Developing and sustaining a culture of safety to benefit everyone
The culture of an organisation and the teams within it is shaped by the behaviour of everyone in it. In maternity and neonatal services, a safety culture improves the experience of care for women and babies and supports staff to thrive. Positive cultures exist in many services, and we want everyone to experience a positive culture at work – poor cultures need to be challenged. The failures in care identified in Bill Kirkup’s report on East Kent stemmed from flaws in culture including a lack of teamworking, professionalism, compassion, listening, and learning. The three areas for developing and sustaining a safety culture for everyone are: developing a safety culture, learning and improving, and support and oversight.
Culture is everyone’s responsibility – especially leaders; evidence shows that compassionate, diverse and inclusive leadership is key to enabling cultural change.
Most of the care delivered in maternity and neonatal services leads to good experiences and outcomes. A continuous learning and improvement approach will promote safer care for all.
Our ambition is framed by the Patient Safety Incident Response Framework (PSIRF) which provides a consistent approach across clinical disciplines, including for maternity and neonatal.
While some maternity and neonatal services are supported by their trust to improve and deliver change; others are not. Good oversight is about understanding the issues faced by leaders and helping to resolve them, including intervention before serious problems arise.
- Develop a positive safety culture: leaders understand ‘how it feels to work here’ so they can make improvements and everyone takes responsibility for safer care.
- Learning and improving: a compassionate approach to learning from safety incidents.
- Support and oversight: services receive support before serious problems arise, in line with the Perinatal Quality Surveillance Model. Change is supported by effective system leadership.
|Description of goal||Where are we now?||What are we aiming for?||When will we get there?|
|All Provider Trusts take part in the national perinatal culture and leadership programme.||3 out of 8 Provider Trusts have already started on the programme.||100% of Trusts have taken part in the national perinatal culture and leadership programme.||31 October 2024|
|Improve sharing and learning from near misses, serious incidents and never events.||LMNS has variable access to Provider Trust incident data.||LMNS has oversight of 100% of Provider Trust incident data so that effective learning can take place.||31 March 2024|
|Effective implementation of maternity and neonatal PSIRF.||Awaiting national maternity guidance (expected on 29 June 2023). NENC event to discuss national guidance planned for 12 July 2023.||Standardised approach to implementation of maternity and neonatal PSIRF across the NENC.||31 March 2025|
Initiatives we are implementing to help achieve our objectives and goals:
- Monitor the impact of work to improve culture and provide additional support when needed.
- Provide opportunities for leaders to come together across organisational boundaries to learn and support each other.
- Share learning and good practice across all trusts.
- Oversee implementation of the safety improvement plan.
- Commission services to support the delivery of safe, equitable and personalised maternity care for the local population.
- Oversee quality, provide support where improvements are required.
- Lead local collaborative working to deliver national programme objectives and improve consistency and access to maternity and neonatal services.