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A turning point for patient safety?

Jo Bibby
Jo Bibby
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Fifteen years ago I was involved in developing a performance assessment framework for the NHS – an attempt to provide the public with a rounded analysis of their local NHS bodies. At the time, we were advised by Don Berwick to include a domain on patient safety alongside clinical effectiveness, health outcomes, access and efficiency.

The response from the 4th floor of Richmond House was that we couldn't possibly, as to do so would be tantamount to saying the NHS was unsafe! So, when reading all the coverage this morning about the Secretary of State for Health making so public an announcement of a raft of patient safety measures, there is no denying we have come a long way.

The speech, which will be symbolically delivered at the Virginia Mason Medical centre in Seattle – a world-recognised leader in safety and quality – reflects a subtlety of understanding of the safety agenda. However, as we know to our cost, good ideas poorly implemented too often lay the ground for tomorrow's challenges. So how can we ensure that these ideas are taken forward in the spirit intended?

Hunt makes a strong argument for the financial as well as the moral case for improving patient safety. Harm to patients costs. It costs NHS budgets to deal with the immediate and longer term consequences. It exacts an emotional cost on patients, families and staff. Our Flow, Cost, Quality work supports this analysis but we need reform to our payment systems if we are really going to incentivise safe care. Payment for activity rather than outcomes does not reward proactive care. Too often, vulnerable people end up in hospitals at greater risk to their health and well-being, rather than being adequately supported in the community.

Recognising that safety depends on the genuine bottom-up involvement of everyone who works in healthcare, we hear that Jeremy Hunt is launching a safety movement – a 'grassroots safety insurgency which will seek out unsafe care, confront it and fix it'.

We all know that patient safety can't be achieved from Whitehall or from the boardroom. However we also know that it can't be achieved without them. A common factor in the many infamous cases of avoidable harm are people who could see what was going wrong but who weren't supported to act. So yes, we need a grassroots movement but we also need leaders who actively support a safety culture.

Hunt highlights how learning from mistakes and near misses has been central to the improvement seen in other safety critical industries. The greatest injustice we can do to patients that are inadvertently harmed is not to learn. Yet this requires a dynamic system of learning and action, not a bureaucratic process of reporting. Recognising that higher levels of reporting are indicative of a safety culture is a step in the right direction, but this needs to be coupled with empowering staff to fix problems, not just report them.

Too often harm to patients has been compounded by the system closing ranks and failing to provide timely and adequate information and explanation. The introduction of a statutory duty of candour will place a legal duty on organisations to tell patients when they have been harmed.

No-one could argue with this in principle, but the real improvement in patient experience will come when there is a commitment to openness, not simply a compliance with the law. Such a commitment needs to start when care commences, not when things go wrong. This requires much more emphasis on providing patients with the information, support and opportunities they need to make informed choices about their own care and treatment, enabling them to understand fully the risks and benefits.

The recognition of the pivotal role data can play in supporting improvement and the continued drive to make data public and transparent is welcomed. However, as our report Measuring and monitoring safety showed, measuring how harmful care is isn't the same as measuring how safe it is. Measuring and reporting harm is necessary, but it only tells us about what care was like in the past. Critically it doesn't tell us whether an absence of harm is by luck or design. Genuinely informing the public requires greater use of measures that are predictive and anticipatory.

Hunt will talk of a 'turning point' for the NHS in patient safety. Arguably, given the work and effort applied across the NHS to improve patient safety following the publication of An Organisation with a Memory in 2000, this is less of a turning point and more of a shift into third gear.

We need to avoid stalling the journey by turning it into the pursuit of targets rather than the pursuit of safety – setting a goal to reduce avoidable harm could be seen simply as a ploy to get a headline. But we've learnt the hard way the toxic effect targets can have in healthcare – we need to be convinced that politicians have also learnt this lesson.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF





 
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Your final paragraph captures the dilemma we face. Complex systems require sophisticated management. Over-simplification of targets often results in perverse outcomes. But politicians like soundbites and simple messages, and ultimately they carry the can for the system.

It is all very well to say we must pursye safety not targets but how can you measure "safety", an abstract concept?

I suggest that the answer lies in Joseph Juran's famous statement " All improvement happens project by project - and in no other way."
Dear Tim,

Thank you for your response. Safety is a difficult thing to measure, given it is made up of so many consistent parts. Charles Vincent and colleagues tackle this in their report, the measurement and monitoring of safety (link below). It suggests measuring safety across five different dimensions. We will be publishing some supporting material on this shortly, as well as testing the framework developed by the researchers in a major new programme to be launched later in 2014.

http://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety/
Thank you very much for an eloquent piece. As you rightly pointed out leadership is required to implement the patient safety agenda but you also mentioned the grass roots implementing this change. The frontline staff must be empowered/allowed to innovate and implement patient safety solutions and the 'leadership', whether local or national has to have trust in them and allow them the freedom. We have a saying we use here in Exeter in our patientsl safety work; 'cultural change needs to be led from the top but culture is organic and organic things grow from the bottom up'.
No mention of the underlying problem which is an acute shortage of staff.
It is an unfortunate, but inevitable, fact that pressure of work on the frontline workforce in the NHS is bound to lead to care procedures being rushed or overlooked.
Meal times are a classic example, staff are too busy to help patients. Fluid intake charts for vulnerable patients are a thing of the past. Falls occur because there are no members of staff available to accompany the patient to the toilet.
These examples are the tip of the iceberg.
Please address the staffing levels as a matter of urgency before the problem becomes chronic.
I think that, in the main, frontline staff are dedicated and caring; we owe it to the patients to ensure there are enough of them.
Carol,

All these things you state are true.
And they are only the tip of the iceberg - true.

When I trained, convalescing patients helped the staff with small tasks like giving out drinks and fluid charts. Now, they are prevented from helping, because of Health and Safety, I believe.

And yet, it was part of the recovery process - being able to do small jobs again, being able to help overworked nurses - was such a pleasure for patients.

Through aiming for safety, rather than patient satisfaction, I would argue that we have let our patients down very badly.
And created problems.
Good piece.

Airlines haven't become safer by telling relatives that a plane has gone dowm, though.

They have become safer by managing risks proactively and by applying human factors. These are known techniques. They must be applied to healthcare. Otherwise all the exhortations and good aspirations in the world will make little difference.
Unfortunately ministers are very good at telling you what they are going to make happen, but in reality this does not usually come up to the standard they promise

Staff numbers are important in giving good and adequate care.

In my opinion it is time hospital management was handled by those who know the profession and not some muddle headed management team
Thought provoking piece. Reporting of incidents has been driven from the top in an attempt to 'improve' and understand safety . There has been little effort to see how much learning really takes place and how much improvement has been achieved.

Many frontline staff are disenfranchised as a result. We need to be actively looking at and assessing risk and supporting small scale changes of improvement suggested by staff. They need to feel included and valued, not preached at from the top corridors or beaten with a stick by the media.

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