Pursuing the continuous improvement of patient safety

Health care is a hazardous business. It brings together sick patients, complex systems, fallible professionals and advanced technology. It is classed as a ‘safety-critical industry’, where errors or design failures can lead to the loss of life.

We all want to make care safer in our health service. But it’s complicated. There are so many things that can go wrong, and just as many that have to go right to deliver reliably safe care.

The search for the secret ingredients to improving patient safety

In 2004, the Health Foundation launched the Safer Patients Initiative (SPI) – the first large-scale safety improvement initiative in the UK. 24 hospitals were supported to reduce patient harms such as MRSA and surgical site infections. It was ground-breaking in its scale, scope and approach.

An independent evaluation found that every site improved their performance on at least half of the selected measures. The ‘problem’ was that many of the comparison sites also improved at the same time, due in large part to a range of concurrent national policy initiatives.

This wide-scale improvement was cause for celebration, not commiseration. SPI deepened our understanding of the complexity of safety improvement.  However, it had been hoped that the programme would unearth the ingredients to successful improvement in patient safety.

Ever since then, the Health Foundation has thrown itself into understanding these ingredients, supporting hundreds of frontline teams, researchers and fellows to test ideas to make care safer. In 2015 alone, we are supporting and funding 27 improvement projects specifically focused on patient safety; many more will hopefully deliver indirect safety benefits.

Taking our collective learning forward

This month we published a new report – Continuous improvement in patient safety – to bring together for the first time what the Health Foundation has learnt from this journey.

The report is about looking forward, as much as backwards. In it, we make the case for building on the successes of the past decade in order to make progress on the most intractable safety problems. We think this can be done by changing how safety is:

• Understood: by monitoring the conditions that lead to harm to patients, not just the harm itself
• Improved: by using new opportunities to address system-wide safety problems
• Managed: by understanding the risks in services, not seeking reassurance that organisations are safety-compliant

What is the case for change?

The past decade shows a mixed picture of safety in the NHS. For instance, while some health care associated infections, such as MRSA, have dramatically reduced, others like E.coli have actually risen and are continuing to rise. This phenomenon is explored in a new report – Infection prevention and control: lessons from acute care in England.

Our experience over the past decade also illustrates the nature of the problem. For instance, there are so often limits to what frontline teams can address on their own. Sometimes this is because solutions require organisation-wide change (such as addressing inadequate IT), or because they require change in other organisations (such as adopting new practices among care home staff). This problem was illuminated in our Safer Clinical Systems programme.

What can be done?

1. Practical improvements at the front line can be done more systematically, based on what we know works. This knowledge is summarised in our checklist for safety improvement. Case studies showing how this has been done are also presented throughout our report. 
2. Senior leaders can take steps to create an environment where such practical improvements can flourish. This involves building an organisational strategy for safety, creating a positive safety culture, and improving how safety is measured and monitored. These are all difficult, long-term ambitions; but we have ten resources to support leaders in the NHS to begin, or continue, this journey.
3. The system should be designed and operated in a way that better recognises the positive, and negative, effects that national policy can have on the front-line. We set out a vision for an effective system for safety improvement, which we ask every UK body with a regional or national remit for patient safety to assess their activities and ambitions against.

What might the future look like?

In our view, patient safety will need to be networked, proactive and seen more from the patient’s perspective to make progress over the next decade.

But perhaps the future is closer than we think. In this newsletter, we feature work from grant holders and fellows from our leadership programmes who are embodying these principles:

• The Making Safety Visible programme in Greater Manchester is bringing together senior leaders from providers, commissioners and the local authority to improve safety across the entire health economy.
• The Closing the Gap in Patient Safety programme is supporting many cutting edge projects, such as at Hertfordshire Partnership NHS Foundation Trust, where techniques are being used to identify hazards in mental health care before they lead to harm to patients.
• An important new book from Charles Vincent and Rene Amalberti, to be published this winter, recasts safety from the perspective of the patient and as the management of risk across the whole health care journey.