Abstract
We discuss how Aspen Healthcare measurably reduced patient harm by engaging staff in ‘STEP-up’, a programme to improve the culture of patient safety. This focused on helping staff to understand their role in the reduction of preventable harm. The organisation admits 45,000 inpatients and has 300,000 outpatient contacts per year. We describe how we worked with all our 1500 staff, across nine sites, during a 12-month period. We used a short film and a four-level programme of training and development, which included elements specifically aimed at sustaining cultural changes. The results have been substantial: 95% reduction in never events, 77% reduction in serious incidents, 38% fewer falls with harm and 19% fewer falls overall. We have seen a 24% increase in incident reporting, on a background of an 11% increase in activity. 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.
Keywords
The challenge
Recent estimates put the number of deaths from medical error at more than 300,000 per year in the USA. In the UK, this may translate to as many as 25–30,000 per year. 1 The overall number of patients harmed, in addition to this headline number, must be substantially higher. Estimates consistently suggest that the rate of adverse events for all hospital admissions is around 14%. 2 This situation is coming under more scrutiny as regulatory oversight and healthcare spending increases and with patients become more aware of the risks.
Aspen Healthcare is a diverse private hospital group in the UK. We treat around 45,000 inpatients and 300,000 outpatients a year across nine very different healthcare facilities. We have four acute hospitals, ranging from 40 to 80 beds which undertake a large number of elective day-case or short-stay surgical procedures, but also treat medical, palliative and oncology patients. We also run a specialist eye clinic, two dedicated day-surgery centres and two cancer centres. Around half of our treatments are commissioned by the NHS.
A few years ago, we believed we had a very good patient safety record. We had no unexpected deaths, and our normal safety metrics – return to theatre rates, unplanned admissions, wound infections and so forth – were all comparable to national averages. However, in 2015, it became apparent that we had a problem, which is, we believe shared across many healthcare settings: we were finding it hard to learn from previous incidents. 3
We found prominent errors kept recurring, not just across the group but even within the same hospital facility. In particular, we found minor mistakes in the selection of prostheses for both cosmetic and ophthalmology surgery were repeated, sometimes within less than 12 months. None of these were classed as causing significant (moderate or severe) harm to patients, but the prominence of these mistakes, classed as ‘never events’, made them stand out. Further investigation identified a similar pattern of repetition in other, more minor classes of error. If we could not eliminate these never events (which are susceptible, by definition, to robust well recognised systemic barriers), what else was happening and being repeated? Our concern was that unless we successfully reduced the burden of minor-harm, a smaller error might lead to a significant incident with severe patient harm. 4
The question we were faced with was why were we unable to make changes to safety that were sustainable? The answer, we came to realise, was a need for a wider appreciation and understanding of patient safety, risk and the link to both behaviour and system design. In other words, we needed to improve our patient safety culture.
Culture
The difference between safe and unsafe practice is primarily one of culture.3–5 If culture is primarily demonstrated in behaviour, then it is how staff recognise and respond to the risk of harm that defines a culture of safety.4,5 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 process and system improvement. 5 However, qualitative research by our clinical director with a selection of front-line staff showed that they had little understanding, or affinity for, the term ‘patient safety culture’. 6
To solve this, we therefore set out to engage our 1500 healthcare staff in a programme of awareness building, motivation and empowerment that would, we hoped, lead to a reduction in the incidence of avoidable harm and an improved patient safety culture.
We did this by structuring our programme around four broad components, based on longstanding research,
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that we felt best comprised a culture of safety, namely:
Reporting – recognising and identifying both actual incidents and opportunities for harm or near misses; Openness – talking about patient safety issues without fear of recrimination or blame, and to make this part of the normal conversation within the organisation; Justice – ensuring that error is seen and treated as a product of the environment, context, and system, and not about individual culpability; and Improvement – creating the desire, capacity and capability to change the organisation’s systems and context to make error less likely in the future.
While we recognised that these represented the four general groups of behaviours which we needed to address, we also realised that these four words (‘reporting, openness, justice and improvement’) would not engage, motivate or easily translate to all our staff. We therefore invented STEP-up. We asked staff to:
SPOT the problem (a culture of reporting) TALK about it openly (a culture of openness) EXAMINE the system and (a culture of justice) PREVENT it happening again (a culture of improvement).
This S-T-E-P acronym has become the basis of our group-wide patient safety programme of training and engagement.
The programme
Our question was how we could use this acronym to inspire and engage 1500 staff across nine different UK locations? The first thing we needed was a way to encapsulate and summarise the STEP-up idea of ‘Spot, Talk, Examine, Prevent’.
Our film
To do this, we first engaged a film-maker to create a memorable film that was short enough to use and that would have real impact – it needed to be different enough and non-sententious to be both memorable and enjoyable, whilst getting the central safety messages across to our staff.
The resulting film 7 ‘How to harm patients …’ is a satirical but impactful look at the opposite safety behaviours from the ones that we want to promote: We set out to show that, if you really want to harm patients, you should simply ‘Look the Other Way’, ‘Keep Quiet’, ‘Point the Finger’ and ‘Resist All Change’. Appended to the end of this is a more traditional exhortation to the four key safety behaviours of ‘STEP’. The intention is that viewers will warm to STEP, having seen the impact of the ‘negative’ behaviours. Using creative animation to provide a touch of humour, the film avoids being sententious. It has had universally positive feedback from those that see it. The film can be found at http://www.bit.ly/STEPupVideo
Armed with this film, we believed we needed to do four things:
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
This led us to create a four-level programme which we describe below.
Level 1: Visit and talk with everyone
The authors, the chief nurse and the medical director, both members of Aspen’s executive leadership team, spent several months visiting every site independently and leading a series of 45 min sessions which covered:
An example – from the authors’ direct experiences – of a patient harm incident, stressing the negative impact on both patient and staff Some examples from the audience sharing their own experiences of safety-related incidents The statistical extent of patient harm in healthcare (to provide the context to why this was so important) The STEP-up film A run through of the ‘STEP’ behaviours: The importance of awareness and reporting (‘SPOT’) The importance of Open discussion (‘TALK’) The importance of ‘Context’ – i.e. systems – in prevention (‘EXAMINE’) The necessity for change, adaptation and improvement (‘PREVENT’) The role that every staff member, clinical or non-clinical, has in the prevention of harm and in improving our safety culture.
Overall, this ‘roadshow’ covered over 1200 staff members – over 80% of our entire workforce – from all departments in all facilities. This took nine months, with both authors each committing over 20 days to the project. We recognised that this was a significant amount of time for the two executive members, but we estimated that the cost of this would be repaid with an improvement in our patient safety and, in particularly, a reduction in serious incidents.
We solicited online feedback from our staff a month after the training, avoiding producing on the day what are sometimes disparagingly referred to as ‘happy sheets’. We asked three simple questions: ‘How satisfied were you with the training?’; ‘Did you learn anything new?’; and – most importantly – ‘Has the course changed anything about how you work?’.
We were surprised by the degree of positive feedback. With a response rate of nearly 50%, over 71% of respondents gave it five-out-of-five stars. Moreover, 56% said they learnt ‘A lot’ and 41% said that the training had ‘Definitely’ changed how they worked.
We also tried to cover a proportion of our visiting, self-employed doctors, who form an important group of staff. Part-time working patterns and their non-employed status makes them hard to engage, so we therefore spent time with the Medical Advisory Committees of each facility and sent-out the film by email to every doctor.
Level 2: Work in particular with first-line leaders
We recognised from the beginning of this programme that the key individuals in our organisation were the first-line leaders: the ward managers, team leaders, departmental supervisors and heads-of-department. For them, we wanted to remind them that ‘the standard you walk past, is the standard you accept’8,9 and that this affects everyone in their area or department.
We therefore developed another, longer session for all members of the leadership team of every department. Again, this was delivered by the authors across a three or four month period, sometimes overlapping with the Level 1 programme.
The four hours that we spent with these leaders allowed us to explore in more detail their own experiences of patient safety issues and, most importantly, their own role in promoting a safety culture, and in managing and preventing safety such incidents. We used interaction and some third-party videos to illustrate key concepts, but we principally relied on allowing pairs and small-groups to talk to each other about the four elements of ‘STEP’ and what this meant for their roles. By doing so, we started a series of safety conversations across the organisation, often between people who rarely conversed during their normal working days allowing them to compare and contrast their experiences. At the end of the session, we asked them to make safety commitments to change their leadership in regard to patient safety.
Once again, we asked for feedback a month later: 80% gave the course five stars; 66% said they learned ‘A lot’ (these attendees had already been on Level 1); 52% said that the training had ‘definitely’ changed how they worked; and 42% said that it had changed how their team was now working.
Level 3: Address the highest risk issues
Analysis had revealed common themes in our serious incidents over the last few years. Unsurprisingly communication, human factors and teamwork stood out as of huge importance in challenging risky behaviours and preventing significant harm. One challenge in the UK independent sector is that our doctors are all visiting professionals and therefore only ever part-time members of the clinical team. We needed to find ways to help staff appreciate the complexities of teamwork and human factors under these circumstances. We therefore asked an external training company, specialising in human factors and clinical training to co-created another four-hour course. This course was to provide a simulation environment for clinical staff who might be confronted by risky behaviours, in particular by visiting consultants. We chose some ‘classic’ problems – administration of allergy-inducing drugs, wrong site surgery for example – and then ran these as mini-clinical simulations during a half-day course. We even invited some of our regular doctors to be there as ‘protagonists’.
The objective was to provide a safe space in which staff could discuss the complexity of issues surrounding effective and safe teamwork, being able to speak up, and safely challenge. We hoped to generate the confidence and skills to ‘SPOT’ and ‘TALK’ about issues that might cause any patient safety issues.
Anecdotal feedback from this course has been very positive and a more formal assessment from our third-party training company is underway.
Level 4: Ensure sustainability
With any such programme, the question always presents itself of how to ensure that the good work achieved is sustained and continues. In this case, how could we make STEP-up the default answer to the question ‘How we do safety around here?’ If we could find a way to create a longstanding culture of improvement, in order to ‘Prevent it happening again’, we could realise the most significant gain.
Traditionally, safety changes revolve around re-education or direct communication: emails are sent, incidents are mentioned in staff meetings and a poster is designed. Much of this is wasted since the people to which such efforts are directed, inevitably leave, taking with them the knowledge. With turnover rates and agency staff, exhortations to ‘simply do better’ evaporate. The answer, as the ‘E’ in STEP-up emphasises, is to implement changes in systems of work that will endure even when individuals leave.
We realised that we therefore needed to set-up an infrastructure that would encourage and support on-going changes to the systems that protect patients. To do that, we needed to create some significant and lasting capability locally, at each facility, to guide and effect systemic changes in response to risk.
Our answer was to develop a group of engaged and enthusiastic volunteers at each of our nine facilities who we have called ‘STEP-up Ambassadors’. The smallest site has two ambassadors. The largest has six. They were drawn and selected locally by the executive team at each facility, on the basis of a job specification and role remit. We agreed that this role would involve at least a half-day per week or 10% of their time. We ensured that this allocation was suitably protected and recognised in the individual’s appraisal and job-plan. We defined their job as being, in essence, to ensure that all staff understood STEP-up and to help develop the necessary systemic changes.
To provide some initial momentum, we took the ambassadors away as a group for a two-day immersion course to help equip and support them in their new role. This role was to provide a number of things. First and foremost, they were there to promote, engage and encourage their colleagues in the adoption of the STEP up behaviours. They were also to act as an adjunct to the local governance leadership team. This had some very practical implications, notably the delivery of the Level 1 STEP-up staff training (we made this a once-only, mandatory training course for all new staff, to be delivered locally). They were also required to oversee and encourage ‘systems thinking’ within their organisation; the EXAMINE and PREVENT part of the programme.
In their new role, the ambassadors therefore needed to understand safety leadership and to learn consulting skills, training skills and implementation skills. This is not something easily achieved in two days, but we showed them the territory and provided some basic tools for them to think about and use where they could. We continue to meet with our Ambassadors regularly and provide further safety training to ensure they are effective in their roles. To ensure the sustainability of the Ambassadors, we have a yearly update of our safety leadership training, made necessary by attrition and recruitment of new Ambassadors.
We have also implemented an annual ‘Chief Executive’s STEP-up award’ which was selected by the STEP-up Ambassadors and presented to a team from across the group, who had demonstrated the safety behaviours that STEP-up aims to promote and deserved recognition of their commitment to assuring our patient’s safety.
Our analysis of this has been that the ambassador programme has been a huge success. Every facility has a committed group of Ambassadors, who have led STEP-up locally. The regularity and importance of the Level 1 training that they have delivered has created a strong sense of corporate memory of the STEP-up principles, upon which individuals can build. The senior leaderships teams within each facility have been able to use the ambassadors to maintain an enthusiasm and support for the STEP-up programme. And the ambassadors themselves help to role-model and promote the STEP-up behaviours on a daily basis. Many are now proactively involved in wider patient safety initiatives, such as undertaking safety leadership walk rounds and audits.
Results
The question we have to ask, having put in this enormous effort in engaging our staff in improving our safety culture is ‘was it worth it?’ Has our STEP-up programme worked? Is it continuing to work?
The answer is unequivocally affirmative. Our outcomes, after 18 months, are – we believe – remarkable. Here are the principal results to date:
Incident reporting has increased by 24%. It may seem paradoxical that increased safety should result in more reporting. But more reporting indicates more vigilance, rather than more harm. We have seen a large engagement by the entire organisation in reporting near-misses and issues which might otherwise have been ignored. This indicates a widespread uplift in the awareness of risk and the acceptance that incident reporting as a critical responsibility for all staff and promotes patient safety Never events have fallen by 95% and serious indents by 77%. We started this journey with a spike in never events. This rise has been reversed. In 2017, we had two quarters (six months) without any serious incidents whatsoever. For the whole of 2017, we had only one never event, which would not have been classified as such, had it occurred two months later.
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Falls with harm have decreased by 38% and falls overall by 19%. The ‘Call before you fall’ project team at our biggest hospital received the Chief Executive’s STEP up annual award for their work over 2016–2017. Their principles and learning have now been translated across the group and we are striving to reduce falls across the group still further. Overall the number of incidents with harm has decreased by 5% despite an increase of 11% in our activity. This speaks for itself. We are doing more, but have had less harm to our patients – which was our overall stated aim. An increase of 8% in our staff’s opinion of our safety since 2014. Using a standardised AHRQ tool,
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81% of our staff rate our facilities as extremely or very safe in 2018, an increase of 4% from the previous survey in 2016. This now put us in the top quartile of organisations against which we can compare ourselves.
Conclusion
Our patient safety outcomes are significant and very rewarding. However, what makes us most proud is the work that our staff are doing, on a day-to-day basis to ensure this. We have measurably shifted the safety culture of our organisation in less than two years. This has come about through the hard work, commitment and enthusiasm of all our 1500 staff, spurred on by our exceptional cadre of STEP-up Ambassadors.
Having said that, however, this has not been that difficult. The interventions we have outlined above are not high-tech or high-cost. As with any change, it requires ambition, application and persistence by senior leaders, but what we have found is that we were pushing against an ‘open door’. No member of staff in a healthcare facility wants to harm patients. We all come to work to do a good job and make patients better, not worse.
So our exhortation at the end of this paper is simple. If you have read this far – and you think that STEP-up could benefit your organisation – just do it. The film and material is an inconsequential cost; the time and resources invested is easily regained from the reduction in serious incidents and patient harm; the associated cost of litigation has undoubtedly been reduced. And through this programme, we have proved that simple interventions such as this can work. It has inspired our staff to promote safety behaviours and patient harm has reduced and, with it, the consequent impact on staff involved in such incidents.
All healthcare organisations are seeking ways to improve patient safety. Our view, given the success of our programme, is that all institutions should be implementing STEP-up – or something very similar – in order to ensure that all our staff understand the fundamental principles and the associated behaviours in a culture of safety.
We urge you all to STEP-up to patient safety.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The STEP-up programme was funded by Aspen Healthcare Ltd as part of its ongoing operations. No external funding was received.
Ethical consent
No ethical consent was required for this paper.