There is a lot written on patient safety both nationally and internationally with many stakeholders all keen to advance their perspectives. Health is everybody's business, and such engagement is understandable and necessary. The patient safety culture debate is kept alive by such dialogue and policies, and practices can become better informed. The difficulty for busy staff, as I have stated before, is keeping up to date with all this information, distilling and applying appropriate findings. Reports need to be effectively analysed and relevant information distilled, cascaded down to appropriate teams and staff. This, however, is much easier said than done.
A new approach to patient safety
In terms of patient safety improvement practices and culture development, a recent report published by Healthcare Excellence Canada (Gilbert et al, 2023) provides some interesting and valuable perspectives. A call for a new patient safety approach is made and there is much food for thought. Progress in improving patient safety has not been as straightforward as expected, with fewer gains. The authors argue a change in patient safety mindset is needed, and consider how this might be achieved. There is a need to shift focus from measuring and responding to harm to taking a more holistic, system-wide view:
‘However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present, and future in all its complexity.’
There is a discussion of such issues as supporting those involved in a patient safety incident, safety of essential care partners, healthcare providers, and others. Health care is founded on relationships:
‘When we invest in relationships that foster respect, trust, collaboration, and open communication, we create a positive culture of safety.’
All types of harm, they argue, must be considered in the work of patient safety, not just physical ones such as falls or healthcare-acquired infections. Other forms of harm can often be overlooked, including:
‘… under- and over-treatment, wrong treatment, delayed or incorrect diagnosis, dehumanization, and psychological harm. Harm may also be compounded in the aftermath of an incident because of how it was managed.’
This is an excellent report, one that conveys critical patient safety information in a simple, straightforward manner. It shares patient safety think points, which can be used to reflect on our approaches to patient safety policymaking and practice. It is always useful to reflect on and reappraise our position and policy values.
Health Services Safety Investigation Body: Safety management systems
The Health Services Safety Investigation Body (HSSIB) replaces the Healthcare Safety Investigation Branch (HSIB). Although continuing the same work, HSSIB has been established as a fully independent, non-departmental public body with enhanced powers (HSSIB, 2023a). It was officially launched on 18 October 2023 (HSSIBB, 2023b), when it published an investigation report on safety management systems (HSSIB, 2023c).
All the investigation reports that I have previously seen from the HSIB have been very thorough, with a lot of key information to weigh up, and have taken some time to read and unpack. This report follows that general pattern. There is a discussion of safety management systems (SMSs) in other industries such as aerospace, maritime, oil and gas, and so on. The report looks at how the principles of SMSs could be applied in health care, and what lessons there are for the NHS.
The report defines an SMS as a proactive and integrated approach to managing safety:
‘It sets out the necessary organisational structures and accountabilities and will continuously be improved. It requires safety management to be integrated into an organisation's day-to-day activities. There is no one-size-fits-all SMS, however, there are four recognised areas associated with many SMS frameworks.’
The four areas associated with SMS frameworks are given as: safety policy, safety risk management, safety assurance and safety promotion. The report goes into more detail on these headings. The HSSIB investigation identified three key opportunities for an organised approach to safety management. These include SMS development in health care, safety accountability frameworks and safety maturity assessments across healthcare systems.
‘There is variability in the current language and definitions that describe the safety activities, functions and processes already common across healthcare.’
Several safety recommendations are made, such as that NHS England should explore, and if appropriate support, the development and implementation of SMSs through an SMS co-ordination group.
The report provides a helicopter overview of SMSs and the information taken from other critical industries is both useful and enlightening. I found the Risk Management Maturity Model (RM3) from the Office of Rail and Road very interesting. It is a complex model, but it is comprehensive and sufficiently detailed. It is worth looking at this model more in the context of NHS patient safety policy development and practice.
State of Care annual report
A good barometer of the state of patient safety in the NHS in England is the annual State of Care report from the Care Quality Commission (CQC). In the latest one (CQC, 2023), the section on healthcare quality outlines a notable decline of quality in maternity, mental health and ambulance services.
All decline in care quality is worrisome, and NHS maternity services have been plagued by what I would regard as a constant stream of high-profile national patient safety crises in recent times. We can see this from Morecambe Bay (Kirkup, 2015), East Kent (Kirkup, 2022) and concerns in Nottingham (Murray and Weaver, 2023).
After all these crises, the hope was that maternity care matters would have dramatically approved, lessons being fully learnt. However, this has not been the case. The patient safety problems in maternity care are well known and documented and are stubbornly persistent.
‘This year, we continue to have concerns around the quality of maternity services. Ten per cent of maternity services are rated as inadequate overall, while 39% are rated as requires improvement. Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led.’
Other patient safety and healthcare quality concerns raised in the report include data from the NHS Staff Survey showing that one-third of staff said they saw errors, near misses or incidents in the preceding month that could have hurt staff or people using services (CQC, 2023: 39). The CQC highlighted that, although most NHS staff (86%) said their organisation encourages them to report errors, near misses or incidents, there has been a decline in the number of staff saying they would feel safe to raise concerns:
‘The greatest deterioration was seen in the percentage of staff who would feel secure raising concerns about unsafe clinical practice, which declined from 75% in 2021 to 72% this year. Staff who do raise concerns are also less confident that their organisation will address them.’
This latest State of Care report does provide a wake-up call on the current state of patient safety and health quality in the NHS, presenting a real-time picture of what is happening and the challenges that must be met.
Another important barometer of NHS success in developing a patient safety culture and care improvement can be seen in CQC inspection reports of individual NHS hospitals and other organisations. Even though these reports concern discrete, individual trusts, the findings often show common themes, in terms of patient failures, that have been around the NHS for some time – important, well-documented patient safety lessons not being learnt. The reports should be read holistically as they will often show successes as well. Unfortunately, the good patient safety work positives can often be eclipsed by the negative findings.
Compassionate communication, meaningful engagement
It is clear from reading past patient safety investigation and other reports that good communication is pivotal in providing safe and effective care. This seems almost too obvious a proposition to state, but failures of communication between health professionals themselves and with patients persist. They can be seen in many reports of investigations over the years as a central patient safety failing. I would argue that a direct correlation can be made between failures of healthcare staff to communicate properly and patient complaints and litigation. An improvement in one will lead to a reduction in the other.
Making Families Count (2023) has produced a best practice guide for supporting patients and families after a patient safety event. Sections in the report include principles of compassionate engagement, duty of candour, confidentiality, and information sharing, just culture, signposting.
Principles of compassionate engagement include such matters as ensuring that the contact details for the family, including details of the relationship to the patient, are accurate, as well as establishing how the patient prefers to be known. This is a well-structured, easy to follow report offering key advice, and practical information.
Conclusion
The reports discussed traverse a wide range of patient safety issues, as well as conceptual approaches to patient safety and the need to refresh perspectives. Advice is given on developing patient safety systems. Barometer readings on the national state of NHS patient safety in England are given as is advice on how to improve communication strategies.
These documents all make excellent contributions to the growing volume of patient safety literature, providing valuable insights into acute patient safety problems. However, the problem of proper dissemination into the NHS remains. These reports are now competing with many others and there will be more to come.