Learning together to improve patient safety – Richard Jeavons

Richard Jeavons interim managing director for NHS Improving Quality

Richard Jeavons interim managing director for NHS Improving Quality

The new national patient safety collaborative programme, which will launch in the coming months, is an ambitious initiative by NHS Improving Quality to provoke a large scale change that will improve the quality of the NHS for its patients. Working in partnership with NHS England, this collaborative will revolutionise the way care is provided at a local level, enabling frontline teams to involve patients and their families in making healthcare safe.

The collaborative programme complements a wider raft of measures outlined today by NHS England in order to reduce harms. Re-launching the patient safety alerts system, making data more accessible to patients, and making information on ‘never events’ publicly available, are all positive steps towards changing the system for the better.

However, our ambition to prevent a repeat of the devastating failures at Mid Staffordshire goes far beyond today’s announcements about safety. Safety is a thread that runs through the fabric of the entire healthcare system, interwoven with clinical effectiveness and patient experience. It is transformational change across the NHS that is needed to achieve our ambition for patients, and to secure public confidence in our NHS.

In his report, A Promise to Learn – a commitment to act, Don Berwick highlighted that key to implementing the Francis recommendations is a shift in culture. We must move away from blaming individuals and look instead at the wider culture of the NHS and its organisations. The vast majority of people who work in healthcare have the best interests of their patients at heart, and the collaborative programme will work to develop the NHS into a learning system which supports, engages, and inspires them to continually improve what they do.

Empowering patients, families and carers so they are present and involved at all levels of healthcare will also make a genuine difference. They have the insight and vision to see where something is wrong often before the professionals do, and they must be listened to and their comments acted on. Experience of care should be embedded within all aspects and types of service delivery, and patients, families, and carers will play key roles in the safety collaborative programme.

Failings in patient care more often occur out-of-hours, and at the interface between different services. Integrated care and seven day services are priority areas for large scale change in which NHS Improving Quality is making a significant contribution. NHS services must be designed to fit around the needs of patients, with 24-hour specialist care and seamless transitions between departments and services.

Don Berwick also observed that our culture must foster learning and continuous improvement throughout the NHS. He points out that ‘safety is a continually emerging property, and that the battle for safety is never “won”; rather, it is always in progress’, and recommends staff are educated in quality improvement methodology. At NHS Improving Quality, we are developing new approaches to build the NHS’s capability in quality improvement through people, knowledge and science. A programme for CCGs to build capability to innovate, improve, and transform systems and services will be expanded in collaboration with other training and learning bodies. And in a world of greater transparency and more accessible data about services, the challenges of measuring for improvement were explored in a recent masterclass series for senior clinical leaders.

Too many people are harmed by things going wrong during their healthcare, and the challenge is to systematically tackle the causes of patient safety incidents and so continuously reduce harm. NHS Improving Quality will continue to focus on what can be done nationally to provoke and enable changes in the NHS that will make the biggest difference for patients. The impact needs to be felt by patients, their families and carers in every interaction with the NHS, so that healthcare is as safe and positive an experience as it possibly can be.

Richard Jeavons is the interim managing director for NHS Improving Quality. He is also senior partner for NHS IMAS and chief executive of the Independent Reconfiguration Panel (IRP), which advises the Secretary of State for Health about disputed NHS service change.

More information: http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety.aspx


2 thoughts on “Learning together to improve patient safety – Richard Jeavons

  1. I’m looking forward to hearing more about the Safety Collaboratives, and especially how “patients, families, and carers will play key roles in the safety collaborative programme”. I have no problem with the emphasis on prevention, and so I guess the investment in developing better measurement goes with that. But two comments on this. First, the NHS is brilliant at gathering data and then not doing anything with it (the NRLS is a prime example of a “reporting but NOT learning system”). We really do need to get better at solving the problems that the data gathering flags up, and the ‘science’ underpinning behaviour change for safety is rudimentary at best. Second, harm WILL always happen, however good we get at preventing it. At present, the way the aftermath is dealt with often adds insult to injury. The Collaboratives (and others) really need to get a grip on “making amends after harm” including supporting staff who inadvertently do harm. If you’re interested in reading some more about making amends there’s a discussion (and a patient talking about their experience) at http://www.clearer-thinking.co.uk/featured/making-amends-alexandras-story/

    • Thank you for your comments which are most welcome and flag up some very important points.

      We are extremely privileged to be working on patient safety improvement at NHS Improving Quality. We will be using all of the lessons learned from both past successes and of course from key failings, as shared through the findings of Robert Francis QC., as well as the recommendations from Berwick in ‘A promise to learn – a commitment to act’ (August 2013).

      Currently still in the design process, we take the work of the Patient Safety Collaborative Programme very seriously. We are holding a design event early in the new year where national and international safety and improvement experts will gather to ensure we use the very latest thinking, experience, research and expertise to devise the programme. Importantly, we will also be inviting a number of patient representatives and service users to this event who will be involved and engaged as partners in the Collaboratives from the very start. Patient and carer representatives will be a key part of the work both nationally and locally and each of the 15 local Collaboratives will have members of the public on their steering committees guiding and informing progress towards safer care for all. There will be some local consultation events held in Feb/March where the Patient Safety Collaborative Programme plans will be shared more widely. Contributions by all attendees will inform the final shape of the work of the Collaboratives, which will be locally owned and led and focused on local safety issues. Continually reducing avoidable harm, as well as developing the NHS into a learning system which supports a safety culture, will be priorities for the Collaborative work.

      Once up and running, the improvement of measurement will form one of the vital work streams of the Collaboratives, and this work, alongside that being done by others on measurement, will improve the process of reporting and use of data on safety in future. Some of the high level detail of this work has been announced by the Secretary of State in Parliament this week and can be found here.

      Sarah Armstrong-Klein
      Senior Improvement Manager
      Patient Safety
      NHS Improving Quality

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