A summit for safer care

Last April, at the BMJ International Quality Forum, we launched one of our most popular reports to date.

It flew off our stands, all copies were gone by lunchtime on the first day and repeat orders had to be brought in every morning throughout the week. It was even rumoured that if you wanted to be sure to get a copy you needed to camp out at our stand the night before. Online, it was our fastest downloaded research report and generated international interest across the patient safety community.

The report was Charles Vincent et al's The measurement and monitoring of safety.

So what was it about this report that generated so much interest?

For many of the people I have discussed it with over the past five months, it was that the ideas presented genuinely shifted their mindset. The report illustrated that, to date, most of the focus of measurement around patient safety hasn't in fact been measuring 'safety' at all, it's been measuring 'harm'. Not only that, it's been about measuring past harm, harm that happened last year or last month.

While this is important information to have, it's like trying to drive a car looking through the rear view mirror – it tells us where we have been, but gives us no clues about what is round the corner.

Measuring safety, rather than harm, requires us to engage with information that will give us insight into what is currently happening and what is likely to happen. Only when we have this knowledge can we respond effectively to prevent patients from being harmed in our care.

Vincent et al draw on insights from other industries faced with the need to protect lives to identify five themes integral to an effective system for measuring and monitoring safety:

• Past harm: this encompasses both psychological and physical measures.
• Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems.
• Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis.
• Anticipation and preparedness: the ability to anticipate, and be prepared for, problems.
• Integration and learning: the ability to respond to, and improve from, safety information.

This framework has resonated across the NHS. It is already finding its way into the thinking of organisations and leaders at every level of the system. However, Charles and his team would be the first to say that it needs further testing and debate.

This is why, today, we are bringing together over forty leading thinkers, practitioners and policy makers from across the UK to consider in depth this approach to measuring and monitoring safety. We’ll be sharing some of the insights over the coming months.

The last year has been salutary for the NHS. The Francis and Keogh reports have highlighted the significant challenges we face to provide the quality and safety of care we would all want for ourselves and our loved ones. The Berwick report offered hope and practical actions to achieve this.

Shifting from a focus on past harms to measuring and monitoring safety at every level of the system will be an important element in transforming the quality of care in the NHS and today's summit will, we hope, bring us closer to this being a reality.

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