Safer Clinical Systems

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, culture and ways of working, 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 began in October 2011. We are now supporting 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 (or system) and then proactively 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 programme continues, building an infrastructure for long term sustainability as the new approaches spread across the UK health services.