STEP-up illustrated patient safety acronym

Judi Ingram, Clinical Director and Chief Nurse at Aspen Healthcare did her Integrated Governance in Healthcare Communities MSc at Westminster Business School, the University of Westminster. Her dissertation project on understanding patient safety culture: qualitative insights from nurses in an acute independent healthcare organisation inspired a course of action that’s led to Aspen Healthcare being shortlisted for two major awards. We asked Judi about her research and its impact.

Judi had been working on governance for a while when she spotted the MSc. “I wanted to get the underpinning theoretical framework, meet like-minded students, and study relevant topics in a way that related to the work I was doing in clinical governance and patient safety,” she says. And the course gave her those opportunities. “Every single assignment for each module was work-based and related to an area of my practice.”

Patient Safety Culture

For her final dissertation project, Judi interviewed directors of nursing and frontline nursing staff to explore their understanding of a ‘patient safety culture’.” It’s a term that’s bandied around quite a lot in healthcare,” she explains, “particularly since the Francis report on the Mid-Staffordshire NHS Foundation Trust.

1,500 people work at Aspen Healthcare’s nine hospitals and clinics across the UK. And whilst the organisation’s record on patient safety was good, they believed they could do better. “In 2015 across our nine hospitals and clinics, we had 13 serious incidents and 8 never events – events NHS England say ‘should never happen in a safe hospital’. For instance, you shouldn’t operate on the wrong leg, because you should have the correct safety checks in place.”

“None of the incidents caused major harm to our patients. But we reasoned that if we were an airline, such figures wouldn’t be acceptable. We wanted to institute a cultural shift so that everyone understood that they were responsible for patient safety.”

A mixed understanding

After analysing her interviewees’ responses, Judi then ran focus groups with directors of nursing and frontline staff to explore the themes that had emerged. “There was as a very mixed understanding of what a ‘patient safety culture’ meant,” she says, “and I realised that to make the change we wanted to happen, we needed to make it real for staff, so they could ground it in their day-to-day practice. As part of her dissertation, Judi produced a set of recommendations for her organisation. Her recommendations covered four main areas: reporting; openness; justice and improvement, and were then developed with her Medical Director into a programme called “STEP-up to Safety”.


“STEP,” Judi explains, “stands for Spot, Talk, Examine and Prevent.”

Spot the error is about encouraging staff to identify issues of safety, and think about their individual role in that.

Talk is about encouraging a culture of reporting, a culture of openness. Spotting an error is one thing but you need the right culture that enables and encourages you to tell others about it.

Examine is about a culture of justice, looking at it in an objective way, not jumping to conclusions or scapegoating, but really exploring what the causes were.

Prevent is about creating a culture of improvement, where you put things in place to prevent the incident happening again.”

The programme has four levels. “The first level involved our medical director and I going out to all our staff across the UK – and doing a ‘roadshow’. We’ve managed to work with more than 1000 of them now. We do an hour-long session to get them thinking about their individual roles in a patient safety culture and the factors that can impact on this.”

The sessions start with a showing of Aspen Healthcare’s short animated STEP-up film.

STEP-up – the patient safety movie

“It’s a bit Pythonesque,” says Judi. “If you talk about patient safety culture in the usual way it can sound like managerial jargon. So we took a bit of a risk and produced a film showing the opposite of what you should do, before introducing the STEP-up acronym. It has really grabbed people’s attention in a way that standard ‘this is what you have to do to keep your patients safe’ instructional videos don’t.”

still from Aspen video saying "avoidable error causes more deaths than breast cancer, and aids, and road traffic accidents added together
Still from the animated film “How to harm patients … and how not to”. Watch at

After showing the film, Judi and her colleague take participants through the four STEP-up steps, encouraging them to think about their individual contribution to patient safety.

“We get them to explore what it means for patients, what it means for them individually, what it means for their team and what it means for their environment. And we ask them to make a commitment to safety and STEP-up. Every member of staff was then given a STEP-up pedometer and asked to STEP-up to safety (and get healthier!).”

One of the themes that came out of Judi’s research was about managers’ behaviour. “It’s great if you speak up about an error,” she says, “but what if your manager has a closed door, is not that approachable, and won’t listen to you? You’re not going to be able to improve patient safety much then!”

Managerial behaviour

STEP-up Level 2 is a four-hour session for team leaders and managers, or anybody in a supervisory position managing staff. “It’s about safety leadership: getting managers to look at what they can do to promote and enable a patient safety culture.”

This will be followed up with Level 3, which Aspen is about to launch. “Level 3 is for clinical staff who deal with patients in critical situations,” says Judi. “So, for example, those who are working with patients who may deteriorate. People working in operating theatres, high dependency units, and, on the wards. This will involve clinical simulations, looking at using STEP-up to manage crisis situations, so we can ensure we work effectively as a team when a patient deteriorates or during a safety incident: we spot it, we talk about it, we work out why it happened and we put something in place to ensure it doesn’t happen again.”

To ensure the programme is sustainable, Judi and her colleagues are now training STEP-up Ambassadors in each location. “The roadshow was great, but because Aspen Healthcare has clinics and hospitals in so many different parts of the country, we need ambassadors to take ownership of the programme for each location. They will deliver the STEP-up content in our staff induction programmes, and ensure the programme is properly embedded in everyday practice throughout Aspen.”

STEP-up patient safety freebies
STEP-up freebies

The Impact

“What’s really exciting,” she adds, “is how enthusiastic everyone’s being about STEP-up. It’s created a real buzz – people have made STEP-up boards, they love the STEP-up freebies we gave them – pads, highlighter pens, hand wash gels, mugs and, the STEP-up pedometer! And the Care Quality Commission has cited the programme in their recent inspection reports. And,” Judi adds, “I wouldn’t have been able to do it without the master’s degree: I wouldn’t have had the time, or the opportunity to do the initial research in a really robust, methodical way.”

“And our safety data have improved dramatically. In one year, we’ve halved the number of Serious Incidents and Never Events, even though we’ve treated 15% more patients, our reporting rates are up by 25%, but those with any harm have reduced.”

The next challenge is to extend the programme to Aspen Healthcare’s Consultants.

“In the independent sector,” Judi explains, “our consultants work on a sessional basis and are self-employed. As they’re only with us on a part-time, ad hoc basis, there’s a logistical challenge to this. But their buy-in is crucial.

“It can be really hard for a healthcare assistant, a junior staff nurse, or even a manager to say to a senior Consultant ‘can you stop for a minute? Can I just check what you’re doing?’ or, even, to say ‘actually, what you’re doing isn’t quite right’. That’s a really difficult conversation, and our aspiration is for everyone involved to feel comfortable with it, and for our Consultants to thank staff members for double checking what they’re doing and keeping our patients, and ourselves, safe.”

Award shortlists

Aspen Healthcare’s STEP-up programme has been shortlisted for the British Medical Journal’s Education Team of the Year Award and in the Changing Culture category of the Health Service Journal Patient Safety Awards.

3 tips for implementing culture change

Judi offers three tips for an organisation implementing culture change

1. Keep it meaningful. It needs to be meaningful to all staff, especially frontline staff. In any culture change, staff need to be involved, understand it, and see their role in it.

2. Enthuse staff. Develop some energy around what you’re doing. Come up with something that’s a little bit ‘off the wall’, that they haven’t seen or heard before. It’s important that it’s something they can then relate to.

3. Feedback & reward. Ensure staff are thanked for their contribution, and get to see the results and impact of their input.

portrait of Judi Ingram
Judi Ingram
is Clinical Director and Chief Nurse at Aspen Healthcare. She is also a trustee of East Anglia’s Children’s Hospices (EACH), Chair of the Department of Health Independent Sector Nursing Advisory Group, Professional Specialist Advisor for the Care Quality Commission, and sits on the Clinical Advisory Group and the Management & Leadership Forum Steering Committee of the Royal College of Nursing.


Governance and patient safety courses at Westminster Business School

Although the MSc Judi took is no longer running, we will soon be offering short courses in governance and patient safety. To find out more and register your interest, please contact Joy Tweed.

Leave a Reply

Your email address will not be published. Required fields are marked *

University of Westminster
309 Regent Street, London W1B 2UW
General enquiries: +44 (0)20 7911 5000
Course enquiries: +44 (0)20 7915 5511

The University of Westminster is a charity and a company limited by guarantee.
Registration number: 977818 England