In discussing patient safety and health quality in the NHS it is useful to reflect on the extent to which theory and practice match up. Nurses and doctors attend—limited financial and time resources permitting—study days and conferences where patient safety issues are discussed. There are also national and international reports and now the new NHS Patient Safety Syllabus from the Academy of Medical Royal Colleges (Spurgeon and Cross, 2021).
A general question can be posed as to whether this syllabus will make, and whether education and training in patient safety generally are making, any discernible difference in terms of the NHS patient safety improvement. We can also add into the mix inspection reports from the Care Quality Commission (CQC). Perhaps, on reflection this is too diffuse a question to ask? A key related question is how exactly we measure impact, although that is another discussion in its own right.
The latest CQC inspection reports reveal major chronic patient safety failings such as poor record keeping and poor communication processes. These and other major failings appear with alarming regularity. This raises in my mind the issue as to whether the NHS is actively learning from the errors of the past. Some of the errors identified in inspection reports are so basic that they beggar belief. This reveals a chasm between what is taught (the theory) and what is happening in practice. There are a host of issues involved in trying to answer the thorny theory/practice question—if we even can. Some recent CQC inspection reports will be discussed here along with some recently published education and training materials. The courses and good practice examples represent the theory. The inspection reports represent the practice, and it is important to compare.
NHS Patient Safety Syllabus
The first batch of level 1 and 2 learning materials are now available on the elearning for healthcare (elfh) platform for NHS staff to access. Level 1 is called ‘Essentials for patient safety’ and this is where everything starts. The blurb for level 1 describes the content as:
- Listening to patients and raising concerns
- The systems approach to safety, where instead of focusing on the performance of individual members of staff, we try to improve the way we work
- Avoiding inappropriate blame when things don't go well
- Creating a just culture that prioritises safety and is open to learning about risk and safety. (elfh and Health Education England, 2021)
Level 2 is called ‘Access to practice’ and is aimed at staff who want to go deeper into patient safety. There are two sessions here, one on systems thinking and risk expertise, the other on human factors and safety culture.
Project reset in emergency medicine: Patient FIRST
Advice from the CQC is always welcome as its reports are well written and largely jargon free. Patient FIRST was written by CQC specialist professional advisors who work as senior clinicians in emergency departments rated as good or outstanding. It is intended as a support tool containing practical advice and examples of good practice. FIRST stands for:
- Flow
- Infection control, including social distancing
- Reduced patients in emergency departments
- Staffing
- Treatment in the emergency department.
Five principles of Patient FIRST are stated in the report, which include:
- Patients must come first, and safety cannot be compromised
- Emergency departments must focus on their core function of rapid assessment and emergency stabilisation of critically ill and injured patients
- Delivering good quality urgent and emergency care must have the support of all services inside and outside hospital. (CQC, 2021a: 3)
Flow
CQC states that good flow prevents crowding within the department and reduces the risk of nosocomial infection. Developing urgent and emergency care pathways is given as a key method of managing flow.
‘Flow escalation. The entire trust needs to be aware of the flow issues in a timely manner to resolve them. Many small “things” might be needed to avoid more significant impacts in flow. A flow escalation manager can be an individual based in the emergency department.’
Infection control
The aim here is that no patient or staff member will acquire a nosocomial infection as a result of their time in the emergency department. Specific examples of good practice include:
‘Don and doffing. Make sure the department has a clear ‘how to’ don and doff procedure in a numbered step approach. It needs to be visible in the areas where staff need to do this. Staff need to be ‘clear’ of other duties to concentrate on this procedure. Checklists can be used as well as the recommended buddy system.’
Aims and good practice are also discussed in some of the other areas addressed in Patient FIRST, such as reduced patients in emergency departments, staffing and treatment in the emergency department.
Meeting the challenges
The above are just two recent examples of good patient safety education and training products that are available to NHS staff. As I have stated previously in this column, the NHS is no sloth when it comes to producing well-developed patient safety materials. There are, however, serious challenges for the theory contained in these reports to meet and overcome in practice. In the harsh reality of the NHS workplace inspection reports provide an important real-time window onto what is happening on the ground in patient safety.
When we reflect on the National Patient Safety Syllabus and begin thinking about the basics of patient safety, it is important to discuss a concerning finding by the CQC, which shows the serious nature of the challenges faced in instilling proper practice.
‘There were some concerns with culture in the trust and staff being confident about speaking up. There were issues for some members of the black, Asian and minority ethnic staff. For example, we heard from a number of staff who had been told by a line manager to use a westernised name as this would be easier for people to pronounce. Another member of staff was not called by their name in a meeting and no effort was made to learn to pronounce it. Some staff told us they did not always raise concerns as they were not always taken seriously or appropriately supported when they did.’
This is alarming when we look at how healthcare staff need to relate to each other and to work together. Good relationships between staff is an important hallmark of a developing patient safety culture. Remembering and using colleagues' real names is a good first step:
Theory vs practice
In terms of Patient FIRST and good emergency care we can see the practical challenges being faced by the theory in the reports from the CQC. In one recent case, inspectors' findings included:
‘Patients in emergency departments did not always receive appropriate care and treatment in a timely way, exposing them to the risk of harm …
‘The trust did not always manage the access and flow of patients in the urgent and emergency departments and in medical care services, with patients spending long periods waiting for an in-patient bed
‘Staff did not always recognise and report incidents and near misses in some services. Also, staff did not always share lessons learnt from these, to help prevent any future incidents from happening.’
Clearly there is a mismatch here in terms of theory and practice. Unfortunately, there is no shortage of CQC inspection reports reporting major patient safety failures. Although outstanding and good practice is identified in inspections reports it is often eclipsed by poor practices. The negatives have the biggest impact as they could result in injury or death to the patient.
In another recent CQC inspection report we can see some dire patient safety failings. Inspectors' findings included:
‘Staff identified patients at risk of deterioration, but they did not always provide care in a timely manner. The system of allocation of patients to doctors in some areas was not clear and led to confusion for nursing and medical staff when patients needed urgent medical review
‘Sometimes staff did not report near misses, as they were not aware it was their responsibility to do so.
This meant that the opportunity to learn from incidents and near misses was often lost
‘Care records were not always complete and/or legible. Medicines were not always well-managed.’
The CQC inspection reports represent a deep dive into the culture of an NHS organisation and a wealth of detail is provided, which can usefully inform patient safety education and training workshops as real-time case studies.
Conclusion
There is a gulf or chasm between theory and practice in patient safety and it is recognised that the same could well be said about other disciplines and fields of study. The key issue, as I see it, is to recognise that there is a major gap and to avoid complacency.
A pervading blame culture can often be seen to persist in some quarters of the NHS and as shown above there can be major deficiencies in how we treat and relate to each other. Education and training and well-crafted reports are not the panacea for righting the patient safety wrongs of the NHS. We need to go back to basics and work hard at the NHS workforce to instil sustainable change.
The theory is in one sense a comfort blanket, while what goes on in practice, as evidenced by CQC inspection reports, is the harsh reality that theory must grapple with and overcome.