Overview
Safer Clinical Systems launched in October 2008. The programme will test and demonstrate ways to improve healthcare systems or processes to systematically improve patient safety.
Healthcare is replete with avoidable harm. We have a one in a million chance of being harmed in an aircraft, yet a one in 300 chance of being harmed during healthcare. It’s an exciting time for patient safety, with campaigns now launched in the four UK nations. Still there are no quick fixes. The Health Foundation believes that new approaches are needed.
Learning from our Safer Patients Initiative (SPI) highlights the need to take a clinical systems approach to improving safety. Clinical processes and systems, not bad clinicians, are often the contributors to breakdowns in patient safety.
Building on SPI, our new programme – Safer Clinical Systems – launched in October 2008. Experienced teams from five NHS sites are working together with expert advisers to co-design the initial phase of the programme. They will design and test a range of clinical systems interventions to improve patient safety.
Why a systems approach?
Through taking a systems approach, healthcare staff can start to define which parts of a clinical care process might be compromising the safe care of the patient. These may include steps on admission, treatment and discharge of patients following treatment in hospital. The approach will highlight the steps where risks to safety can be detected and where they might be improved.
This means focusing on the clinical care of the patient, but also on the systems that support clinical care such as access to sterile supplies, test results or accurate medication histories.
Aims of Safer Clinical Systems
The programme aims to develop a set of strategies to improve patient safety building on those developed through the Safer Patients Initiative and other patient safety programmes. By testing and measuring their impact we will seek to fill the current gap in the evidence base.
We’ll develop a set of standard shared measures to demonstrate impact against. We’ll then share this knowledge and learning with the wider NHS.
Phases
Phase 1 – Co-design system techniques to improve patient safety
October 2008 – December 2010
The ‘proof of concept’ stage will design and test systems improvement approaches to improve patient safety. Five experienced teams will work closely with expert advisers to co-design and test a range of clinical systems interventions.
Each site has been involved in the development of new approaches using methods and tools that help to identify defects and system factors, and subsequently identify solutions. A variety of lean/improvement approaches, which were already familiar to the teams, have been employed, together with the adoption and testing of several safety engineering approaches.
Phase 2 – Demonstrate impact of techniques at scale
Until the end of 2012
Phase 2 will demonstrate successes and lessons from phase 1 on a larger scale. It will support up to eight UK healthcare organisations to implement and monitor the successful interventions tested in phase 1. We expect that phase 1 participants will make up an expert support faculty.
Phase 3 – Promote adoption across the NHS
Until the end of 2013
Phase 3 will aim to speed up the spread of systems approaches to patient safety across the UK. It will aim to build an infrastructure for long-term sustainability. We expect the expert faculty of phase 1 participants to continue to play a key role.
Teams
Teams involved in the co-design of phase 1
- Bolton PCT and Royal Bolton Hospital NHS Foundation Trust: Safer handovers across the health economy
- Hereford Hospitals NHS Trust: Creating safe and resilient prescribing systems
- Plymouth Hospitals NHS Trust: Design and implement a reliable handover system
- NHS Lothian: Provide the right information, at the right time, for the right patient, every time.
The teams are skilled and experienced in using systems approaches to improve services. They are expert in data collection and management, have strong senior leadership and are committed to improving patient safety.
Technical support team
Expert technical support is being provided by a consortium lead by Warwick University. This expertise is drawn from field leaders in clinical systems improvement, lean methodology, safety and reliability, human factors, industry, as well as senior clinicians from within the NHS.