Improving Patient

Safety Culture
A practical guide

In association with
 Foreword
Safety culture can appear nebulous and We hope that this ‘toolkit’ will give teams an understanding of
it can be unclear how to improve it or how to craft, create and nurture a positive safety culture and
indeed how the shift occurs. This has led provide a theoretical underpinning to how to shift the culture.
to a broad number of approaches which  
are associated with improvements in This is the first in a series of safety culture toolkit pieces. We are
Dr Matt Hill, safety culture but are not always successful still learning how to do this, and we invite you to share your
National
Clinical Advisor,
when they are used in similar or different experiences of using the toolkit and share what has or hasn’t
NHS England contexts. worked, but most importantly share the ‘how’ of what has made a
difference in your teams. This will shape the future work.
In considering the safety culture of where we work we often
separate out ‘what’ work we do from ‘how’ we work. This can We want to work with you to shape this ‘toolkit’ and to learn
lead to a disconnect and lead to ‘how’ we work not transferring together to understand how we can make positive changes to our
into the ‘what’ we do. NHS culture.

By considering the ‘what’ and the ‘how’ as two intertwined

threads where each is necessary to provide a strong team, we can
see that unless we give them equal attention the overall strength
of it will weaken.

2 Improving Patient Safety Culture: A practical guide

 Preface
Changing culture takes concerted effort Each of these while important on their own when combined can
and time and we all need a bit of help help build the momentum we are seeking, and to spread a positive
along the way. The Improving Patient patient safety culture throughout the NHS.
Safety Culture toolkit provides us with
that help. No matter what your job or This toolkit will help you get on the front foot, learn from what
Professor role is in healthcare this toolkit applies works and what doesn’t, and be far more proactive. Desmond
Suzette
Woodward to you. Tutu is quoted as saying ‘there comes a point where we need to
stop just pulling people out of the river. Some of us need to go
Changing culture takes concerted effort and time and we all need upstream and find out why they are falling in’. This toolkit will
a bit of help along the way. The Improving Patient Safety Culture help you do just that.
toolkit provides us with that help. No matter what your job or role
is in healthcare this toolkit applies to you. Professor Suzette Woodward

The toolkit is not a recipe, rather a menu of ingredients and a

toolbox to help the reader create a personalised strategy. Like any
recipe there are some ingredients that provide the foundation for
the rest; a positive approach to safety, a restorative just culture,
psychological safety, inclusivity and civility.

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Introduction
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1. Introduction
Safety culture has been a key and recurring theme in reports where Taking an appreciative approach:
there has been poor care (Francis Report; Morecambe Bay; East Kent;
and Ockenden Report) and its importance highlighted in responses “A positive safety culture is one where
(Berwick Review; Response to Winterbourne View). the environment is collaboratively crafted,
created and nurtured so that everybody
Its ubiquity has hampered our understanding of what it is, and it has
become apparent that it means different things to different people, (individuals, teams, patients, service users,
and at different hierarchical levels. Without a common understanding families and carers) can flourish to ensure
of what we perceive safety culture to be, it is difficult to understand brilliant safe care.”
how to create a positive shift.
Prof Seligman on PERMA – YouTube
The nebulous nature of culture and focusing on where the culture is
less positive have not allowed us to consider what we are trying to
achieve in focusing on it.

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The NHS Patient Safety Strategy starts to explore how culture is crafted where the
“importance of individuals day-to-day behaviour” and how we interact with each
other in the moment is increasingly recognised as creating the local culture. These
local relational interactions are complex and we do not routinely consider how we are
working alongside what work we are doing. Understanding the complexity in these
interactions and considering culture as a dynamic social construct can give us useful
insight into how interventions which are associated with improvement in culture have
their effect, and why they may not work in different contexts.

How does culture shift?

Seeing culture as a dynamic social construct focuses our attention on to our
interactions with those in our team and other teams. This emphasises the importance
of how we create the space to optimise the relational aspects of the work. In
structured parts of work we have traditionally focused on, and measured, process
metrics e.g. that teams are meeting, who is there and how long it takes, and not
considered the quality of how we work together. It is often only when outcomes are
poor or relationships break down that we try to understand how a team is working
together.

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When we consider how we can influence these social interactions and amplify the relational opportunities
there are three elements:

Space/time: We need to create time for teams to come together. These may be structured parts of the working day (eg
briefings, huddles, ward rounds) or more informal (e.g. coffee room, corridor conversations, cafe).

What we talk about: We will pay attention to the aspects of work that we talk about and in doing so, what we value becomes
explicit. By focusing on the balance between how we ensure brilliant and safe care and what the individuals and team need to
flourish allows teams to consider how work is sustainable. There is a ripple effect from these conversations into others as teams
make sense of their work.

How we talk and work together: The “values based enactment” of how we speak and behave towards each other is crucial
in crafting the conditions where we can all flourish and ensure brilliant care. To do this, we need to routinely reflect as a team
on how we are working together, and invite and value the perspectives of others within the team to understand how each of
us feels and the impact that our behaviour has on others. In doing so we can create the conditions where we all feel included,
invited to contribute, safe to speak up and that our contributions will be explicitly valued and appreciated.

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Recent research by Dr Nicola

Mackintosh et al found that the:

“Fidelity of function of interventions is linked

as much to the supporting social structures as
the form of the intervention itself.”

This focuses our thoughts on the social connectedness, peer

learning and the importance of the relations between members.

As you use the tools within this toolkit we encourage you to focus
on ‘how’ the practices and interventions are done and consider
the relational elements of the work and the extent to which they
embody positive values, alongside the practices and interventions
that you use in your teams.

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The key elements

of a positive
safety culture
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2. What are the key elements of positive safety culture?

All of these are valuable approaches to shifting the culture but we are starting the toolkit with those in bold.
We explore how we can craft, create and nurture the conditions (in alignment with the People Promise) to support the key elements of a
positive safety culture:

Individuals and team flourishing Brilliant, safe care and experience

Leadership Continuous learning and improvement
Teamwork Safety I & Safety II
Communication Learning from Excellence
Just Culture National Patient Safety Improvement Programmes
Psychological safety Appreciative inquiry
Promoting diversity and inclusive behaviours Patient centred collaboration
Staff well being
Civility
Organisational Development

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Teamwork and
communication
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3. Teamwork and communication

What is it?
Teamwork in healthcare can be thought of as two or more people interacting to deliver safe, high quality care, wherever that is be it in
primary care, social care, mental health or acute hospitals. Good communication is essential to this. It should be open, respectful, honest,
two-way and inclusive across disciplines and professional groups. Good communication is also about curiosity and seeking to understand
the perspectives of others.

Why is it important?
A breakdown in communication between healthcare staff has been identified as the most common cause of safety problems. When
communication in teams is poor, it’s easy to feel your colleagues are being uncooperative, that your voice isn’t being heard, and that
you aren’t being valued. But when teamwork and communication is good, you feel that you’re listened to and that concerns you raise
about safety are quickly dealt with. Team members feel motivated and empowered to put forward safety ideas to the team and get them
sorted.

What does good look like?

Professor Amy Edmondson has studied what “good” looks like when people come together to work as a team, often for the first
time. She calls this ‘teaming’ and describes four steps to do it well (see Top Tips below), which are particularly helpful if you’re working
in constantly changing teams. The approach helps break down silos and creates opportunities to develop new solutions for complex
problems.

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TOP TIPS: TOP TIPS:

Working together as a team Safety culture discussion cards

Adapted from Extreme Teaming: Having informal conversations with colleagues about safety and risk within
How to Deliver Integrated Care services is a great place to start. The NHS Scotland safety culture discussion
cards, originally developed by Steven Shorrock, are a great resource.
Aim high: set a clear, ambitious, compelling,
meaningful vision which inspires people by Remember, receiving feedback is hard for anyone if it feels negative. Taking a
focusing on the things that matter to the team positive approach to giving feedback to colleagues, delivered empathetically,
helps to reduce anxiety and contributes to a continuous learning cycle.
Team up: value the diversity of the team as
this will lead to a greater ability to achieve Taking a structured approach to the communication of safety-critical
breakthroughs information (tools such as SBAR – the Situation, Background, Assessment,
Recommendation) in specific circumstances can be helpful, but imposing a
Fail well: identify opportunities for intelligent structure in all circumstances may not always be the right approach.
failures that provide information on how to
improve approaches and systems next time round Approaches like safety huddles – regularly scheduled, short meetings to
discuss safety – can be an effective way to communicate key information,
Learn fast: maximise learning from mistakes improve cohesion, build relationships and reinforce shared values and
– apply focus, discipline and structure when purpose.
reviewing them.

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CASE STUDY:

Huddling up for safer healthcare – Yorkshire and Humber AHSN

Yorkshire and Humber Patient Safety Collaborative’s ‘Huddle Up for Safer Healthcare’ (HUSH) programme supports and coaches
frontline teams to implement safety huddles and deliver sustained improvements in care.

A safety huddle is a short, multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk.
Effective safety huddles involve agreed actions, are informed by visual feedback of data and provide the opportunity to celebrate
success in reducing harm.

The original HUSH focus was falls prevention, and has stopped more than 6,000 falls happening, equating to an estimated £15m in
avoided healthcare costs.

From its work helping teams address their safety priorities, the Patient Safety Collaborative now has evidence of effectiveness in
addressing pressure ulcers, deteriorating patients, nutrition and hydration; and for mental health teams, seclusion, self-harm and
violence and aggression.

Read more about safety huddles in Yorkshire and Humber here.

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TOP TIPS:

Conducting safety huddles

Taken from the Culture Change Toolbox:
• Identify a team or small group of staff that is willing to try something new. Host a trial safety huddle during one shift.
• Start by explaining the purpose of the huddle. Consider how we optimise care by discussing safety concerns of the past,
present and future and examples of excellent care as well. Emphasise that it’s about learning and improving safety, not about blame.
• Think about some example issues to bring up at the first huddle. At first, it might not be clear to everyone what sort of topics
they can talk about.
• Keep it short. Five minutes is reasonable.
• Thank everyone for their participation and be clear about next steps. Will someone follow up on the issues raised? Will there
be another huddle? What changes can we make to the structure of the huddle to make it more effective?
• Adjust the structure of the huddle using this first group, then expand to have them more often or with more staff. Aim to
include all team members eventually and determine how often you would like to hold safety huddles in your work area.
• Be transparent with follow-up. Share the outcomes of the huddle using email, meetings, posters or personal conversations.
Acting on the information shared during safety huddles sends a powerful message that safety matters.
• Invite other team members to host them once the huddles happen regularly, so that they can take place without requiring the
original facilitator.

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Three change ideas to try:

Use structured feedback:

1
Space/time: This can be done throughout our work and can be very quick to do, and have a big effect. Especially if it is
positive feedback that is being shared.

What: Feedback is a key ingredient of the learning cycle. Give each other positive feedback, and the reasons why. Use a
structured approach to giving constructive feedback, such as the Situation, Behaviour, Impact (SBI) approach:
eg Situation: ‘When you were with that patient/relative/colleague in the……. ‘ This needs to be a specific context.
Behaviour: ‘I noticed that you did….. ‘ This needs to describe what you observed without being judgemental.
Impact: ‘It had a real impact on me and made me feel… ‘
‘I noticed how the patient/relative/colleague responded to you and I noticed that they did……..’

How: Think kindly about the other person and, with respect and care, give them a clear description of what you
observed at each stage of the feedback.

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Teach or treat: This is from the Each Baby Counts group

2
Space/time: These learning conversations can occur at any time when clinical concerns are escalated or another
opinion is sought.

What: When a concern about a patient/service user is raised the response from the senior member of staff is framed
as either Teach or Treat. If the senior member of staff is happy with the current management then they can respectfully
explain their rationale so that each is clear about the other’s perceptions. If they believe that new treatment is required
then this can be taken in a timely fashion.

How: This encourages staff to have a ‘respectful, learning conversation’ at times of escalation. This flattens the
hierarchy and supports team members to feel that they have been heard and their contribution valued. This
helps to support learning and mutual trust through enhanced relationships.

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Initiate safety huddles

3
Use resources including the “Yorkshire Safety Huddles Manual” to initiate safety huddles, starting with a single team.

Space: Create a time in the day when safety huddles can occur.

What: Any aspect that affects safety can be discussed. Consider the importance of the conversation in developing the
social relationships between team members, as well as what is discussed.

How: Starting with everyone introducing themselves (even if we think we know everyone) flattens the social hierarchy
and makes it more likely that everyone will feel able to speak later and contribute to the huddle and allow all forms of
expertise to be valued and heard.

Read about the Innovation Agency’s Coaching for Culture programme, which included accredited coaching
training for team leaders, use of a team culture diagnostic, and use of practical QI skills to support the
development of safe, high-quality, and compassionate services in the North West.

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Just and
restorative culture
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4. Just and restorative culture

What is it? “A just and learning culture
A just culture is about creating a culture of fairness, transparency and learning. It recognises
is the balance of fairness,
that success or mistakes are the product of many factors and focuses on changing systems
and processes to make it easier for people to do their jobs safely. It is about ensuring everyone justice, learning – and taking
is confident they will be treated fairly when something goes wrong. responsibility for actions. It is
Why is it important? not about seeking to blame
NHS Resolution develop this idea further by saying that “What we need is a restorative just the individuals involved
culture (Dekker, 2018) that is about repairing and building trust and relationships when things when care in the NHS goes
have not gone as planned. This means we need to develop working practices that move
people away from fear and blame, including tackling incivility and bullying, and addressing the
wrong. It is also not about an
health and wellbeing needs for staff to help them work safely. Ensure everyone’s needs are absence of responsibility and
met, no matter who they are. Treat everyone fairly, no matter what their background is, and accountability.”
help them speak up.” (Being Fair, NHS Resolution)
Being Fair, NHS Resolution
Sydney Dekker described a restorative culture as one that looks to the future by exploring what
needs to be done and who should do it. There are three questions:

1: Who is hurt? 2: What do they need? 3: Whose obligation is that?

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Underpinning this approach are the practical applications taken in Being Open and the subsequent Duty of Candour publications.

Shifting to this approach is not just about using the NHS Just Culture Guide but is a wholesale shift of approach, supported by the Patient
Safety Incident Response Framework (PSIRF) - “a system designed for safety and learning rather than performance management”. (PSIRF)

Importantly it is recognised in PSIRF that the NHS Just Culture Guide is:
• Used only when there is reason to believe the deliberately malicious, negligent or incompetent actions or decisions of an individual
contributed to an incident, and not routinely whenever an incident is reported or a Patient Safety Incident Investigation is conducted.
• Managed completely separately from any activity to examine an incident for the purposes of learning and improvement.

The use of the NHS Just Culture Guide in these situations will also help to “reduce the role of unconscious bias when making decisions
and will help ensure all individuals are treated equally and fairly no matter what their staff group, profession or background. This has
similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black, Asian
and minority ethnic staff.

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CASE STUDY:

Duty of candour community of practice – Health Innovation Network South London

Duty of candour is a statutory requirement in the NHS when a patient experiences harm while receiving healthcare. It ensures patients
and staff understand how things may have gone wrong and reassures everyone involved that lessons have been learned.

The Health Innovation Network South London created a community of practice (CoP) to support staff to share and learn best practice
when dealing with difficult situations. The community brings clinicians, managers and patient groups together. It has created a set of
generic training materials that are used across the area, promoting consistency and tackling difficult aspects of Duty of Candour, such
as how practitioners say sorry to patients when things go wrong.

The CoP is still going strong and has proved an effective forum for sharing concerns and making decisions. There is a genuine passion
from the professionals who attend about sharing their experiences and effecting positive change within their organisations.
Find out more information here.

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CASE STUDY:
“Managers don’t trust us, we’re
closest to the patients and yet when
Supporting team health: A simple framework and a tale of three teams we put ideas forward, no one listens,
we’re the bottom of the pile” Team A
Jo Davidson, Associate Director Organisational Effectiveness and Learning and
Melissa Holt, Strategic Organisational Effectiveness Lead “In this team I’ve lost my confidence
  and any sense of feeling valuable or
Overview valued” Team B
More than two years responding to COVID has reinforced the significance that great teamwork has on both “Changes are not discussed. They are
staff wellbeing and the safety, quality and experience of care they provide. NHS organisations are full of dictated, regimented and we are told
people caring for others but what happens when those teams, become stuck in conflict, toxicity or resistance - not asked” Team C
to change? These sorts of comments are not common to any one organisation, the experiences by these
teams are all to common across the health service.
This piece tells the story of three such teams, brought back to health with the use of a simple tool - The
Mersey Care “Team Canvas”, and how that tool has been used to facilitate team health and culture across
the Trust. It includes how it has been designed and implemented to integrate with our clinical assessment,
improvement and accreditation processes which enables us to track and measure improvement and
demonstrate the impact not just to our colleagues, but importantly to our patients.
This excerpt provides detail in relation to just one of the OD interventions that have been designed and
developed to support a Restorative, Just and Learning Culture at Mersey Care NHSFT, all of which are
described within the recent publication of ‘Restorative, Just Culture in Practice’.

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Three change ideas to try:

Consider how to adapt and use the Just and Learning Culture Charter in NHS
1 Resolution ‘Being Fair’:
Space/time: Use a team meeting to discuss what a just and learning culture means to your team, and what their
experiences have been. The shift to a just and learning culture requires a continuous approach that is anchored in the
elements of a Just and Learning Culture Charter. The key purposes of transparency, fairness, learning are underpinned
by the principle that patients and families involved in a patient safety incident need to be looked after and have their
questions answered.

What: In the discussion ask what the people’s experiences have been when things have gone wrong and how they felt
and how they thought it was for the patient and families. There is a need for a shift in the language that we use
and the approach to incidents that focus on the learning – what happened not who was involved.

How: Consider how to involve everyone in the discussion so that all the perspectives are heard and
the process supports the principles of openness, honesty and transparency.

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Three change ideas to try:

Recognise staff as the victims of Use the NHS Just Culture Guide:
2 unsafe systems too: 3
This is a way to ensure that everyone is treated
Staff who are involved in an unanticipated adverse fairly in the event of an incident of harm. The
patient event, caused by systemic issues, including NHS Just Culture Guide is a tool to support
human factors, can be traumatised by the event. individuals to treat staff fairly, consistently and
constructively if they have been involved in a
Resources to support second victims are available patient safety incident and to help to prevent
through the Improvement Academy’s dedicated unconscious biases.
Second Victim Support website

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Psychological
safety
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5. Psychological safety
Psychological safety was first described by Amy Edmondson who It does not mean that we will always agree and that teams will be
defined it as: free from conflict, but that by feeling valued we can all contribute
“A shared belief held by members of a team that the team our ideas to a find a better solution.
is safe for interpersonal risk taking.”
In the book The Four Stages of Psychological Safety, Timothy
It describes the ability of members of a group to feel free to speak Clarke describes how teams move through each stage:
up, ask questions, report errors, raise concerns and ask for feedback
without fearing the consequences and being judged. We learn early
Stage 1 Inclusion Safety: Team members, whatever their
in life about making mistakes and the feelings of embarrassment and
age, sexuality, ethnicity or race, feel that they are included and
awkwardness it provokes. As adults we naturally avoid these awkward
valued and that they are appreciated by the team.
situations. When discussing safety, it’s important to create conditions
Stage 2 Learner Safety: Team members are able to admit that
in which we feel safe to take what can feel like personal risk, saying
they don’t know things and are able to ask questions and start
for example, “I made a mistake” or ‘this didn’t go as planned”,
to try new things.
without fear of judgement.
Stage 3 Contributor Safety: Team members are able to voice
Psychological safety in a team does not happen by chance – it needs their own ideas without fear of being ridiculed or embarrassed.
to be actively created and nurtured. The feeling of inclusivity and Stage 4 Challenger Safety: Team members are able to
trust are key to crafting the conditions where diversity of thought in question the thoughts of others in the team including those
ethnicity, gender and age is welcomed and valued as it leads to a more with power.
complete picture and better care.

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In ‘The Fearless Organisation’, Amy Edmondson describes three ways to help to create psychological safety in healthcare.

Leadership tasks Accomplishes

Set the Frame the work: Emphasise purpose: Shared expectations
• Set expectations about • Identify what’s at stake and meaning
stage failure, uncertainty and • Why it matters
interdependence to clarify • For whom it matters
the need for voice

Inviting Demonstrate situational Practice inquiry: Set up structures and Confidence that voice is
humility: • Ask good questions processes: welcome
participation • Acknowledge gaps • Model intense listening • Create forums for input
• Provide guidelines for
discussion

Responding Express appreciation: Destigmatise failure: Sanction clear violations Orientation toward
• Listen • Look forward continuous learning
productively • Acknowledge • Offer help
• Thank people • Discuss, consider and
brainstorm next steps

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1. Try using a survey to measure psychological safety in

your team to understand and then discuss the different Psychological Safety Survey
perceptions within the team.
1. If you make a mistake in this team, it is often held against
you.
2. Leaders and team members sharing their stories about when
2. Members of this team are able to bring up problems and
things went wrong for them, and what they learnt.
tough issues.
3. People on this team sometimes reject others for being
3. National Staff Survey and National Quarterly Pulse Survey
different.
results are available on the Model Health System – start a
4. It is safe to take a risk on this team.
discussion about the team’s results.
5. It is difficult to ask other members of this team for help.

6. No one on this team would deliberately act in a way that
Consider using the King’s Fund ABC (Autonomy, Belonging and
undermines my efforts.
Contribution) Framework which links the questions to these topics.
7. Working with members of this team, my unique skills and
This is a good way to start a conversation about the results
talents are valued and utililsed.

Amy Edmondson. The Fearless Organization.

Wiley, 2019

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Promoting
diversity and
inclusive
behaviours
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6. Promoting diversity and inclusive behaviours

What is it? Inclusion is the degree to which a person perceives that they are an
esteemed member of the work group through experiencing treatment
The NHS People Plan states that: that satisfies their needs for belongingness and uniqueness. Team
“The NHS was established on the principles environments that promote inclusivity and psychological safety of their
members usually achieve the best patient safety outcomes. Such teams
of social justice and equity. In many ways,
model behaviours characterised by civility, inclusivity, trust, respect and
it is the nation’s social conscience, but professional courtesy. They offer team members the chance to thrive
the treatment of our colleagues from and be themselves and foster diversity, equality and fairness. Such
minority groups falls short far too often. environments value and encourage continuous input from patients,
carers and families into the design and delivery of their services.
Not addressing this limits our collective
potential. It prevents the NHS from achieving
excellence in healthcare, from identifying
and using our best talent, from closing
the gap on health inequalities, and from
achieving the service changes that are
needed to improve population health.”

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Why is it important? What does good look like?

There is strong evidence that where an NHS workforce is Inclusive teams recognise and celebrate diversity and difference
representative of the community that it serves, patient care and both for team members and their patients. Inclusive teams
the overall patient experience is more personalised and improves. promote equity and fairness for everyone, no matter your
Yet it is also clear that in some parts of the NHS, the way a ethnicity, age, gender, sexuality, religion or power.
patient or member of staff looks can determine how they are
treated. Undermining, humiliating and discriminating behaviours They hunt the good stuff – the things that unite and energise you
increase fear and decrease team psychological safety and learning. and which give you shared common purpose.
Celebrating difference and diversity in all forms stimulates learning
and creativity, if harnessed in the right way. Civility between health Diversity of thought is paramount.
and care staff in the work environment matters because it reduces
errors and stress and fosters excellence. Encourage patients, carers and families in all their diversity to be at
the centre of your plans and involved in co-creating them.
Patients, carers and families are in a unique position to provide
new ideas and insights and to identify safety and care quality
concerns that insiders may have ceased to notice long ago. They
may also spot team issues and behaviours that are unsafe.

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Three change ideas to try:

Support staff wellbeing and joy in work

The Institute for Healthcare Improvement (IHI) has developed a range of resources, including a
Conversation and Action Guide to support staff wellbeing and joy in work after the COVID-19 pandemic.

Reverse mentoring
It can be difficult to understand how it feels to be different members in a team. By partnering with a
more junior member of a team from a different diverse background, a leader can spend time with them
to understand the different perceptions that they have and understand ‘work as done’ rather than ‘work
as imagined”’.

Always events
Implement the Always Event methodology – aspects of the patient and family experience that
should always occur when patients interact with healthcare professionals and the system –
as a means of consistently putting patients at the heart of the care provided.

33 Improving Patient Safety Culture: A practical guide

 Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

CASE STUDY:

Seema Srivastava is a geriatrician and Associate Medical Director at staff attended, giving rich insight into the issues they were facing. Some staff
North Bristol NHS Trust. Here she discusses how responding to the had been unwell with COVID-19 themselves; others knew friends or family
COVID-19 pandemic provided an opportunity to engage with Black, members who had sadly died.
Asian and Minority Ethnic staff at the hospital.
Themes emerging from these events included worries about PPE and access
One of the most worrying findings in the research and reviews into COVID-19 to health risk assessments. This led to immediate improvements, with some
is how it has disproportionately affected some groups more than others in our of the attendees co-designing an updated risk assessment process, to enable
society, particularly people from ethnic minority backgrounds. In April, during better safety and better conversations between managers and staff.
the height of the pandemic, we realised there was an urgent need to find out These sessions also coincided with the Black Lives Matter movement, and
how this was affecting staff at North Bristol NHS Trust, particularly those from they became a platform for people to share their feelings and experiences
ethnic minorities. about the impact of racial injustice in their daily lives.
We wanted to understand how people were feeling at this time and what we While the trust had held staff engagement events before, it had never
could do to create a space that felt safe, where people felt cared for, and which attempted something on this scale. As the hospital employs over 9,000
would build on a safety culture that recognised and addressed this inequality. people, they are really important to create safe spaces for listening. The
existing BAME network has also increased its membership, and we are
Supported by Jackie Marshall, the Trust’s Director of People, we arranged a contributing to conversations about wellbeing as part of the trust’s ‘People
series of virtual listening events to hear from staff from ethnic minorities, listen Strategy’.
to their lived experiences and ask what meaningful actions we could take. They
were held as open forums for any member of staff, regardless of their role or We found COVID-19 has brought many existing issues to the surface, but it’s
level in the trust. also given us the time and permission to address them in a way we haven’t
before. I hope we can maintain this momentum and build on the framework
We knew that not everyone would be able to attend virtual meetings, so we’ve created to ensure a safer culture for staff in future.
we also ran face-to-face sessions in a large marquee with social distancing in
place. Between April and June, we held 11 events in total and around 240

34 Improving Patient Safety Culture: A practical guide

Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

Civility
 Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

7. Civility INCIVILITY
THE FACTS
WHAT HAPPENS WHEN
Civility is essential for individuals and teams to fulfil their potential and “civil work environments matter SOMEONE IS RUDE?
because they reduce errors, reduce stress and foster excellence.” It “creates that sense of safety and is a key
80% ofworrying
recipients lose time
about the rudeness

ingredient of great teams.”

38%
reduce the quality
The Civility Saves Lives campaign promotes the importance of respect, professional courtesy and valuing of their work

each other. The campaign aims to raise awareness of the negative impact that rudeness (incivility) can have 48% reduce their
time at work
in healthcare, so that we can understand the impact of our behaviours. Patients, carers and families notice
incivility between team members, which can lead to increased feelings of fear and vulnerability, and a poorer 25% take it out
on service
users
patient experience. The campaign includes examples of how teams have sought to make patients active Less effective clinicians
provide poorer care
participants in fostering a positive safety culture.
WITNESSES
There is also a NHSE Civility and Respect Toolkit with a number of resources within it to support teams. 20% decrease in
performance
50% decrease in
willingness to
help others
Space/time: Add the topic of civility to a team meeting.
  SERVICE USERS
What: Use the infographics to start a discussion or watch a video. Discuss what team members experiences 75% less enthusiasm
for the
organisation
of civility and incivility are and how they have felt when these have occurred.
  Incivility affects more than just
the recipient
How: Discuss what clear standards and expectations the team have and role model respect and care for IT AFFECTS EVERYONE
others to enable meaningful and respectful connection and participation. CIVILITY SAVES LIVES
The price of incivility. Porath C, Pearson C,
Harvard Business Review 2013 Jan-Feb ;91(1-2):114-21, 146

36 Improving Patient Safety Culture: A practical guide

Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

References
 Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

8. References
[Link]
[Link]
[Link]
Professor Michael West, referenced in: [Link]
Woodward, S. Implementing Patient Safety: Addressing culture, conditions, and values to help people work safely. 2019.
Neily, J. Association Between Implementation of a medical team training program and surgical mortality. JAMA. 2010; 304, (15): 1693-1700.
[Link]
[Link]
[Link]
[[Link]
[Link]
[Link]
Page 9: [Link]
[Link]
The report based on the planned series of roundtable discussions is expected to be published in 2021 on the NHS England and NHS Improvement website.
[Link]
[Link]
[Link]
Page 50: [Link]
[Link]
[Link]
[Link]
[Link]

38 Improving Patient Safety Culture: A practical guide

 Introduction Safety culture Teamwork and Just and Psychological Promoting diversity & Civility References
communication restorative culture safety inclusive behaviours

[Link]
[Link]
[Link]
[Link]
[Link]
]The Joint Commission. Disease specific care certification - national patient safety goals [Internet]. Washington: The Commission; 2008. Available from
[Link] [Link].
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
Institute of Healthcare Improvement. [Internet] Boston: The Institute. Safety briefings. 2004 [cited 2017 Oct 1].
Available from: [Link] Memberships/Passport/Documents/[Link].
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]
[Link]

39 Improving Patient Safety Culture: A practical guide

 Acknowledgements
The following people contributed to this practical guide,
and we would like to express our gratitude to them:
Joanna Pendray, Susanne Smith, Suzette Woodward, John
Illingworth, Matt Hill, Paul Wastell, Bernard Allen, Lee
Gridley, Sarah Papworth-Heidel, Sarah Tilford, Hester Wain,
Heather Pritchard, Chloe Morales-Oyarce, Caroline Angel,
Peter Jeffries, Nathalie Delaney, Phil Duncan, Sarah Speck,
James Nicholls, Jane Reid, Alison Lovatt, Seema Srivastava,
Joanne Crawford, all of the NHS and AHSN teams who
kindly shared their work in the case studies and throughout
the guide, and the National Patient Safety Team at NHS
England.

40 Improving Patient Safety Culture: A practical guide