Lessons from NHS Patient Safety Guidelines

A culture of patient safety must be the primary healthcare goal of any organization targeting continuous quality improvement. NHS defines the elements of improvement, insight, and involvement as the three important goals to achieve a patient safety culture. Patient safety frameworks promote psychological safety, team work, and set safety standards. Safety improvement is possible in primary and community settings through integrated care pathways in a patient-centered manner. The Improvement Academy of the NHS implements a patient safety culture through multiple networks including the Acute Sepsis Network, Patient Safety Collaborate Network, and Quality Improvement Trainers Network to reduce harm, improve quality and safety, and execute initiatives across multiple domains. 

Geography: United Kingdom; Focus Area: Patient safety

Patient safety is the primary healthcare goal at the NHS. According to the NHS, patient safety is not an individual effort, and promoting continuous improvement in patient safety requires a patient safety system and patient safety culture. In this connection, three strategic goals support the purpose: involvement, insight, and improvement (NHS England & NHS Improvement, 2019). 

• Insight refers to deriving intelligence from multiple sources of patient safety information to improve the understanding of safety - the use of safety measurement, culture metrics, safety learning systems, medical examiner system, improve response to emerging risks, share litigation insight and prevent harm, and implement the Patient Safety Incident Response Framework

• Improvement refers to the design and execution of programs for effective and continued change in the fields that require most attention - deliver the National Patient Safety and Improvement program, Maternal and Neonatal Safety Improvement program, Mental Health Safety Improvement program, Medicines Safety Improvement program, support safety programs for older people, people with learning disabilities, improve safety in the area of microbial resistance, and promote research and innovation to support safety improvement

• Involvement refers to assisting partners, patients, and staff with the opportunities and skills that will improve patient safety for the whole system - involve patient, carers, and families to promote safer care, create system-wide patient safety training and education framework, train people to respond to positive and negative events, assist safety specialists to lead safety improvement, and ensure healthcare system involvement in safety agenda

Promotion: Washington Manual of Patient Safety and Quality Improvement Paperback – 1 January 2016 by Fondahn (Author)

  

In a patient safety framework, psychological safety of staff is promoted, diversity is respected, vision and leadership is promoted at all levels, and openness and teamwork is supported for learning. Regulations are required to check whether safety systems meet the required standards (NHS England & NHS Improvement, 2019). Regulatory organizations such as the Nursing and Midwifery Council, General Medical Council, Health and Care Professions Council, Care Quality Commission (CQC), and  Medicines and Healthcare products Regulatory Agency (MHRA) set standards in their respective areas.

Safety improvement has different meanings in diverse healthcare contexts. In primary and community care, integrated care pathways are utilized to promote accountability and safety. Likewise, digital strategies, medication safety will enable safe care (Improvement Academy, 2021). The Improvement Academy of the NHS implements a practical, flexible, and collaborative approach in partnership with stakeholders to improve patient and staff experience through patient-centered care, apply behavioral change methods to address quality improvement challenges, utilize evidence based interventions to reduce patient harm and improve communication and safety culture, provide practical implementation expertise to health services and researchers, measure and benchmark team safety culture, and understand human psychology to keep patients safe.

Promotion: Patient Safety Ethics: How Vigilance, Mindfulness, Compliance, and Humility Can Make Healthcare Safer 1st Edition, Kindle Edition by John D. Banja (Author)

     

The Improvement Academy operates through multiple networks to address major healthcare concerns (Improvement Academy, 2021):

• The Patient Safety Collaborative Network enables improvement in health and social care. It is a platform to discuss challenges, share ideas, and collaborate to expand networking opportunities that will support its initiatives. The patient safety network operates through multiple themes including mental health, medication safety, deterioration management (through patient safety networks, emergency department networks, and sepsis network), maternal and neonatal health, and adopt and spread network (through COPD and asthma acute hospital discharge network, emergency laparotomy collaborative, and tracheostomy care).

• The Acute Sepsis Network is engaged in supporting safe care for people living with sepsis. Injury to tissues and organs due to sepsis is a growing concern. The Improvement Academy manages this through the involvement of multiple programmes including Managing Deterioration Safety Improvement Programme (improve safety in care homes, test interventions for early recognition of deterioration, improve communication and response in care homes with a focus on recognition, response, and communication, support advance care plans, primary care networks, and patient safety networks), System Safety Improvement Programme (mobilize effective Patient Safety Improvement Networks and support the Patient Safety Incident Response Framework), and Patient Safety Collaborative (reduce harm and variation, share learning).

• The Quality Improvement Trainers Network provides training and professional development as a platform for continuous learning. Quality Improvement training equips leaders with the skills and knowledge required for operational and strategic support for a sustainable improvement culture within the organization. Quality improvement is the combined training consisting of human factors, behavior change, utilizing data in improving healthcare, in addition to improving quality.

In conclusion, the Improvement Academy of the NHS provides resources to nurses, midwives, doctors, allied health professionals, social care workers, managers, and home care staff to promote patient safety and reduce harm through a multitude of initiatives spread across domains, from specialty care, to emerging infectious diseases, to patient experience, safety, and quality improvement.

Promotion: Handbook Of Healthcare Quality & Patient Safety Paperback – 1 January 2017 by Gyani J Girdhar (Author)

Promotion: Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare Audible Logo Audible Audiobook – Unabridged by Craig Clapper (Author), James Merlino (Author), Carole Stockmeier (Author), Gary MacFadden (Narrator), McGraw Hill-Ascent Audio (Publisher)

     

Keywords

NHS Improvement, learning systems, patient safety, prevent harm, quality improvement, safety, safety measurement, safety improvement, NHS England, accountability

References

Improvement Academy. (2021). Improvement Academy. Improvementacademy.org. http://www.improvementacademy.org

NHS England, & NHS Improvement. (2019). The NHS Patient Safety Strategy. In Improvement Academy. https://www.improvementacademy.org/wp-content/uploads/2022/04/Report-template-NHSI-website-for-PSC-Page.pdf