Culture eats glitter for breakfast

This is article thirty-three in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

Jane was driving home from Betavets and thinking about the interview she had just been to. She wondered why she felt so pleased.

Jane almost didn’t go. She had had an interview at Alpha Vet Hospital yesterday and thought no one else could possibly compete with what they had to offer.  

Alpha was in a brand-new purpose-built premises, with state-of-the-art kit everywhere.  She was almost dazzled by the shininess!

She had come home desperate to get the job and really nervous in case she didn’t. They had told her there were other excellent candidates still to interview.

Betavets was in a converted house premises, and needed a bit of updating. It wasn’t in the same league as Alpha, but her tutor had told her they were very supportive of new graduates.

Her mother persuaded her to go anyway, saying it would at least be good interview practise.

Now here she was driving home and imagining herself working at Betavets!

What was different?

Everyone had been very nice to her at both practices, but at Betavets she noticed that they were all really friendly and polite to each other. There was just a lovely atmosphere about the place; the vets were offering to make the nurses a brew as they were busy, and everyone helped with cleaning up too. It was difficult to describe.

Jane had come away from Betavets after her brief visit with the impression that the practice had a lovely atmosphere and a good culture. What had given her that gut feeling?

What is practice culture?

Braithwaite et al 2017¹ define practice culture as “the way we do things round here" and as a group of attitudes, beliefs and behaviours that team members share.

In practices with a positive culture, team members are civil to each other, they support trainees and new team members. These practices also have a positive approach to care emphasising learning from everything and continual improvement².

So, what were the signs Jane had observed? They were pleasant, civil, and obviously had respect for each other. They listened to each other and cared how their colleagues felt. One of the other things that Jane noticed about the team was their relaxed body language. They seemed comfortable around each other, and made good eye contact with each other and with her. These micro behaviours put Jane at ease.

Incivility not only makes for an unpleasant work environment for team members but also has a direct impact on quality of care for patients³.

Let’s look a little bit more into what Jane had noticed.

She had asked how practice meetings worked. Alpha had impressive journal clubs but the nurses had told her these were for vets only and they couldn’t attend (something which obviously bothered them).

The Betavets team explained that the practice shuts (apart from emergencies) for an hour or so every other Friday. The team has lunch together and afterwards, everyone gets together and has a jolly good chat about everything that is going on in the practice. They are all encouraged to bring their ideas along.

At Alpha while looking round she heard a surgeon being rather short with an intern. There was a bit of a tense atmosphere in the theatre.

She had asked both whether they measured their outcomes, an idea from their Quality Improvement lecturer to see if they were open to making changes. At Alpha the Clinical Director told her they were confident they always provided gold-standard care and most of the vets had multiple further qualifications.   

At Betavets the receptionist told her the vets always wanted to do the best job so they looked at the results of neutering. They had been worried about a few post-op infections, but now they submitted their data to the National Audit for Small Animal Neutering for benchmarking. They also shared the results with the whole team, including reception, so they could discuss it with clients.

But the real clincher was when the one-year qualified vet, Jim, told her how brilliant the Betavets team had been after he had dispensed the wrong tablets. They had reassured him that these things happen but they would all learn from it together. They discussed it as a team and didn't blame him, instead looking at how to improve systems in the dispensary.

In a good practice culture, blame is replaced by the understanding that errors will occur and should be discussed. The focus is on looking at ways to improve systems rather than blame individuals. Colleagues who make a mistake or are involved in an adverse outcome are supported, helping them to grow professionally.

Research in veterinary practice, however, on patient safety culture suggests blame is still common and communication is still based on hierarchy in some areas⁵.

Betavets had shown itself to be open to many Quality Improvement (QI) activities; they measured what they did and were open to making improvements. All team members could input into practice meetings and their ideas were listened to and respected.  

QI and patient safety activities nourish practice culture by allowing team members to talk openly about their concerns, accept that we are all human and errors are inevitable, and encourage teams to work closely together⁶.

By the time Jane got home – she had decided. Betavets it was then! Her mother was very happy and couldn’t resist a small “I told you so!"

Checklist: What you can do next

• Culture in a practice is continually shaped by the interactions that we have with one another. Read our QI Feature 'Team culture in veterinary practice - why its essential for success' to understand the relationship between organisational culture and improving aspects of work.
• Listen to 'Incivility and the impact on patient care' where Dr Laura Playforth and Pam Mosedale discuss the evidence suggesting incivility can increase the chances of errors occurring, and the knock-on impact to the whole team, as well as patient care and outcomes.
• Read our previous QI Feature 'Good practice culture - great job satisfaction' to see how a civil work environment can help reduce errors, reduce stress and foster excellence to the benefit of individuals, teams and patient care.
• Access free CPD in the QI Boxset Series 6 'Learning from everything - Significant Event Audits and root cause analysis'.  This will teach you about the tools available to help look at errors and foster a learning culture in practice where everyone feels empowered to speak up in a safe environment. The QI Boxset is available in bite sized episodes to help you learn about Quality Improvement in a way that suits you best.
• Evidence-based veterinary medicine (EBVM) has the potential to improve clinical outcomes, increase confidence in decision-making, and contribute to an atmosphere of cohesion and support among veterinary teams. To find out how you can incorporate EBVM into your daily practice, access free CPD with the EBVM for Practitioners course. 
• Help support improvements in patient care by submitting your neutering data to the National Audit for Small Animal Neutering (NASAN), a simple audit where practices share their data anonymously to establish UK benchmarks in post-operative complication rates for neutering of small animals.

References

1. Braithwaite, J. et al. (2016) Association between organisational and workplace cultures, and patient outcomes: systematic review protocol. BMJ Open, 6 (12) https://doi.org/10.1136/bmjopen-2016-013758
2. How doctors in senior leadership roles establish and maintain a positive patient-centred culture (2019) [General Research Council] [online]. Available from: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/how-doctors-in-senior-leadership-roles-establish-and-maintain-a-positive-patient-centred-culture [Accessed 10 January 2024]
3. Riskin, A. et al. (2015) The impact of rudeness on medical team performance: A randomized trial. Pediatrics, 136 (3), pp. 487-495 https://doi.org/10.1542/peds.2015-1385
4. Katz, D. et al. (2019) Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety, 28 (9), pp. 750-757 https://doi.org/10.1136/bmjqs-2019-009598
5. Turner, M. (2017) The use of a modified medical safety culture assessment tool to investigate veterinary patient safety culture in small animal practice. Master Thesis, University of London
6. Mosedale, P. and Turner, M. (2022) Quality Improvement for patient safety and a better practice culture. The Veterinary Nurse, 13 (4), pp. 156-161 https://doi.org/10.12968/vetn.2022.13.4.156

About the author 

Pam Mosedale BVetMed MRCVS

Pam qualified from the RVC in 1979 and worked in mixed practice for the first part of her career, then was a partner in a small animal hospital for 17 years.

Pam joins the RCVS Knowledge QIAB as the Chair of the Board, having had extensive involvement with the college. She was a Practice Standards Inspector from the beginning of the BSAVA practice standards scheme and continued with the RCVS, becoming Lead Assessor from April 2015 till October 2020. She welcomed the increased emphasis on quality improvement and clinical governance, clinical effectiveness and audit in the new scheme.

Pam is editor of the BSAVA Guide to the Use of Veterinary Medicines and an SQP assessor for AMTRA. 

Pam first got involved in clinical governance when on BVHA council when she started to look into whether clinical audit could be applied to veterinary practices. She wrote the first article published in the UK on clinical audit in veterinary practices in 1999.

Pam has spoken at BSAVA Congress, BVNA congress, SPVS Congress, BEVA clinical audit workshops, CAW TP conference and on many RCVS webinars and CPD courses about clinical governance, clinical audit and Quality Improvement.

Pam is passionate about QI becoming part of the normal working day for veterinary teams and contributing to a just learning culture in practice. 

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