Today (9 April), a new research report, Responding to challenge, has been published by the Patient Experience Library. This report looks at how to identify ‘red flags’ (early warning signals) and harmful patterns of behaviour in health and social care.
CQC commissioned the Patient Experience Library to analyse warning signals from 10 years of avoidable harm inquiries in health and social care. The report uses real-life examples to show the red flags for what could indicate a poor culture.
Findings
The report found that where there is a problem, it usually involves multiple people who have failed to spot or deal with avoidable harm. It identifies 3 states in which problem cultures can give rise to failures:
- complacency
- avoidance
- denial.
It further identifies 6 different organisational subcultures that can feed into an overall harmful culture where failures happen. These are:
- reporting culture
- compliance culture
- caring culture
- teamwork culture
- accountability culture
- learning culture.
Through these findings, a tracker to help spot red flags in harmful cultures was developed. This can be used by anyone who feels something is ‘not quite right’ in a service to check their initial concerns against the evidence.
The report adds to our growing body of evidence and research on closed cultures.
Professor Sir Mike Richards, Chair, said:
“This is a powerful report which underlines the importance of early identification of issues in order to prevent avoidable harm. This also shows that complex organisations have multi-faceted cultures. To understand how well-led an organisation is there needs to be engagement with staff at all levels, particularly frontline staff, to work out whether the culture set by leadership is correct and is providing the right framework for improving services for people.”