Two years ago this organisation embarked on a journey towards ‘Perfect Care’ and we thought long and hard about what signal we were sending. We decided it was important to develop a culture that does not solely limit itself to objectives set down by regulatory bodies or commissioners and that we should aim higher and set more exacting standards that resonated with staff, patients and carers alike.
As part of that process, we have made significant progress against those big, hairy, audacious goals (BHAGs) for zero suicide in our care, the introduction of No Force First across our organisation and a focus on physical health and wellbeing for our service users, patients and staff. By changing our work patterns we have shown that we can limit restraint even with the most complex of patients. Yes, there is much more to do, but there is no doubt that momentum has been achieved.
Zero Suicide is arguably even more complicated - perhaps one of the most complex issues any NHS Trust has ever said it will tackle - but here, too, we have shown a level of determination that has resulted in a phenomenal increase in awareness of suicide within our services. Over the last year we have already developed suicide prevention training for all staff, which is rapid, accessible, easy to complete and costs just £4 a head to implement. This compares to a market rate of several hundreds pounds per head if we had looked into going outside the organisation for this training.
This also means that well over 3,000 staff now have an awareness of suicide, both in the work environment as well as in their communities. But even this puts us 'not even at base camp for Everest,' if I can borrow an analogy. That said, I believe we have momentum and focus now in a way that we haven't had before and our task is to harness that energy and push on with a progressive march towards the zero aim.
Understandably, as we have started to pursue Perfect Care by really working on the zero-based BHAGs, it is not surprising that you have started to ask, quite rightfully, about another type of zero-based BHAG; this time about a zero blame culture. That in itself is an indication that we have made a change in thinking as it is only by promoting openness and transparency that we will accelerate our rate of improvement on the three clinical BHAGs.
In response to the issue of how to dispel a blame-based culture in favour of openness and transparency, we have been doing a great deal of structured listening and have talked to many different people over the last 12 months. Significantly and importantly, over 300 clinicians have contributed powerful insights to help us truly understand the barriers that prevent us from operating in an open and transparent way. What has been fantastic about this is how excellent people within this organisation have shared their concerns and fears about how transparency would work and engaged in a way that was solution orientated, rather than problem focused.
Following much consideration of all that we have heard, on Wednesday at the Senior Managers’ Forum at Aintree Racecourse we talked about our intent to add a fourth Big Hairy Audacious Goal (BHAG) – following Zero Suicide, No Force First and physical health and wellbeing – by developing what we call “a just culture.”
So what is a just culture? From a Mersey Care perspective, it’s an environment where we put an equal emphasis on accountability and learning. It’s a culture that instinctively asks in the case of an adverse event "what was responsible, not who is responsible". It is not finger-pointing nor blame-seeking. That said a just culture is not the same as an uncritically tolerant culture in which anything goes - that would be as inexcusable as a blame culture.
The focus of how we do things in a just way has to resonate with staff but it must also be just for patients, carers and their families. This won't drop into place overnight because we will have to work out how to manage the tension of wanting all aspects of what we do to be open and transparent while simultaneously not accepting that we can be tolerant of every and any action.
This isn’t something we’ve just dreamed up. We’ve learnt from industries like airlines, nuclear technology, oil and exploration and (some) healthcare in the US, all of which go about their daily business knowing there is always an element of risk. Indeed, there is a very current example of how difficult this move can be captured in the story of "Sully", a new film release starring Tom Hanks. It focuses on Captain Chesley Sullenberger, who famously made an emergency landing on the Hudson River in New York and saved all the 155 passengers and crew. Despite being a national hero, he was later investigated by airline authorities which goes to show that a ‘no blame’ culture is not always as easy to implement as it is to introduce.
Here at Mersey Care we believe this is not just an ideal but a methodology that we are adapting to stop pointing the finger of blame or sanction those who speak out. It’s right on a human level – we have to ask ourselves would I want this to happen to me? – but it’s also good for our organisation to learn from these experiences and improve how we do things.
There is obviously much work to do with this yet, but the overwhelming feedback from people we have spoken to about this is that they very much like the idea. I see this as the perfect example of co-production and we will be working more closely with our experts with experience to achieve this.
As part of the process towards establishing a just culture, I will be holding one or two ‘mega-conversations’ in their classic form that we used a few years ago. We need to get your views on what this means, what would stop it being successful and how do we overcome those hurdles?
I’d like to get these mega-conversations organised early in January so please look out for the dates and try to attend. It’s important as many of you as possible take part in these conversations and if you cannot go, can we make sure at least one member from each team attends so we get a widespread variety of views.