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
- Don Berwick: Improving the safety of patients in England (highlights) (elftqualityimprovement.wordpress.com)