Download - Amanda Oates - ECO14: Patient Safety
Innovation in a Just Culture
Amanda Oates | Executive Director of Workforce
Innovation in a Just & Learning Culture
Amanda Oates, Executive Director of Workforce Wednesday 13 December 2017
A Just Culture
A just culture accepts nobody’s account as “true”
or “right” and others wrong … Instead it accepts
the value of multiple perspectives, and uses them
to encourage both accountability and learning.
Sidney Dekker
What is Innovation?
“The process of translating an idea or invention
into a good or service that creates value”
“There is no innovation and creativity without
failure.” Brene Brown (Research Professor)
Just & Learning Culture and Innovation
• Systems and processes that we use around patient safety, harm reduction and the
associated need for candour, transparency and openness
• These set up so many opportunities for us to fail (not to go as expected)…..and for
us to LEARN!
• Understanding human error is about understanding the inside perspective not the
outside or hindsight one
• Terms line “investigation” can feel threatening and get in the way of trust or the
ability to make improvements
• Staff surveys – staff speaking out?
Barriers to Transparency
• Fear of consequences, blame, shame and being dismissed
• Lack of support or trust, ‘adversarial’
• Incident investigations
• Lack of feedback . . .
Impact of Culture on Workforce
• High performance
• Compliance
• Quality
• Trust
• Attrition
• Sickness
• Employee openness, raising concerns
Delivery of Perfect Care in
Mersey Care
• Delivering our ambition for Perfect Care depends on the development of a
non-punitive culture
• We have found that learning can only flourish when responses to mistakes
are compassionate
• Personal responsibility and professional accountability drives the
organisational learning
• It’s not about 'blame-free' or being tolerant of absolutely anything
• It’s a careful balance of accountability and learning
• A prospective outlook rather than a retrospective bias
• Staff should expect a compassionate response if things don’t go as
expected
Benefits of a Just & Learning
Culture …
For Staff • Acceptance we are not always on our
‘A’ game
• Even the best employees will have blips
• Safe to raise a concern
• Culture that allows the boss to hear bad news
• Empowered to catch errors
• Accountable but not punished for human errors
• Learn when things go well and when they cause harm
• Asking 'what' and 'why' instead of 'who' will drive learning and improvement
For Patients
• All staff protect our values by the choices they make every day in doing their job
• Accountable staff
• Reduce risky behaviour – catch errors before they occur to minimize or prevent errors of the future
• Reckless behaviour is not accepted by anyone
• Staff morale is high as staff are empowered to do the best job they can do
Exposing Errors
Reporting Risk
Identifying
Weakness in
Process
Just Culture
supports us
to Learn and
Create
Positive
Outcomes
and prompts
innovation
Innovation
How does Just Culture & Learning
act as a vehicle to drive Innovation?
High Performing
Systems
Effective
Leadership
Autonomy and
Accountability
Best practice
Creates
Opportunity
Quality Account Objectives Year 1
What are we doing? Our Mission,
our Research, our Measure!
• Feedback, and learning will be disseminated within a seven day window
• Mutually influence and shape how we apply new practice
Objective 1:
72 hour review
• Maximise on how we reflect and learn form the practice of colleagues.
• To reflect and learn from the practice of colleagues
Objective 2:
Good practice Stories
• To celebrate success and ‘temperature check’ that our performance reporting correlates with the change in culture
• To provide Intel and support for teams that might require additional support
Objective 3:
Publish quarterly data
Innovation
• Developed a Supporting Colleagues Policy in conjunction with ward
managers, staff who have been involved in incidents, Staff Side, HR, and
our wellbeing at work services
• Agreed and developed an incident management and resolution process
• Reviewed Management of Attendance policy – going forward this will
become Supporting Attendance Policy
• Established a Just & Learning Culture Task and Finish Group
• Recruited our ambassadors across the organisation
• Focused on the language
• Focused on HR policies and practice
So far we have……..
26
29 29
22 22 22
18 18
13
11
9
7
43
1 1 12 2 2
0
5
10
15
20
25
30
Disciplinary Cases: Jan 16 - Aug 17
Live Cases New Cases Linear (Live Cases)
Workforce Update
Secure Division
Key indicators
DATIX REPORTS
PATIENT MORTALITY
STAFF SURVEY
SPEAK OUT SAFELY
ER CASES
SICKNESS ABSENCE
DATA
OH /STAFF SUPPORT
DATA
RETENTION
OUR
INDICATORS
Next Steps
• Sign off the questions that will inform us whether or not we
are getting it right
• Continue to recruit new ambassadors across the
organisational footprint
• Sidney Dekker back to the Trust January
• Give staff the opportunity to ‘Bid for Sid’
• Learning with Stakeholder event in January 2018