Amanda Oates, Joe Rafferty, Stuart Eales, Arun Chidambaram – Mersey Care NHS Foundation Trust

Implementing a just and learning culture

What the judges said:

The fair treatment of staff in all aspects of investigation (HR/Serious Incident) should support a culture of fairness, openness and shared learning. The submission from Mersey Care NHS Foundation Trust demonstrated how the senior leaders of the Trust both reflected and engaged with global expertise (Sidney Dekker) and actively listened to how their staff were feeling acting with compassion and care.

Mersey Care NHS Foundation Trust is a mental health and community trust. A few years ago, it had many of the formal processes and procedures for managing their people that would generally be regarded as good practice. The trust was ambitious: it had instituted a programme, Perfect Care, that had ambitious aspirations for patients, such as zero suicides and zero restraints for inpatients. Yet this programme wasn’t having the desired impact in all areas. The Trust’s robust approach to incidents was inhibiting its success. The Trust followed standard practice after every safety incident by investigating it robustly, which sometimes led to staff being suspended for the duration of the investigation.

But the perception by staff was that investigations were concerned primarily with determining blame and that the investigative process and outcomes were punitive. Staff were fearful and unhappy. Through staff engagement sessions, more than 50% expressed fear of being caught up in the Trust’s investigation of an incident. The Trust struggled to find a way out of the twin challenge of following a procedurally correct and formal process while still keeping faith with their staff.

Then, in 2016, Amanda Oates encountered the work of Sidney Dekker on 'just culture'. Professor Dekker’s approach, drawing on a wide range of sources and industries, is about understanding what is responsible for something going wrong, as opposed to who is responsible. It assumes that when good people try to work with good intent, but unsafe outcomes happen, the cause of the problem is most likely to lie with the systems and environment in which they are working, rather than in the individuals themselves. If we blame the individual instead of addressing these causes, then we may simply be setting up the failure of the next person who faces the same circumstances. Worse, blame sets up a toxic environment, where people seek to avoid being blamed, rather than help the organisation learn from incidents.

A just culture, on the other hand, does not assume blame but, instead, seeks to find the real causes of an incident. It is about treating people fairly, not just correctly, and it is about helping the organisation to learn to do better.
Mersey care engaged Professor Dekker to help them establish what they termed a ‘Just and Learning Culture’ at Mersey Care.

It’s been a sustained journey. Everyone has been engaged. But they began under the radar. They formed a team of people at all levels, willing to try an alternative approach to patient risk and incident investigation. There was no publicity. They just tried it, tested it, adjusted it and tried it again. They tried investigating incidents for root causes, not blame. They started having different conversations about causes and ways to fix them. They engaged the Board and helped them to have the hard conversation about thinking differently about investigations and safety, and about apologising, where needed, to staff and patients. They changed the HR process at the start of an investigation, which has led to a significant reduction in formal investigations.

As more of these new investigations happened, more people began to be involved. Ambassadors were trained to encourage adoption of new thinking and new kinds of conversation, based on candour rather than fear of punishment. Gradually staff began to own it.

Then Mersey Care took over the operation of the former Liverpool Community Health Trust, which they have had to bring on a journey, also from a blame culture. This has helped show how far Mersey Care have come and has helped cement their progress.

The philosophy behind the Just and Learning Culture adopted by Mersey Care is summarised in two sentences: 'Don’t meet hurt with hurt. Meet hurt with healing.' This principle is at the core of their approach and has profound resonance for everyone who has been on the journey.

The results have been excellent. The number of investigations has reduced by 54% - while (with the adoption of Liverpool Community Health Trust) staff numbers have almost doubled. Suspensions are down 65%. Staff survey perceptions of fairness in relation to investigations have significantly improved. More staff report felling able to report concerns. The improvements in suspension numbers and reduction in investigations and associated costs have led to savings of at least £1.7m over the last two years.

There is still a long way to go. Mersey Care estimates that a sustained improvement in culture requires ten years to bed in. But the results have been excellent. More importantly, the staff now feel much more able to contribute to patient safety – more than ever before report that they feel more able to intervene if they had concerns about a patient’s risk of suicide; more felt a better understanding of suicide prevention; more felt positive about the trust’s suicide prevention strategy.

And it is this combination of improvements in culture and learning, tied to real results and an improvement in staff’s ability to address a critical patient safety issue, that has led our panel of judges to recognise the success of this project.

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