To achieve the goal of making the NHS the safest health service in the world, DAC Beachcroft looks at why we need to understand when the vast majority of things go right, as well as why a small minority go wrong.
The NHS has announced ambitious plans to make it "the safest health service in the world". The plans, announced in December 2018, propose major enhancement of the National Reporting and Learning System (NRLS), which receives over two million incident reports every year.
It proposes that the most important types of avoidable harm, such as medication errors or 'never events' (such as wrong side or wrong site), will be halved over the next five years. The focus will be on areas where litigation costs are highest – such as maternity – and where there is the greatest variation.
In the 15 years since the NRLS was introduced, its analysis of incident data has led to enhancements that have removed or reduced significant risks. And whilst the NRLS receives two million reports a year, it only reads those regarding significant harm and uses that information to search its database. A new patient safety incident management system will replace the NRLS and use artificial intelligence and machine learning to explore how to enhance what goes well, rather than just looking at what goes wrong.
LOOKING AT THE POSITIVES
While learning from mistakes is important, the NHS is being asked for a shift in philosophy from ensuring that "as few things as possible go wrong" to ensuring that "as many things as possible go right".
This perspective, known as 'Safety II', relates to the system's ability to succeed under varying conditions. "A Safety II approach assumes that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and hence is the reason why things go right. Humans are consequently seen as a resource necessary for system flexibility and resilience," its proponents state.
Denise Chaffer, the Director of Safety and Learning at NHS Resolution, says learning from claims will also bear fruit. She cites opportunities for improvements – in areas including maternity services, reduction in cerebral palsy cases, prevention of needle-stick injury and suicide prevention – that have arisen from analysis of its claims data.
NHS Resolution's clinical research fellows carry out 'deep dive' analysis of closed cases to examine what went wrong and make subsequent recommendations. For example, the investigation into cerebral palsy contributed to the development of the Clinical Negligence Scheme for Trusts' (CNST) Maternity Incentive scheme and an initial ten maternity safety actions. "The actions were agreed with the national maternity safety champions in partnership with the Collaborative Advisory Group, which includes royal colleges and other interested groups. Trusts that demonstrate that they have achieved all ten, will recover the element of their contribution to the CNST," Chaffer says.
Trusts also receive data in relation to their own claims (known as 'claims score cards'), so they can identify and learn from them and triangulate with incident and complaints data to support the prevention of harm.
LEARNING FROM MISTAKES
In March 2019, a Care Quality Commission (CQC) report, concluded that NHS trusts need to move faster to implement CQC guidance on learning from deaths. The report makes a number of recommendations around how trusts engage with families and carers, board prioritisation of learning from deaths, improved resources for staff training and creation of an open learning culture.
The "safest health service in the world" proposals concur that the NHS must promote development of a 'just culture' where staff are supported to speak up when errors occur. A 'curriculum for patient safety' is proposed that can be used from boards to wards to standardise how incidents are reported and acted on.
Similar curricula have been used in Australia and Canada for over a decade. However, currently in the NHS, all staff are given training in fire safety, but not patient safety. This is despite many witnessing a patient safety incident during their careers.
Amber Jabbal, Head of Policy at NHS Providers, says that trusts are now developing an open culture. "A supportive culture can lead to higher levels of staff engagement and patient satisfaction, and can reduce errors."
But she says rising demand and workforce challenges make it difficult to learn from incidents, and make the requisite changes amid myriad competing priorities.
LEADING FROM THE TOP
She wants greater support for staff by developing quality improvement training programs. "Trusts need to be supported by national bodies to prioritise this work, reduce regulatory burden and ensure changes to national safety policy are given reasonable time to embed."
DAC Beachcroft Partner Corinne Slingo agrees: "We see continuing tension between the absolute commitment by most providers to achieve a truly open safety culture, and the increasing enforcement activity at a regulatory level (corporate provider), and individual level (criminalisation of clinical incidents)."
She says leaders embrace the moral drive to do no harm and to lead on quality improvement, but fear of sanctions weigh heavily. "Increasingly severe penalties for getting it wrong can create the opposite set of behaviours to the well-led culture of safety that regulators expect," she says.
While legal, regulatory and disciplinary frameworks exist to ensure sanctions, the ambition for regulators "is to create meaningful 'bite', to act as a deterrent and a motivator for providers to increase safety measures and drive through a more effective culture".
Sanctions, Slingo feels, "need to find a natural balance such that they do not become so commonplace as to reduce the impact, nor punish genuine human error in such a way as to increase the fear of raising concerns and learning openly from flaws in care."
She continues: "A proactive safety culture is unlikely to be achieved through fear of sanction alone, and yet those remain the headline grabbers. Finding a way to materially reward safety innovators - individually and corporately, to offset the fear drivers, would potentially deliver a greater motivational balance to the next era of safety in health and social care."
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