NHS leaders note: organisational culture is keyBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4814 (Published 28 July 2014) Cite this as: BMJ 2014;349:g4814
All rapid responses
Dear Sir/ Madam,
We read with interest the article by Kunal Kulkarni published on 4th October 2014 which stated "it is only by empowering staff that a positive team culture can be fostered at the heart of an organisation," and closed by commenting that "rhetoric is endemic but action sparse.” 
We would like to share our most recent experience of initiating direct involvement of frontline clinical staff at Nottingham University Hospitals NHS Trust (NUH) in changing organisational culture through engagement with patient safety and quality improvement work. NUH employs approximately 14,000 staff and provides services to over 2.5 million residents of Nottingham and its surrounding communities, and specialist services for a further 3-4 million people from across the East Midlands. NUH has joined NHS England’s Sign up to Safety Campaign to reduce avoidable harm by 50% in the next three years. Staff involvement at all levels of the Trust in meeting this commitment is integral to our hopes of achieving this aim.
In June 2014 we launched SIPS (Staff Improving Patient Safety) at a formal event involving presentations from Sir Stephen Moss (former Interim Chairman at Mid Staffordshire NHS Foundation Trust) and Dr Peter Homa (Chief Executive, NUH) with support from national institutions and attendance by multiprofessional staff from across the Trust. This followed a significant amount of preparatory work in the preceding months to lay the foundations for SIPS and define its purpose. During his opening presentation Sir Stephen Moss commented "The key to improving patient safety is getting frontline staff in the driving seat. NUH is very much leading the way."
The goal for SIPS is to involve frontline staff directly in enhancing the patient safety culture across our organisation. This aligns with local and national strategy toward prioritisation of patient safety in the NHS, including Health Education England (HEE) which recognises that patient safety should be the first and most important lesson learnt by staff as they train to work in the NHS. The new HEE Commission on Safety  has added further emphasis to embedding patient safety in education and training of all staff in healthcare, and hence the timing of the SIPS launch at NUH is timely and highly relevant.
SIPS was initially set up by trainee doctors working at NUH but has rapidly spread to involve multiprofessional frontline staff including nurses, physiotherapists and pharmacists. We hope this diversity of staff groups will continue to expand as activity builds and wider groups become aware of the opportunities available. Representatives of the SIPS group have become integrated into the governance structure at NUH, including direct reporting to the Trust Clinical Risk Committee and Patient Safety Lead. SIPS identifies potential projects through direct experiences of its staff members as well as by liaising with relevant Trust governance and patient safety committees. An evidence-based approach to undertaking supervised quality improvement projects enables the SIPS team to demonstrate the need for improvement. SIPS members are then able to implement small scale changes to monitor for improvement through repeated measurement. This approach harnesses direct involvement of staff in providing care and being empowered to suggest and test changes to practice and systems. Simultaneously staff are learning to measure improvements in terms of reduction in avoidable harm to patients, enhanced efficiencies and productivity of care where relevant, and providing opportunities to implement innovations locally or at scale. Plans for dissemination of progress with SIPS and the projects undertaken include a presence on the NUH website (intranet), planning for a Trust-wide Patient Safety Conference (supported by the NUH Charity) open to all NUH staff and external delegates, and presentation of the initiative and specific projects at national conferences and subsequent submission for publication of completed projects in peer reviewed journals.
Current and completed SIPS projects to date include comparison of Early Warning Score (EWS) versus National Early Warning Score (NEWS); support for Junior Doctors managing acutely unwell patients; exploring delays in diagnosis of hip fractures; improving on-call handover in Trauma and Orthopaedics; and addressing missed medication doses on Health Care for Older Person wards. Two significant Trust-wide projects now under consideration are a Paramount Project of Medication Error Interventions and also considering how we can improve electronic discharge for better communication between primary and secondary care.
We hope that this letter illustrates how the empowerment of multiprofessional frontline staff can make a significant contribution to patient safety improvement and also contribute to positive changes in organisational culture. If you would like any further information about the work of SIPS, our achievements to date and future focus, please get in touch with us by emailing SIPS@nuh.nhs.uk.
Mr Ben Rees (ST3 General Surgery)
Dr Nick Woodier (Patient Safety Research Fellow)
Mr Joe Whitton (ST3 Paediatric Surgery)
Mr Jon Holley (CT2 Surgery)
Owen Bennett (Patient Safety Lead, NUH)
Prof Bryn Baxendale (Director, Trent Simulation and Clinical Skills Centre)
Dr Peter Homa (Chief Executive, NUH)
1) BMJ 2014;349:g4814
2) Health Education England [internet]. Health Education England announces new Commission on safety led by Professor Norman Williams. Available at: http://hee.nhs.uk (accessed October 2014)
Competing interests: No competing interests
Thank you for publishing such an intriguing piece (Kulkarni K. BMJ 2014; 349: g4814). It clearly communicates and explains underlying feelings endemic amongst healthcare professionals in NHS England. Unfortunately, even if the bumbling rhetoric expounded from Westminster and countless NHS trusts in England became translational into decent common sense one fears (and countless colleagues fear) that it is too late.
The damage through the blind pursuit of foundation trust status, four hour waiting times in A&E and countless financial and clinical target setting has demolished lateral thinking on an individual clinical level, e.g. the countless new initiatives in some A&E departments, and therefore on a collective, managerial, corporate and ultimately patient care stage.
Our NHS has historically been one of hard work, long hours and tough bosses, tough working conditions but one of kindness, compassion and the meticulous destruction of these, e.g. managers so quick to respond to patient complaints that any drivel is written up to appease patients irrespective of the facts, coffee, tea and milk (that cost peanuts) stripped away, cheaper sutures enforced into surgical practice as a cost saving measure (but trusts then simultaneously employ a highly expensive world famous researcher to boost its chances of foundation trust status), consultants having poured their guts into their hospital for thirty years are waved goodbye by no one more senior than a newly qualified nurse (instead of senior management) than it is time to consider pulling that plug (NB: these examples are not specific to any person, trust or organisation).
A story was once told of a newly appointed consultant general surgeon receiving a phone call from someone in human resources (back in the good old days), inquiring as to the correct spelling of his name. Odd, this surgeon thought. However, on arriving to begin a long consultant career this surgeon was trying to find a car parking space. To this surgeons surprise, above a patch of concrete, was a stake rammed in the ground having this surgeons names in bright letters making it clear that this parking space belonged to one person, and one person only. Fast forward thirty years and this same consultant cannot find a parking space, gets fines if an expensive permit is not bought, and has to arrive even earlier to work to secure one (NB: this situation is not specific to a single consultant and is not identifiable to one).
This is an example of how senior consultant surgeons are treated, let alone nurses, porters, cleaners and the countless humble folk that go about their jobs quietly and never get to feel they belong to a team of people making sick people get better. It is that simple.
The NHS in England is on its knees regarding almost every single facet required to treat people in a proper and decent manner, e.g. both patient and staff. As someone who has worked in both NHS England and NHS Scotland it is clear the situation in NHS Scotland is fortunately less grave, less concerning and less fraught in uncertainty, e.g. the closing of Charing Cross Hospital last week could never happen in Scotland in that sort of blatantly savage, greedy and ultimately immoral fashion. One thing that might swing Scottish Independence to a "Yes" vote is the fear of an abominable situation in NHS England being repeated in NHS Scotland.
Competing interests: No competing interests