Safer Clinical Systems

Rationale

We need to make healthcare systems more reliable. People need to be sure they will receive the same high standard of care and safety wherever and whenever they access healthcare services.

Improving patient safety has always been a priority for the UK health services. However, high profile failings such as those idenfitied as part of the review of care at Mid Staffordshire have added public and political pressure. This focus on safety was reflected in the Next Stage Review for the NHS, and the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) programme also aims to deliver improvements. Despite a change in Government and planned budget cuts we are hopeful that the drive to ensure safe and reliable systems of care in the NHS will remain as important as ever.

A strong evidence base

To support our work to improve the safety of care, the Health Foundation commissioned important research into the reliability of NHS healthcare systems. This provided groundbreaking evidence of the extent to which clinical systems and processes fail, and the potential this has to lead to harm.

The research identified a huge variation in the reliability of care across the UK, with vast differences in practice between teams, services and organisations. Common problems were found to be repeatedly creating risk of harm, including errors in prescribing, a lack of information when making clinical decisions at handover points and key equipment being unavailable.

Researchers highlighted what they saw as the underlying causes for these failures:

• lack of feedback mechanisms, both for individuals and systems
• lack of standardisation
• poor communication, both written and verbal
• overly complex processes
• staff acceptance of poor systems or lack of consistency
• lack of individual ownership of issues.

The research provided much needed evidence on which to base future improvement work. It also made it clear that there was a need to make systems and processes more reliable across the NHS in order to make care safer for patients.

About the programme

The Safer Clinical Systems programme is at the heart of the Health Foundation’s work to improve patient safety. We believe that by addressing the current variation in healthcare processes and by developing safer systems and culture, we can reduce avoidable harm.

Launched in October 2008, the programme is testing and demonstrating ways to increase reliability in systems of care and reduce the number of failures in clinical systems. This will provide vital evidence and learning which can be shared across the wider health service.

Developed as a five-year programme, it builds on the insights and learning gained from the Health Foundation’s Safer Patients Initiative, which looked at interventions at the point of clinical care. Safer Clinical Systems takes a wider view, looking at the entire system of care in order to improve safety.

Why a systems focus?

When something goes wrong with the care of a patient, it is tempting to look for an individual to blame. However, the fault rarely lies with just one person. More often than not it is the system that is flawed.

Human error has to be understood in the context of a wide range of system factors such as available technology, human errors, staffing levels, hours of work and workplace distractions. By taking a systems approach, healthcare staff can start to define which parts of a clinical care process might be compromising safe care.

Sharing the learning

Phase two of the programme will begin in 2011, supporting up to eight healthcare organisations to implement and test the systematic approach developed in phase one. The approach provides a structured way of looking at an unreliable system and deciding how it can best be improved.

It involves mapping the clinical pathway, understanding how it is influenced by the wider organisation/system and then pro-actively identifying and diagnosing risks before harm can occur. Once this has been done, solutions are implemented and tested using traditional quality improvement methods such as Plan, Do, Study, Act (PDSA) cycles.

We have chosen two widely applicable areas in which we will test this approach – handover of clinical information and prescribing. The teams involved in the initial projects will continue to play a key role as the programmes continue, building an infrastructure for long term sustainability as the new approaches spread across the UK health services.