Closing the gate before the horse bolts: a new approach to patient safety

In the 12 years since the establishment of the National Patient Safety Agency, there’s been concerted effort to improve patient safety, largely through the reporting of harm incurred during healthcare. Despite this work, it remains unclear whether care is any safer today than it was in 2001.

Part of the reason is that we don’t know whether low rates of reported harm are due to underreporting, luck or design. This is of particular concern in the wake of the report of the Public Inquiry into Mid Staffordshire NHS Trust and an increasing public concern that unsafe care can continue in a heavily monitored and measured NHS.

Now is the time for a stepwise change in how we measure the presence of safety. In order to know whether care is safe, we need to consider what actually contributes to patient safety and then how we might measure it. High quality care is dependent on having safe structures and safe processes that support good outcomes: we need to have good measures of these structures and processes to predict current and future safety, as well as having measures of outcomes that tell us how safe care was in the past.

To date, most of our efforts have focused on measuring the outcomes, such as infection and pressure ulcer rates or the number of deaths and falls within a given hospital. Our Lining Up research has shown that even apparently straightforward measures such as these can be problematic, with different working conditions leading to different interpretations of the criteria for calculating the rates. We are continuing to explore how this can be made more reliable.

At the Health Foundation, we believe that the time is now right to move to more actively designing and managing patient safety (see our latest newsletter on the subject). Measuring proactive approaches, however, remains a challenge as measuring a non-event (the absence of harms) is not an option – we need a new approach. We’re running a number of programmes, including our Safer Clinical Systems programme, to test out how this can be done in practice.

We also recently published a report by Charles Vincent, Susan Burnett and Jane Carthey that we hope will help to start a discussion about the way we know care is safe. The authors have proposed a framework that suggests five questions that need to be answered before we can be confident that care is safe by design:

• Has patient care been safe in the past?
• Are our clinical systems and processes reliable?
• Is care safe today?
• Will care be safe in the future?
• Are we responding and improving?

The authors explore the background to each of these questions and how these questions might be reframed into measurable concepts. We are sharing this framework widely and seeking feedback through a structured survey on whether it is comprehensive and how it might be used in healthcare services. The report and the feedback, together with a number of other activities, are helping us to develop our thinking in this area.

I hope that our new resource centre on patient safety, which has just launched, will also help with spreading a more proactive approach. It aims to help practitioners and mangers looking to promote safety management and has a particular focus on safety in diabetes care and falls (more areas of care will follow). As well as learning from our own work, we’re also pulling together material from a range of other UK and international sources. We want it to be a valuable tool for those who feel as strongly about the need to improve patient safety as we do, so do let us know your thoughts.

Finally, we're opening a new round of our Closing the Gap programme in early June with a focus on patient safety. We have £4 million on offer to support up to nine project teams to implement and evaluate tested, evidence-based patient safety interventions at scale. Keep an eye out for developments or sign up to receive alerts of new programmes to get involved in.

We’re reviewing our work around patient safety because, ultimately, we have to change how we think about patient safety if we’re going to continue to make improvements. It’s simply not enough to have systems in place for when things go wrong, we need to look much earlier on in the care pathways.

Elaine is an Assistant Director at the Health Foundation