“We are not here to curse the darkness, but to light the candle that can guide us through that darkness to a safe and sane future.” (John F Kennedy, 1960)
At its heart patient safety is all about making sure we are continuously learning – not only from the things that go wrong- but also those which go right. The new NHS Patient Safety Strategy, commissioned by the Secretary of State and published following careful consultation with NHS staff, senior leaders and patients, sets out NHS England and NHS Improvement’s plans for continuous improvement in patient safety. Focusing on addressing the current challenges being faced and outlining a number of measures to overcome these, the message is clear: in order to achieve this, we need to do two things. Firstly, we must design effective and consistent patient safety systems that help us learn and share those lessons and, secondly, we need to develop a patient safety culture which empowers staff to speak up and to contribute to patient safety improvements.
Below we focus on 10 important takeaways from the new strategy:
1. We need to tackle the ‘blame game’ culture
Within NHS trusts a culture of blaming can often develop when it comes to patient safety incidents and this in turn creates a reluctancy or unwillingness to admit mistakes for fear of the repercussions. Blame is a natural response when errors have been made, but it can prove hugely costly; according to the report 11,000 lives a year could be saved if it weren’t for such cultures. By cultivating a culture of ‘psychological safety’ – an environment of compassion and inclusiveness where individuals feel they will be treated fairly and supported should they speak up – people are more likely to be honest and admit errors so that lessons truly can be learned. Incidents involving malicious or intentional harm are extremely rare; the overwhelming majority of healthcare workers are simply trying to do the best job they can and may not even be aware that their actions have been harmful. Treating them with kindness and civility is key to identifying where systems and processes have failed – rather than individuals themselves. Put very simply, if people are too afraid to admit errors, then we cannot and will not learn from them.
2. Training and supporting all staff is key
Organisations must do more to equip staff with the necessary skills, tools and opportunities to enable and incentivise them to improve patient safety throughout the whole system. The report suggests that although people are aware of the need to improve safety, very few have a true understanding of ‘safety science’, and as a result it sets out the plans for a new ‘patient safety syllabus’. This will include a robust programme which will ensure staff at all levels receive certified, in-depth training which is appropriate to their role. When it comes to incident investigation training specifically, our work with patient safety teams across the country highlights considerable inconsistencies in the quality and frequency of training as well as the tools and systems that are provided to investigators. Having the correct policies, and even the right culture, in place will only get you so far if we fail to equip staff with the practical tools and skills required to act appropriately.
3. Involving patients and families is vital
Although they are often the ones to feel the effects of poor patient safety most acutely, too often families, patients and carers can feel they are being left out, or even excluded from the process. This results in a strained relationship between the families and staff at the respective hospital which can ultimately lead to negative publicity and increased litigation costs. As Don Berwick stated: “patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of trusts.” The new strategy outlines the creation of ‘Patient Safety Partners’ – individuals recruited from outside the trust, and ideally who have been affected by a patient safety incident themselves – to work with the organisation at all levels to ensure the voice of the patient is heard and that their experiences are used to inform policies, practices and training across the organisation.
4. Sharing is caring
Another key point made within the NHS’s patient safety strategy is the power of insight and the sharing of this insight to prevent incidents. Many hospitals within the UK operate in complete silos, meaning that data and resources are simply not shared and therefore any benefit to come of these remains within that singular trust. In order to make real, long-term and wide-reaching improvements in patient safety, trusts need to be willing and able to share their lessons and their data (albeit within the constraints of anonymity). In light of this, the NRLS (National Reporting and Learning System) is being replaced and the new system will seek to rationalise data so it can be shared and access more easily. Data is now the most valuable resource and, if used in the right way, we can foster a more proactive and preventative approach to patient safety.
5. The cost of clinical negligence is rising
Clinical negligence and litigation costs have risen significantly in the past 10 years. The report highlights that in 2006/07 the cost was £0.4 billion. In 2017/18 this figure hit at a very high £2.2 billion. This was a result not only of an increase in the number of reported claims, which almost doubled from 5,400 to 10,600 during this period, but also the average cost of each claim. This number is rising ever year and is costing NHS trusts more and more of their much needed budgets – all this in a climate of increasing patient numbers, decreasing budgets and extreme pressure on trusts to deliver better patient care with limited resources. This represents a further incentive for trusts to find better ways of not only capturing learnings, but also sharing these more effectively so actions can be taken to prevent further incidents. If they can succeed in doing this, then more money and time can be spent on delivering better care to patients on the front line.
6. Continuous improvement and collaboration
It is fundamental that all parties embrace habitual learning so we can improve patient safety. The National Patient Safety Improvement Programme will be built upon and further work and objectives have been noted for 2020 to 2025. In its recent patient safety report, the NHS highlighted research and innovation as integral to that improvement and Academic Health Science Networks will play a key role in this, acting as catalysts for improvement by aligning education, clinical research and information to bring new innovations and initiatives to trusts. As the famous words of Henry Ford go; “Coming together is a beginning; keeping together is progress; working together is success.”
7. We must embrace new technologies
‘Digital developments and technologies offer the potential for transformational improvements in safety’, according to the strategy. From Electronic Patient Records providing better access to more robust medical records, to the use of electronic prescribing and medicine administration systems (EPMA) which help reduce medication errors, embracing innovative new technologies will play a vital part in transforming the current system. Ensuring that healthcare professionals looking after patients have access to complete and correct information in real time reduces the possibility for mistakes or delays in treatment. And when you factor in how Artificial Intelligence could make use of this data to recognize patterns and highlight potential risks, allowing healthcare professionals to become more proactive in their care, the possibilities really do seem endless. But trusts need to embrace the digital revolution and view it as a tool to help them do their jobs better, as opposed to replacing them entirely.
8. Patient Safety Specialists will be appointed in every trust
Whilst the strategy makes it clear that patient safety is everybody’s responsibility and announces a patient safety training syllabus for all, it recognises the need for all trusts to appoint a dedicated individual to act as a key leader and expert. However, their vision is that trusts develop existing, senior staff who are already leading in this area as opposed to creating new roles; all NHS trust are being asked to put forward at least one member of staff who is suitable to take on this role by April 2020. Whilst there is an admission that more work needs to be done to define they exact responsibilities and duties Patient Safety Specialists, there is talk of ultimately professionalising the role through accreditation or similar routes. The PSPs will also be part of specialist local, regional and national networks which will facilitate the sharing of best practice, learnings and support.
9. Measuring the impact of the strategy will be challenging
Often in healthcare, systems are too complex and the scope for variables too great, to be able to measure and predict the impact of improvements – especially those relating to education and training – whether that be in economic terms or otherwise. Added to this, due to the fear healthcare staff can have around reporting incidents, the report estimates that the actual harm is at least double what is recorded. It goes without saying that if we are unable to quantify the current impact of harm as things stand, any measurement of the reduction of this harm is going to prove extremely difficult. Nevertheless, there is a clear commitment to promote and adopt key safety measurement principles and make use of culture metrics and the NHS Staff Survey in order to better understand the impact the strategy is having.
10. We must tackle the bigger picture too
Whilst individual hospitals and trusts are responsible for improving patient safety practices, the bigger picture is much more complex. Organisations such as CCGs, STPs and integrated care systems have the power to make bigger changes across a wider remit, as do regional and national bodies. Their role is to think of the ‘bigger picture’, recognise examples of best practice from individual organisations – including those across the world, and help to share and develop these at scale. One issue which affects healthcare providers on a global scale is workforce capacity; according to the World Health Organisation the world will be short of workers by 2030 – roughly a fifth of the number needed. We must ensure that we are working to in conjunction with bodies at all levels – national and international – to ensure that where individual organisations have found credible solutions to such issues, these are scaled and implemented so their impact can be maximised.
This report clearly indicates that the NHS has recognised that things need to change in order to make significant improvements in patient safety and care. The estimation that at least 1,000 lives and £100 million in care costs could be saved annually by implementing the changes put forward by the strategy show that the prize is one worth fighting for.
In particular, there is a real focus on exploring what part technology has to play in this and, along with the recent promise of £250million investment to support the use of Artificial Intelligence, there is a sense that things may be about to change. The Eva Investigation Application is a perfect example of how technology can be used to support, not replace, clinicians in their role of incident investigators. The fundamental principles behind the tool mirror the key recommendations set out in this report:
- Making time-consuming tasks easier and more efficient
- Supporting the user to conduct an objective investigation which examines system failure rather than blaming individuals
- Collecting information so it can be analysed and shared at scale
- Keeping patients and families in the loop
The final piece in the puzzle now is to empower trusts with the power, resource and support they need to embrace the new initiatives and this is especially true when it comes to innovating and embracing new technology.
For more information on the Eva serious incident investigation software please get in touch by calling 020 7494 5676 or email [email protected].