Safer Clinical Systems

Learning

Our learning from the programme so far may be useful for health professionals thinking about testing similar system improvements in their organisation.

Adopt a systematic approach

A new proactive and structured approach has been developed during this programme, which pulls together a combination of lean, safety and reliability methods. The tools and techniques are not new but together they create a staged approach that can be used by any healthcare organisation to make systems safer and more reliable and to manage risk

Align improvement at all levels

There is a need to work across the whole healthcare system to ensure the different parts of the system relate to each other in support of quality. Many of the improvements required may need whole system changes or multiple approaches at different levels of the system.

Culture and relationship changes are required, as well as technical

Creating a culture of safety requires attention not only to the design of tasks and processes, but to the conditions under which staff work, how they interact with each other and how teams are trained to participate in the quest for safer patient care.

The link between unreliable systems and safety

We know that safety cannot be achieved when unreliable systems exist. However, the relationship between system reliability and specific forms of patient harm is often indirect, has many factors and will take time to demonstrate.

Engage, motivate and involve staff

A pro-active approach to patient safety is needed. In order to build and sustain capacity in improvement methods we must develop expert staff networks with the skills and enthusiasm to push forward continual improvement.

Work across organisational boundaries

Working across organisational boundaries provided excellent opportunities to identify safety issues and build better relationships to facilitate improvements. However, there needs to be clearly defined parameters for each project to ensure that the next steps are manageable and rewarding.

Leadership and direction is vital

Sites experienced more sustained results when work was aligned with existing strategy and improvement activity. The involvement of senior clinicians and leaders to support teams and to enable change and innovation within the organisations is also pivotal.