Stephen Ramsden on cultural revolutions

Workplace culture is often described as a set of attitudes, norms, beliefs, practices and rules that influence behaviour. More colloquially "it's the way we do things around here".

This mix of history, folklore, tradition and unwritten rules is partly why it is so difficult to influence an organisation's culture. Another factor is that in healthcare organisations there is not just one culture, there are many. The way we do things around here in the operating theatre may be very different from the way we do things around here in paediatrics. But change the culture(s) we must if we are to dramatically improve service quality and safety.

Staff inter-relationships, the means of communication, the rules and policies, the formal and informal interactions and power make up the human factors influencing cultures. This in turn affects patients' experience, safety and outcomes. Nevertheless big themes are important in setting the direction of travel.

My own trust has a transformational vision of "leading the NHS in patient safety". I remember working hard in the 1990s on a "blame-free" culture, reinforcing it by actions to protect staff who had made a genuine mistake. Some people thought that went too far and, while it made incident reporting more possible, it did not hold people to account for their actions.

A "just" culture focuses on giving appropriate responsibility to people and systems. Flagrant disregard of hand washing is an example of individual responsibility, and in some places is now a disciplinary matter. System failures need system solutions.

There are tools and techniques to address the interaction between individuals and teams. In my trust a healthcare assistant successfully challenged an obstetrics registrar and averted an unnecessary caesarean section. Such examples should be celebrated and communicated around the organisation.

But how will we know if our changes improve safety and patient experience? Patient safety culture surveys enable us to establish a baseline and monitor improvement. These should be fed back to departments/directorates specifically so that they can focus on improving their own microcosm and learn from other areas.

So don't be surprised if, despite the leadership demonstrating its will to transform quality and safety, it is in the execution that the greatest challenge is faced. This is partly because we have often not won the hearts and minds of staff and partly because we have not paid enough attention to the cultural barriers to change at the micro-level where the real behaviour change may need to take place.

We know, after all, that culture eats strategy for breakfast.