Culture Change

As with other maternity and neonatal services in special measures, many of the challenges for these services at a Welsh Health Board were cultural. During our time working with the maternity and neonatal service leaders, lots of progress was being made and, in some areas, these services were beginning to set standards for the rest of Wales.

One area identified repeatedly by external reviewers was the culture, relationships and integrated working between maternity and neonatal services, a key safety concern. These services weren’t at loggerheads, rather they just struggled to work with each other.

Responding to a shift in leadership, we set about nudging the cultural norms to see if we could improve joint working, even if this was just the service leaders to begin with. The response to the changes was significant and much more positive than we’d thought.

Over four months, we constructed several things that ensured that these services worked together seeking to improve the culture and joint working between the services, the key ones were as follows:

Joint Self Assessment – we started by redesigning an existing self-assessment assurance process to include a joint working element, assessed by the service leaders together. This provided a baseline, generated a mature conversation about where the services were and established a way of capturing developments.

Joint Workstream – we then signalled the need for a joint workstream, covering all the improvement work needed to respond to the recommendations made by external agencies that had reviewed the services. The governance was formalised, a project document describing the work was developed and approved, a plan agreed, and regular reporting of progress was initiated. Progress was steady and broadly as planned in the early stages, aided by two leads who met regularly and unblocked many of the issues impacting progress.

Joint Assurance – during this period a joint operational assurance framework was developed, an output both services collaborated on. Meanwhile, some of the active assurance processes covering a clinical review of past cases, and recent serious incidents were bringing clinical staff and leaders together in a way they hadn’t experienced before; they reviewed cases together, determined root causes and shared the learning from these in joint education sessions and simulations.

Term admissions – early on we discovered a backlog of around 6 months for reviews of term babies being admitted to neonatal units, a joint best practice requirement. This seemed to be driven by key professionals from both services not attending review meetings and with the level of term admissions higher than other areas, the learning from these reviews was necessary to improve outcomes for babies. We started reporting attendance at review meetings and the percentage of term babies being admitted to neonatal units. We included these metrics in the progress reports that went to Board and Board sub-committees, which generated questions and focus on this joint issue.

Joint Showcase – with the assurance panel that oversaw the improvement work in the Health Board, we’d started to setup showcases as a way of assuring them that good progress was being made. We included a showcase within the schedule for term admissions, even though the services might not have been fully ready for this. Selecting positive leaders to take forward the planning and preparations for this showcase, they brought the two services together to do this effectively, after an initial period of uncertainty and anxiety.

So how did we know that these things made a difference? Conversations changed, people commented that it felt different, there was more inclusion of both services within operational and improvement matters, and service planning and escalations were much more joined up. The tangible evidence comes from the backlog of term admission reviews, which fell from 6 months to just a few weeks, and from the self-assessment process, where the service self-assessed itself two levels higher (on a five-point scale) than the baseline position.

Evidence regarding successful culture change is weak with many saying that culture change initiatives don’t work. Our experience is different, as this case study has demonstrated. By nudging a historical cultural challenge, using carefully constructed tensions and events, positive progress was made in a very short period of time.