Safer Patients Initiative
In brief
Our Safer Patients Initiative ran from 2004–2008. It was set up to test practical ways of improving hospital safety and to demonstrate what can be achieved through an organisation-wide approach to patient safety.
Why?
Ensuring safety and reliability in care for the one million people who use NHS services every day is a massive challenge for our health service. While the majority of people are treated without incident, it is estimated that one in 10 people admitted to hospital in the UK will experience some sort of harm during their stay.
In nearly every case the problem is caused by unreliable healthcare systems and processes.
Background
A million people use the NHS each day and the vast majority are treated without incident or threat to their safety.
However, it is estimated that one in 10 patients admitted to hospital will experience some form of harm during their stay. In half of those cases the harm could have been avoided. In nearly every case the problem is caused by unreliable healthcare systems and processes.
We know we need to make healthcare systems more reliable. People need to be sure they will receive the same high standard of care and safety whichever part of the NHS they access. But healthcare is complex and there are no quick fixes to improving patient safety.
About the Safer Patients Initiative
The Safer Patients Initiative was the first major improvement programme to start to address the issue of patient safety in the UK. It was complex and large-scale in its approach to improvement, recognising that change needed to take place across whole organisations and systems rather than focusing on individual incidents.
The programme had ambitious and stretching goals to improve safety. Although it did not achieve the level of organisational impact hoped for within the timeframe of the programme, it did have a significant effect and influence on participating hospitals and their staff, on patient care, and on the wider NHS system.
The need for large-scale improvement
By 2004, seminal publications, including 'An Organisation with a Memory' and the report on the Bristol Royal Infirmary inquiry, had begun to raise the profile of patient safety within the NHS. However, there was little concerted activity to address issues of harm and safety at an organisational level.
At a national level, NHS agencies had traditionally focused on the retrospective reporting of incidents. Hospital managers focused on risk management and assurance, while their boards received little information beyond formal complaints relating to the safety of care in their organisations.
Safety was largely subsumed within the clinical governance agenda and deemed the responsibility of individual clinicians rather than seen as an organisational issue.
It was obvious that a more proactive approach to improving patient safety was needed.
Small pockets of good practice existed but we recognised a major gap in the knowledge and skills required to achieve significant change. We set up the Safer Patients Initiative in order to test ways of improving patient safety on an organisation-wide basis within NHS hospitals.
Delivering the programme
The first phase of the programme, launched in 2004, brought four UK hospitals together to test ways of preventing harm from routine care by making clinical processes more reliable. They introduced a range of interventions in particular clinical areas, with a focus on strengthening the role of executive leaders to create a culture of patient safety.
Healthcare teams worked with the Health Foundation and US-based Institute for Healthcare Improvement on ways to improve safety in areas such as infection control, preventative antibiotics for surgery and medicines safety.
In 2006, a further 20 hospitals joined the programme for phase two, which ran for 20 months. The phase two hospitals worked in pairs to take forward safety improvements, building on the learning from phase one.
‘[Safer Patients Initiative] gave us capability, confidence, courage, and a sense of “can do” that we were able to build upon. There’s a natural resistance towards change... But I think SPI’s just been such a superb model of how to go about changing a process’
Our learning
The Safer Patients Initiative has generated considerable learning. It has given us important insights into patient safety and ways to deliver improvement in this area. As our first large-scale demonstration programme it has also helped the Health Foundation to develop how we design and deliver our improvement programmes.
