"Carrying out the SCORE survey has been really beneficial; staff engaged and have shown real care for their results. The survey has given us a structured way to look at our culture at work, identify aspects that are important to our staff, and generated workable ideas to improve staff health and wellbeing."
Carrie Biddle, Therapies Clinical Governance and Quality Lead, Royal Cornwall Hospitals NHS Trust


The South West Patient Safety Collaborative has introduced a validated assessment tool for safety culture in England, using a survey called SCORE (safety, communication, operational risk, resilience and reliability, and engagement). As part of the ‘Safer Culture, Better Care’ programme, this anonymous survey gives individuals and teams a fresh perspective on their current patient safety culture. Over 10,000 staff in 122 teams have taken part in the programme, leading to improved patient safety and new ways of working.

In the NHS, the culture of the organisation and the culture of the team can have a huge impact on the quality of care patients receive and the outcomes of their treatment. Within organisations, an improved safety culture is also associated with greater satisfaction and engagement from staff. The South West Patient Safety Collaborative (SW PSC), led by the South West Academic Health Science Network (AHSN), set out to find a different approach to help health and care teams understand their culture and take steps to improve it.

The South West is the first region in the UK to use the SCORE survey methodology from Safe and Reliable Healthcare, LLC. The survey is an internationally recognised way of measuring and understanding the culture that exists within organisations and teams. It provides an overview of culture but also provides detailed feedback in specific focus areas such as communication, staff burnout, resilience, leadership and teamwork.

Aims, objectives and scope

Safer Culture, Better Care - Livewell South West teamIt is well-recognised that the safety culture in a team affects its ability to deliver safe care, improve and learn. Professor Don Berwick’s 2013 report, ‘A Promise to Learn – a commitment to act’, made a series of recommendations to improve patient safety, noting that ‘Culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.’

The implementation of the SCORE survey had two objectives:

  1. Support teams across a wide range of health and care settings to improve their safety culture and quality of care.
  2. Increase the knowledge and understanding of the role safety culture plays in the delivery of high-quality care.

While there has been considerable focus in the South West to train health and care staff on how to improve patient safety, the SCORE methodology provides a framework that helps address team culture and facilitate change.

Method and approach

The aim has been to engage as many teams as possible around the region to take part in the SCORE survey. This has included staff in all of the acute trusts in the South West, plus mental health trusts, hospices, care homes, a clinical commissioning group and GP practices, ranging in size from 12 to 400 staff. Survey results have helped teams to identify and work on improvement projects, such as admission processes and staff briefings.

Measurement plan

100 teams have used the survey. The act of surveying staff on their culture raises awareness in itself; the process of debriefing staff allows the identification of the things that are going well in a team and those which the team would like to improve. Progress can then be tracked, usually by repeating the survey at least once a year.

Results and evaluation
  • Since April 2015 to 2018 10,300 staff in 122 healthcare settings in the South West have been surveyed.
  • Over 90 staff from across the South West have been trained in interpreting and debriefing the results of SCORE surveys.
  • The SW PSC has now worked with teams in the West of England and Salford to spread SCORE and the West Midlands PSC has procured SCORE for teams in their region. Teams in the national Maternal and Neonatal Health Safety Collaborative are also being invited to take part in the SCORE survey across England. The SW PSC has provided training on debriefing to support all of these teams.
  • The Safer Culture, Better Care programme is part of a poster showcase at the International Forum on Quality and Safety in Healthcare in Amsterdam. (May 2018).
  • The ‘Safer Culture, Better Care’ programme, was shortlisted for a HSJ Award in the ‘Creating a supportive staff culture’ category, 2018.

SCORE is having an impact. One example is the emergency department at Derriford Hospital in Plymouth, which used the survey with its 250 staff, across all roles. A theme emerged about burnout and the causes of burnout and unhappiness. As a result, the department tackled staffing issues, overcrowding and lack of space, even taking their safety culture evidence to the Board. The hospital has now introduced a quality improvement slot to its twice-yearly safety days, to proactively discuss improvement methodology.

‘What was made clear by the survey was that we didn’t give staff enough feedback. So we put staff meetings into place, ensuring that we reviewed significant events and fed back on these. We introduced feedback in a more positive way – and now any member of staff will email or note if someone has done something really good and we feed this back to the individual.’

Kerry Westcott, Practice Manager, Dunster Surgery

Learning points
  • The package of support was critical and included training in organisational debriefing and culture improvement project development, using the AHSN-wide Life QI system.
  • Using local change agents was key to engaging the team at every stage of the process.
  • Having a toolkit to complement learning and improvement activity could be helpful to teams going through the process.
  • Ensuring that debriefing is part of the programme, with structured training in place, has uncovered local good practice and issues for improvement which can be specifically addressed.
Plans for spreading learning and encouraging adoption

Momentum has built both regionally and nationally. The SW PSC co-leads a national patient safety culture workstream, and other regional and national collaboratives are now using safety culture assessment. The work in the South West will continue to spread SCORE to more teams, linked to the SW PSC ‘Deteriorating Patient’ workstream and the Maternal and Neonatal Health Safety Collaborative roll-out.  Top tips for adoption:

  • The approach concentrated on the quality of the process.
  • Word of mouth and recommendation was key.
  • Awareness-raising of safety culture regionally generated interest.
  • Public and patient involvement should be part of the process. Some teams have involved patients in their debriefing or improvement planning.

Individuals leading the work within teams usually have an interest in the subject matter, which motivates their involvement and that of the team.

Start and end dates

April 2015 to present

Contact us for help and advice

Jo Pendray, Improvement Lead for Patient Safety, South West AHSN
E: joanna.pendray@swahsn.com