Data and patient safety - are we asking the right questions?

It’s been quite a year in patient safety policy. We have seen:

• Don Berwick conclude a review of patient safety in England recommending the use of  local measures to act as ‘early warning signals’ for safety problems
• Bruce Keogh investigate 14 trusts with persistently high mortality rates
• children’s heart surgery at Leeds General Infirmary suspended (then re-opened) due to reportedly high mortality rates
• the government respond to the Francis Inquiry with plans for a patient safety website and a new measure of avoidable death
• the Care Quality Commission introduce its new surveillance methodology to identify poorly performing organisations
• the NHS Litigation Authority revise how it calculates trust clinical negligence contributions to be based on past litigation claims.

And this isn’t even an exhaustive list. But what runs through it is the enhanced role that data and information will play in trying to understand how safe the NHS really is.

The NHS excels in measuring incidences of past harm, and many of the activities in the list above rely (or relied) on information relating to past performance as a trigger for further inquiry. Such information is the cornerstone for understanding safety in health care, but is only one part of a broader set of questions that Professor Charles Vincent and colleagues argue give us a more rounded picture of safety. Based on these questions, the researchers developed a framework consisting of:

• Past harm – has patient care been safe in the past?
• Reliability – are our clinical systems and processes reliable?
• Sensitivity to operations – is care safe today?
• Anticipation and preparedness – will care be safe in the future?
• Integration and learning – are we responding and improving?

There are already a great number of examples of NHS organisations pioneering ways to better understand how safe their services are, and how they are anticipating risks before they lead to harm to patients – we will be profiling some of these in the coming months.

To guide organisations who are already on this journey, or to help those just embarking on it, we have just published a practical guide to implementing the framework for measuring and monitoring safety. The guide includes a brief summary of the research and what it might mean for staff and patients. We don’t want it to be prescriptive or preaching, and its strength lies in it being adapted to each local context, but we hope the following guiding principles and questions are helpful:

• Be open: Which of the five areas of the framework are you strongest and weakest in? How can you target your efforts on those areas of weakness?
• Be thoughtful: Does the framework seem deceptively simple? Are there deeper issues that the questions surface that are more complex to address?
• Be reflective: What information do you currently collect and does it add value? Do you need to stop collecting some data and start collecting others?
• Be inquisitive: Are you ‘ticking off’ centrally-mandated requirements, or generating a sense of ownership of safety in your organisation?

This last point is often where tensions can arise: how can the reporting of specific safety measures serve both to improve the safety of services and provide assurance to external organisations and the public? In our briefing in response to the publication of Hard Truths we made the following point to NHS England:

Be clear about how publishing the information [through the new hospital safety website] will improve safety...is it intended to drive public choice of care providers? Or to develop a competitive spirit between professionals? Or to embarrass staff into action? Or a combination of all three? Without a clear theory as to how data reporting will foster improvement, there is a risk that it will become an end in itself.

An example of how this tension might be managed is in the publication of data on staffing levels. The government announced that NHS organisations will be required to publish ward level staffing information on a monthly basis. This is a welcome development. Staff numbers (combined with an assessment of staff skills and level of treatment required to care for patients) can be an indicator of a ward’s ability to provide safe care.

However publishing data alone won’t improve care, but what just might is using this information to inform operational decisions and making it visible to patients, carers and families when they enter a ward. We must now approach safety in a reflective, inquisitive way and – above all – be open, if we are to move forward and continue to make care safer.

John is a Policy Manager at the Health Foundation.