Evaluating culture in your unit or network

Perinatal care alongside other areas of medicine has become increasingly complex. Within any complex system, preventable harm occurs. National reports have highlighted preventable harm alongside recommendations to improve safety. Care in the acute setting involves complex planning and procedures by skilled individuals often from different professional teams. Coordination and delivery of care is underpinned by reliable teamwork, which is turn is associated with improved outcomes. Communication has been identified as a significant factor in error within the acute setting. For perinatal teams, the nature of work demands clear communication, intense rapid change requiring response, coordinated psychomotor skills, in addition to rapid reflexes.

The basis of any quality and safety work is to understand how the current system is working and given that good team working is associated with improved clinical outcomes it is important to have valid measurements to assess team performance. The science of team working within healthcare remains in its infancy, however there are a number of options to undertake assessment of team working. It is important when measuring teamwork to examine a) the structure of the team, b) attributes of team members, c) trust between team members and d) organisational culture. Furthermore, it is also important to measure clinical outcomes following any initiative to improve team performance.
 
There is a wealth of information available that can inform discussions regarding the current view of culture in our services. Within the MatNeoSIP programme in England, a comprehensive safety culture (SCORE- Safety, Communication, Organisational Reliability and Engagement) survey took place across all maternity and neonatal services between 2017 and 20189. There are plans in place to repeat these surveys across all services during 2022. The results from these surveys can provide a key set of insights into the perceived culture within the service. A key component of any source is that is provides robust, reliable and timely views of culture. Information from SCORE also can be broken down by role type and care setting to allow this information to be tailored further. SCORE is clearly not the only tool to be used for undertaking culture surveys. Culture surveys are also not the only tools that can and should be used to assess local cultures.

Safe working environments are critical for creating opportunities where people can learn from mistakes. Organisational culture is also important to assess as culture provides operating conditions to promote effective teamwork. Surveys on psychological safety can assess team trust, the ability of team members to speak up and organisational culture. The RCPCH website has a safety survey and BAPM Neonatal Service Quality Indicators (NSQI) recommend an annual psychological survey for teams.
 
Trainee feedback surveys also provide valuable information for team leaders and educators. Training can be associated with beneficial change within organisations with positive training experiences leading to greater learning and engagement and ultimately improved teamwork.  Teamwork competencies are often assessed through multisource feedback by educational and professional regulators. These can highlight areas for improvement with questions covering domains to assess individual attributes as well as ability to work within teams.
 
Robust reporting mechanisms for identifying harm can demonstrate communication errors. The latter are more common in acute areas of medicine such as surgery (almost 30% incidents relate to communication issues). Perinatal Teams also work within an extremely acute context.
 
Observational approaches can measure team performance in real time during acute clinical care or simulation eg resuscitation. There are limitations around accurate assessment which relate to the validity of raters’ assessment. Assessing steps or an algorithm through using a checklist or standardised assessment proforma can go some way to mitigate these issues. Healthcare team improvement tolls include checklists, goal sheets and case analyses. Many teams review these to audit care but results can be impacted if these tools have been implemented with little instruction or support. However, when used well, handover tools can encourage greater exchange of information and are associated with improved patient outcomes. One caveat is that the amount of improvement in outcomes following the implementation of structured handovers is strongly related to the culture of the organisation and psychological safety highlighting assessment of the latter as an important first step on the path to assessing team performance.
 
Specific scales to examine interprofessional working have been developed with the aim of measuring how different teams work together. These can be used at undergraduate level where it is increasingly recognised that teams that train together work better  together with less silo working. The Readiness for Professional Learning (RIPL) scale has been designed to measure interprofessional learning. In relation to assessment of team collaboration the Assessment of Interprofessional Team Collaboration Scale (AITCS) aims to evaluate collaboration under three main domains a) partnership/shared decision making, b) cooperation and c) coordination. Other methods for assessing communication around resuscitation have also been used. Further research to improve validity of these scales within different clinical environments are necessary.
 
Having undertaken baseline assessment and analysis, attempting to move team cultures in a positive direction can seem complex and intangible; the changes that can be made may need to be very broad or be difficult to measure. Linking planned improvements in culture directly to improvements in safety and quality of care is key. As a working example: The SCORE survey may reveal the presence of communication issues between the neonatal unit and the delivery suite, and that these issues are difficult to raise or voice. In reference to perinatal optimisation work, the same organisation also has found that they have low reliability in relation to normothermia for their preterm babies.
 
When looking at how the pathway of care in relation to normothermia can be improved, one potential intervention may involve timely discussions regarding timing of birth of preterm babies with both teams so that the thermal environment can be optimised for the baby. The initial planning of the change can be to discuss the barriers and consequences to the timely communication from both teams and then to agree an effective way forward. As with all improvement work the proposed solutions can be tested and measured. But considering the timeliness and the nature of the communication anchors a part of this improvement in a cultural space.

Other interventions that can be considered may be centrally focused on supporting positive cultures across services. These can be based on developing behavioural charters or employing more positive communication styles across teams. Again, these can be measured using more qualitative techniques.

 Culture change takes time and requires persistence and reinforcement to avoid regression. A number of sources of intelligence including data from culture surveys like SCORE provide a robust view of the culture at that point in time. It is not practical to re-run these surveys any sooner than 24-36 months later. Other data sources may shift earlier, and it is vital that more real time measures are used to track improvements. In part this may be reflected in the improvements in the processes themselves, but it is important that we attempt to track all elements of processes that we strive to improve.