How to engage all staff to improve patient safety culture: The STEP-up programme

Why is patient safety culture important?

The difference between safe and unsafe practice in healthcare is primarily one of culture3–5.

If culture is primarily demonstrated in behaviour, then a culture of safety in healthcare is defined by the behaviour of staff when they recognise and respond to risk.

Developing such a culture must therefore revolve primarily around developing the skills and willingness to **report issues**, **discuss or confront problems**, and to **become involved in system improvement**5.

However, research clearly shows that staff have little understanding, or affinity for, the term ‘patient safety culture’6.

To solve this conundrum, STEP-up sets out to engage healthcare staff in a programme of awareness building, motivation and empowerment that in turn leads to a reduction in the incidence of avoidable harm and an improved patient safety culture.

Watch the film

https://player.vimeo.com/video/718237642?dnt=1&app_id=122963

What is STEP-up?

STEP-up is a structured programme to improve the culture of patient safety.

It creates great results – and it's fun!

We describe it below in summary – and also in our write-up here: https://journals.sagepub.com/doi/10.1177/2516043518792180

The programme was initially run at Aspen Healthcare, by Dr DJ Hamblin-Brown and Ms Judi Ingram. It has subsequently been run at United Family Healthcare in China.

The programme measurably reduced patient harm by engaging staff in a programme to improve the culture of patient safety.

STEP-up delivers spectacular results

In Aspen, we worked with all 1500 staff, across nine sites, during a 12-month period. We used the short film (above) and a four-level programme of training and development (described below), which included elements specifically aimed at sustaining cultural changes.

The results were substantial:

• 95% reduction in never events
• 77% reduction in serious incidents
• 38% fewer falls with harm and
• 19% fewer falls overall
• 24% increase in incident reporting

Overall, the number of incidents with harm has fallen by 5%. Staff perception of our organisation as ‘extremely’ or ‘very’ safe has increased from 73% to 77%. The financial cost of this has been modest and has, we estimate, been recouped in reduced cost of serious incidents. We make the case that a programme such as this is possible, at minimal cost, in any healthcare organisation. Given the results, we argue that all healthcare leaders have a duty to implement something similar.

The four components of patient safety culture

STEP-up is structured around four broad components, based on longstanding research5 that we felt best comprised a culture of safety, namely:

1. ****Reporting** – recognising and identifying both actual incidents and opportunities for harm or near misses**
2. ****Openness** – talking about patient safety issues with- out fear of recrimination or blame, and to make this part of the normal conversation within the organisation;**
3. ****Justice** – ensuring that error is seen and treated as a product of the environment, context, and system, and not about individual culpability; and**
4. ****Improvement** – creating the desire, capacity and capability to change the organisation’s systems and context to make error less likely in the future.**

The STEP-up approach

The four principles of STEP-up (outlined in our paper), are as follows:

• **Visit and talk with everyone** – and that meant everyone – personally to ensure that they realised this included them whatever their roles, clinical and non- clinical staff
• **Work in particular with first-line leaders**, upon whom a safety culture is critically dependent
• **Address the highest risk issues**, where patient harm could be most severe
• **Ensure sustainability** through local resources

For more information about STEP-up, please contact us at hello@careful.online.

References

1\. Makary M, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;:i2139.

2\. de Vries E, Ramrattan M, Smorenburg S, Gouma D, Boermeester M. The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care. 2008;17(3):216-223.

3\. Graban M. Lean hospitals. 3rd ed. Boca Raton: CRC Press; 2016.

4\. Vincent C. Patient safety. 2nd ed. Chichester: Wiley-Blackwell; 2010.

5\. Reason J. Managing the risks of organizational accidents. London: Routledge Taylor & Francis Group; 1997.

6\. Ingram J. Exploring staff perceptions of a patient safety culture \[Unpublished MSC Thesis\]. University of Westminster; 2015.

7\. Greenlions Ltd. How to Harm Patients … and how not to \[Internet\]. 2015 \[cited 23 June 2018\]. Available from: https://greenlions.com/projects/improving-patient-safety-aspen-healthcare/

8\. Morrison D. Chief of Army Lieutenant General David Morrison message about unacceptable behaviour \[Internet\]. 2013 \[cited 23 June 2018\]. Available from: https://www.youtube.com/watch?v=QaqpoeVgr8U

9\. David Morrison – Wikiquote \[Internet\]. En.wikiquote.org. 2018 \[cited 23 June 2018\]. Available from: https://en.wikiquote.org/wiki/David\_Morrison

10\. Never Events list 2018 \[Internet\]. London: NHS Improvement; 2018 \[cited 23 June 2018\]. Available from: https://improvement.nhs.uk/documents/2266/Never\_Events\_list\_2018\_FINAL\_v5.pdf

11\. Hospital Survey on Patient Safety Culture \[Internet\]. Ahrq.gov. 2018 \[cited 23 June 2018\]. Available from: https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/hospital/index.html