engaging clinicians and changing behaviour is difficult in practice. “Knowing what to do, doesn’t actually make it happen,” he commented, adding that “true change happens from the bottom up”. In his view, teamwork and leadership are essential factors in improving safety. “Quality assurance is not the same as quality improvement. You cannot mandate safety; you cannot buy it; and reporting without learning is useless,” he continued. “We have a long way to go to create the culture of change that we need.”

Team working

A universal characteristic of health systems, in his view, is that healthcare is authoritarian and physician centred. “There is a lack of mutual respect. We ask ‘who?’ not ‘why?’ when something goes wrong and there is a paternalistic sense of privilege and entitlement. ‘We know best’ is part of the heritage of healthcare, which needs to change,” he commented. “There needs to be a focus on the team, fostering openness and support – safety is all about relationships. The golden rule is: treat others the way you would want to be treated.” He highlighted three key areas that need to be improved: teamwork, disclosure and support for the second victim (the care giver). He explained that the characteristics of effective teams is strong leadership, a clear aim and focus, commitment from all team members to the objective, communication and mutual respect, and an environment where everyone is heard and listened to. “In the past, we have been secretive when things have gone wrong and there appears to be a ‘conspiracy of silence’,” Lucian Leape continued. This has either taken the form of paternalism or selfprotection. “Physicians have taken the view that the patient or family is ‘better off not knowing’ what went wrong, but what right have we to withhold such information? Honesty is the foundation of trust. What would you want in the event of an incident? You would want to know what happened, for the healthcare provider to say sorry, to know what they are doing to prevent it from happening to others.” There is a perception that saying sorry is more likely to result in litigation. This is a myth, he pointed out, stating that, in fact, patients are less likely to sue if they receive an apology. Lucian Leape said that, in the event of a safety incident, often the care giver is also wounded emotionally and experiences profound feelings of guilt, shame and fear. “We ignore this and offer them no support in dealing with their emotional state, disclosure or their apology; even worse, we demand their silence – compounding the injury. We need to offer healthcare professionals training in full disclosure and support champions and teams from the bottom up, while ensuring leaders lead.”