Memorandum by The Health Foundation (PS
1.1 NHS care and treatment is replete with
avoidable error. The bulk of this is caused by system failure
resulting in chronically unreliable care delivery.
1.2 The managerial and clinical leaders
of all acute hospitals in England should make patient safety their
top priority, implementing proven changes in clinical practice
to reduce harm; banishing the blame culture; and changing the
way they identify risks and measure performance.
1.3 Ministers and NHS top management can
aid this by ensuring a coordinated use of managerial, commissioning
and regulatory levers. They should lead by example, putting patient
safety, visibly and practically, at the very top of their agendas.
Responsibility for patient safety at the Department of Health
should be clarified and backed with sufficiently senior and experienced
technical expertise. In the context of High Quality Care for
All: NHS Next Stage Review Final Report, they should act to
build a cadre of expert clinical leaders in patient safety.
1.4 Other industries have seriously addressed
safety and the same can be done in the NHS. Healthcare is highly
complex and there are no quick fixes. A holistic approach is necessary.
Senior leadership, clinical engagement and a committed workforce
are all vital. Time must be invested in embedding a long-term
1.5 The Health Foundation's work over four
years with 24 hospitals across the UK has many lessons for the
rest of the NHS.
1.6 The Safer Patient's Initiative (SPI)
is a cost effective intervention and is just one important element
of The Health Foundation's development of a suite of approaches
to transform patient safety. The four home nations are now introducing
core elements of it into all acute hospitals.
1.7 SPI has shown that care processes can
be improved to deliver reliable, high quality care. It has built
on positive will to change, leadership attention on safety and
implementation of evidence-based measures designed to make routine
care processes as reliable as possible.
2.1 The Health Foundation works to improve
the quality of UK healthcare. Uniquely, we identify international
learning and practice, demonstrating the benefits by working with
healthcare organisations across all four home nations.
2.2 The Foundation is independent of interest
groups, forming constructive partnerships in healthcare policy,
research and practice. We spend £25 million annually to close
the gap between the best care and what patients routinely receive.
2.3 The Health Foundation's patient safety
work interlocks with our approach to developing leadership, improving
quality by engaging clinicians and patients and building knowledge
of what works. These are all facets of quality. Creating and sustaining
safe and reliable healthcare requires a holistic approach with
the following important elements: developing clinical teams to
become learning communities providing constructive feedback; providing
structure and discipline around testing and measuring outcomes;
stimulating local adaptation anchored in evidence and encouraging
multidisciplinary learning drawing on patient perspectives. Safety
culture must be embedded over time in daily practice to be truly
2.4 Safety needs long-term commitment, senior
leadership and engagement, passionate clinicians and experienced
managers. The Health Foundation has supported a range of initiatives:
the independently evaluated SPI, Professor Charles Vincent's Journey
and Quality Improvement Fellowships which
enable clinical staff to become quality and safety experts. We
are continuing our catalytic investment through Safer Clinical
Systems a programme to design systems that can support defect
3. WHAT ARE
3.1 The National Patient Safety Agency (NPSA)
estimates that 850,000 incidents and errors occur every year in
the NHS. Other estimates suggest that one in ten patients in hospital
experiences an incident that puts their safety at risk, roughly
half of which could have been prevented.
3.2 In 2000 the Department of Health's An
Organisation with a Memory
painted a stark picture of an NHS without
systematic ways of identifying error, learning from its causation
and reducing risk for future patients.
3.3 The vast bulk of human error in healthcare
is attributable to system failures rather than poor clinical judgement.
We must abandon the belief that healthcare is inherently unreliable
and tackle system failures by investigating, understanding and
acting upon avoidable harm as a departure from the norm.
3.4 SPI built a system-wide approach by
recognising the size of the challenge; shifting from a culture
of individual blame; focusing leadership attention on safety as
a first priority; using evidence to make routine care processes
as reliable as possible and building the will and skills of staff
to support these strategies.
3.5 With this approach, the NHS could strive
to match the safety culture and performance of industries such
as commercial aviation. Only one in every 10,000 plane landings
is unsafe. In healthcare, anaesthesia has reached this level of
reliability. This is not matched by other healthcare areas where
one patient is harmed for every 100 medication doses given in
3.6 The role of public perceptions of risk
in determining NHS policy
NHS policy is too easily led by media and public
focus on single issues such as healthcare acquired infections
(HAI). Though valuable, this focus cannot ensure that hospitals
address safety issues throughout the patient journey. HAIs are
symptoms of leadership, systemic and cultural failures. Isolated
initiatives such as deep cleaning may satisfy public anxiety but
there is little evidence they can address root causes unless they
are undertaken within a long-term safety strategy.
4. CURRENT EFFECTIVENESS
OF NHS BODIES
4.1 The 24 hospitals participating in SPI
demonstrate the NHS's potential to ensure patient safety. SPI's
success lies in the recognition that care processes must be improved
to give all patients the care and treatment they need all of the
time. As the case studies below illustrate, SPI hospitals have
found that improving the reliability of care leads to reduced
4.2 Case Study 1: Reliable monitoring of patients
The National Confidential Enquiry into Patient
Outcomes and Death found that patients who died in hospital often
showed signs of deterioration long before death. The Luton and
Dunstable Hospital NHS Foundation Trust estimates that there are
1.5 fewer cardiac arrests per week following the introduction
of an early warning score system on the wards. The system allows
staff to monitor the condition of patients and take rapid action
if they go into decline. It has led to a fall in the crash call
rate as the rapid response team can now take action sooner to
avoid patients developing serious life-threatening conditions.
4.3 Case Study 2: Critical care
It has been known for some time that systematically
implementing four actions reduces the risk of ventilator acquired
pneumonia (VAP). Yet, SPI hospitals measuring whether these steps
were being taken in their units found poor compliance with all
actions. Conwy and Denbighshire hospital increased compliance
from 87% to 100%, virtually eliminating VAPs from a starting point
of 30 infections per 1000 bed days. As infection free patients
need less time in critical care, bed availability increased. Conwy
and Denbighshire treated 350 more patients over the last two years
within the same capacity as well as reducing medication and saving
£78,000 over a 12 month time period in the medications budget.
4.4 How far Boards of NHS bodies have established
a safety culture
Demonstrating that it is possible to avoid infections,
medication errors and other routine defects in care taps into
staff's intrinsic motivation to help patients. SPI hospitals work
to build on staff's will to change, not their fear of punishment.
Overcoming the traditional view that mistakes leading to harm
are regrettable but an unavoidable aspect of routine care.
4.5 Boards can provide the key leadership
and vision to help staff improve. They can drive change by simple
methods of staff engagement ensuring that on the ground solutions
and challenges are brought home to the executive and non-executive
4.6 SPI senior leaders receive monthly reports
against a basket of key outcome and process measures from which
it is possible to drill down to specific areas of concern. Executives
and non-executives are involved in weekly leadership "walk
rounds", taking them into clinical areas to discuss areas
of risk and potential harm. Senior leaders identify actions needed
to create a safer clinical care context, signalling to frontline
staff the priority of patient safety.
5. CURRENT EFFECTIVENESS
5.1 In much of the NHS there is limited
available, real-time, clinical performance data. In SPI hospitals,
teams track safety improvements against a range of process and
outcome measures. The collection of meaningful data enables each
team to see in real-time the impact of the changes they are making
and equips them to identify areas for practical improvement.
5.2 The quality agenda has largely focused
on the dissemination of guidelines and standards. Little attention
has been paid to how to introduce change reliably. All SPI hospitals
had extensive quality assurance and risk management systems in
place at the start of their work with the initiative. However,
all found highly variable compliance with agreed standards when
monitoring actual practice.
5.3 SPI teaches "the model for improvement",
enabling staff to make planned, small-scale changes to care delivery
and assess their impact before attempting to make wholesale changes
to clinical practice. This approach focuses not on what should
be done but how it can be done reliably. Clinical teams build
confidence and take ownership of changes in care, resulting in
greater compliance and sustainability.
6. CURRENT EFFECTIVENESS
6.1 The Health Foundation welcomed, and
participated in, the formulation of the recommendations made by
Safety First. However, progress towards the review's objectives
has been regrettably slow. The failure of the National Patient
Safety Forum to make significant progress in driving forward the
patient safety agenda has been disappointing.
6.2 The Foundation welcomes High Quality
Care for All's strong focus on quality, the emphasis on outcome
metrics and clinical leadership. It recognises that real sustained
change can only happen if driven by clinical leaders on the ground.
6.3 National targets are necessary and helpful
but are not sufficient in themselves.
7. WHAT SHOULD
THE NHS DO
7.1 Are measures taken to improve safety supported
by adequate evidence regarding their clinical effectiveness and
We know what works in healthcare, the challenge
is how it is reliably implemented to benefit every patient. SPI
was the first national or international programme to bring together
evidence-based interventions to improve the safety of clinical
care and the leadership responsibility to create a safe environment
of care. It was based on the knowledge that there was:
growing evidence of widespread harm
to patients that needed to be addressed
an evidence base for what works to
ensure patients' safety, but a substantial gap in the implementation
of best practice
an internationally recognised and
respected technical partner organisation (the Institute of Healthcare
Improvement, Boston, USA) to implement the teaching and support
7.2 There are numerous examples of how participation
in SPI has improved the reliability of evidence-based care processes,
by November 2006, NHS Tayside increased
its hand hygiene compliance to 96% on general wards, helping to
Down Lisburn Health and Social Services
Trust reduced the percentage of times to below 10% that the medication
given to a patient in hospital does not match those they are already
taking when admitted. This followed the development of a system
for tracking and managing the drugs their patients take. The system
also links to GP patient records and helps to reduce mistakes
in primary care
compliance with pre-operative briefings
in Luton and Dunstable increased from 8% in June 2005 to 100%
by April 2007 and has been sustained
NHS Tayside has experienced a reduction
in surgical site infections in orthopaedics from 6.1% to 1.3%
per 100 surgeries between November 2006 and June 2007.
7.3 Health Foundation SPI funding, acts
as a catalyst for the improvement of patient care. These hospitals
have shown that for the relatively small investment of £90,000
per trust per year, and another £55,000 per year in skills
development, they have been able to utilise existing resources
in a new way to deliver lasting benefits. Encouragingly, hospitals
who failed to win an award have decided to implement a safety
agenda without Health Foundation funding.
7.4 Spread of best practice
The Health Foundation is driven by a belief
that it is possible to speed on-the-ground uptake of interventions
that could address a known and serious problem. The impact of
SPI has been far-reaching. It has led to demonstrable improvements
in patient safety in the 24 participating organisations. It has
also shaped the landscape of patient safety across the UK as each
of the four home health departments has developed their approach
7.5 The four home nations are now introducing
core elements of SPI into all acute hospitals. The health departments
of Wales, Scotland and Northern Ireland have all responded positively
to this work, each now actively leading safety initiatives across
their territories to which we are contributing advice and support.
7.6 More work is needed in England to deliver
a national spread strategy backed by sustained and coordinated
activity at every level. In partnership with the National Patient
Safety Agency and the NHS Institute for Innovation and Improvement
we are supporting and developing the English safety campaign which
spreads SPI approaches across English acute hospitals.
7.7 Implementing learning
Building and sustaining capacity and capability
in improvement methodologies is a significant challenge. While
the NHS Institute and some SHAs are starting to offer training
in these areas, current provision falls short of demand. The demand
for open days run by SPI sites is increasing. At Luton and Dunstable
NHS Foundation Trust each session has upwards of 70 participants.
7.8 A high proportion of the individuals
working on safety at regional and national level have come from
SPI sites. Yet previous modernisation efforts could not be sustained
when key individuals moved on. This is a matter of concern.
The publication of performance data by individual
hospital, such as mortality statistics where HAIs were the main
or a contributory cause, has the potential to incentivise clinicians
and managers to improve the quality of care.
Under the new Commissioning for Quality and Innovation scheme
proposed in High Quality Care for All, by 2010 the payment
providers receive for the care they deliver will be dependent
If applied appropriately such financial incentives could be beneficial.
7.10 The Foundation opposes the imposition
of financial sanctions on hospitals which have unintentionally
harmed a patient. Fining publicly-funded institutions penalises
the population and can lead to the manipulation of performance
data and the demoralisation of staff.
8.1 The Health Foundation will continue
to invest in patient safety by building a new network of safety-minded
organisations across the UK able to test, develop and export approaches
to improve safety and build capability in the wider system.
This will generate new knowledge and practice that can be used
across healthcare. By supporting some sites to become expert in
the training and mentoring of these approaches they will be able
to export expertise to the wider system.
8.2 Safety is a complex challenge with no
easy answers but the managerial and clinical leaders of all acute
hospitals in England could make patient safety their top priority.
They could act now to:
implement tried and tested changes
in clinical practice to ensure safe care is delivered every time
to every patient
banish the blame culture and harness
the energy and enthusiasm of their staff to improve patient safety
change the way they identify risks
and measure performance to better support clinical teams to take
responsibility for their own performance.
8.3 The Department of Health should ensure
a coordinated use of its managerial, commissioning and regulatory
functions to ensure this is achieved. Additionally, they could
influence immediate improvement if they ensured that:
ministers and NHS top management
recognise there are no quick fixes in patient safety. It depends
on developing leaders and providing them with the skills to lead
improvement, at every level of the system. It cannot be driven
from Whitehall. Ministers and NHS top management must lead by
example, putting patient safetyvisibly and practicallyat
the very top of their agendas
responsibility for patient safety
is clarified at the Department of Health and is backed with sufficiently
senior and experienced technical expertise
a strong emphasis is placed on building
a cadre of expert clinical leaders in patient safety in the light
of the potentially more conducive policy environment created by
High Quality Care for All: NHS Next Stage Review final report,
with its strong focus on developing clinical leadership.
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