Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety

It’s widely recognised that organisational culture has a high impact on patient safety. However, through our maternity safety investigations it has become clear that there is no consistent approach that supports safety organisations to understand the impact culture may have had on a patient safety incident.

To support our work, and ensure that we have a holistic understanding of all elements that may have contributed to a patient safety incident, we have developed COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety). This tool has been developed by Chris McQuitty (Clinical Fellow) and Nicki Pusey (Maternity Investigation Team Leader) to provide a standardised process for our staff to articulate, analyse and feedback observations about organisational culture.  We believe the tool will help our teams to reflect the cultural approach to safety investigations within trusts.

Later this month we will be launching a pilot for COMPASS within our own investigations and in partnership with 12 NHS Trusts. As part of the pilot, our team will use the COMPASS tool as part of a thematic review of cultural observations from investigations within the pilot trusts. Findings from the COMPASS tool will be shared with trust leadership teams to support safety and cultural improvement. We will also seek feedback from trusts who are part of the trial to help determine the future value of COMPASS to trusts and its potential broader use across different healthcare environments beyond maternity care.

COMPASS has been developed based on the work of the Patient Experience Library (PEL), who conducted a literature review of avoidable harm enquiries over 10 years, including the East Kent, Morecombe Bay and Mid Staffordshire reports. The review they conducted demonstrated that poor organisational culture is a recurrent theme in avoidable harm enquiries, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers.

To find out more about the COMPASS trial, please email: enquiries@mnsi.org.uk.