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CQC calls for a ‘change in safety culture’ to reduce NHS harm

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Lack of training, staff shortages and the complexity of the system are all contributing to unnecessary harm to patients, despite the best efforts of nurses, according to a major review by a regulator.

As a result of the findings, the head of the Care Quality Commission has today called for a change in culture within the NHS to reduce the number of patients who experience avoidable harm.

“Despite their best efforts, never events and other patient safety incidents continue to happen”

Ted Baker

In its national report, also published today, the CQC warned that that too many health service patients were being injured or suffering unnecessary harm.

It said this was because staff were not supported by sufficient training and that the complexity of the patient safety system made it difficult to ensure safety was an integral part of everything they did.

The CQC report – titled Opening the door to change – examines the issues that contribute to the occurrence of never events and wider patient safety incidents in NHS trusts in England.

The review was carried out at the request of the government and sought to help understand the barriers to delivering safe care and to identify learning that can be applied to improve patient safety.

Based on its findings, the CQC said it was calling on the NHS and its partners to promote a change in safety culture across the NHS, so that safety is “given the priority it deserves”.

The review was based on evidence gathered by inspectors during visits to 18 trusts and through group discussions with frontline staff, patients, and experts from other safety critical industries.

“We are developing a new patient safety strategy to sit alongside the long-term plan”

Aiden Fowler

The CQC said its findings revealed a strong commitment from NHS staff to make the care of patients as safe as possible.

But it noted the complexity of the system, with trusts receiving guidance from various different bodies – leading to confusion and a lack of clarity on which could provide information and support.

Added to this was the impact of increasing patient demand and staff shortages, which left little time for staff to implement safety guidance effectively, highlighted the regulator.

Although healthcare was by its nature “high risk”, the CQC review found that due to increasing pressures within the NHS, this was not consistently reflected in its culture and practice.

In contrast, other safety critical industries accept that their work was high risk, ensuring that this approach informed everything that they did, said the CQC.

There is still much the NHS can learn to ensure risks were identified and managed proactively, with a greater understanding of team dynamics, situational awareness and human factors.

The review identifies a need for a new programme of training to ensure the entire NHS workforce had a shared understanding of their role in patient safety from the moment they started their first job in healthcare and throughout their careers.

Ted Baker

edward ted baker

Ted Baker

Professor Ted Baker, the CQC’s chief inspector of hospitals, said: “NHS staff do a remarkable job to keep patients safe. But despite their best efforts, never events and other patient safety incidents continue to happen. In theory these events are entirely preventable: in practice too many patients suffer harm.

“Staff know that what they do carries risk, but the culture in which they work is one that views itself as essentially safe, where errors are considered exceptional, and where rigid hierarchical structures make it hard for staff to speak up about potential safety issues or raise concerns,” he said.

He added: “We know there is a strong commitment to patient safety within our NHS and we must support staff to give safety the priority it deserves.”

Dr Aidan Fowler, national director of patient safety at NHS Improvement, noted that a new patient safety strategy was being developed to go with the NHS Long-Term Plan, which is now due next year.

The strategy would propose “halving the number of patient safety incidents in key areas and introducing a national curriculum to standardise how incidents are reported and acted on”, he said.

Dr Fowler said: “The NHS is already leading the way for patient safety and much of this is a testament to the professionalism of frontline staff. But we must not be complacent.

“That’s why we are developing a new patient safety strategy to sit alongside the long-term plan which will ensure that there is an increased focus on safety improvement throughout the NHS,” he said.

“As CQC states in its review, key to this will be to develop a ‘just culture’ across the NHS, where staff are supported to be open and transparent about what is going on without fear of punishment for errors that are beyond their control,” he added.

“Continuous learning and improvement must be at the heart of protecting patients from avoidable harm,” stated Dr Fowler.

“Organisations must be able to respond effectively when staff raise concerns about risk and harm”

Amber Jabbal

Responding to CQC review, NHS Providers head of policy Amber Jabbal said: “Patient safety will always be a top priority for the NHS and CQC make clear that NHS staff are committed to ensuring that patients are kept as safe as possible.

“However, the CQC also found that funding, rising demand and workforce challenges make it difficult to learn from incidents and make changes effectively amid so many competing priorities, and that the current NHS approach to patient safety improvement adds confusion on top of these pressures,” she said.

“We very much welcome the report and are supporting the development of a national patient safety strategy,” she said. “The CQC have made recommendations that will bring much-needed clarity, consistency and alignment to patient safety efforts across the NHS.

“It is vital that they are supported as a priority, with all NHS organisations and staff given the training, expertise and resources needed to fully embed an effective safety culture, underpinned by a new coordinated national long term patient safety strategy,” said Ms Jabbal.

She added: “Organisations must be able to respond effectively when staff raise concerns about risk and harm in NHS care, to help reduce the risk of further patient safety incidents.”

Following its review, CQC has committed to strengthening its assessment and regulation of safety during inspection of NHS trusts and other sectors. The report has made the following recommendations to the government to support a change in approach from all parts of the healthcare system:

  1. NHS Improvement should work in partnership with Health Education England and others to make sure that the entire NHS workforce has a common understanding of patient safety and the skills and behaviours and leadership culture necessary to make it a priority. NHS Improvement and Health Education England should also develop accessible, specialist training in patient safety that staff can study as part of their clinical education or as a separate discipline.
  2. The National Patient Safety Strategy must support the NHS to have safety as a top priority. Driven by the National Director of Patient Safety at NHS Improvement, it should set out a clear vision on patient safety, clarifying the roles and responsibilities of key players, including patients, with clear milestones for deliverables. It should ensure that an effective safety culture is embedded at every level, from senior leadership to the frontline.
  3. Leaders with a responsibility for patient safety must have the appropriate training, expertise and support to drive safety improvement in trusts. Their role is to make sure that the trust reviews its safety culture on an ongoing basis, so that it meets the highest possible standards and is centred on learning and improvement. They should have an active role in feeding this insight back to NHS Improvement so that other NHS organisations can learn from it, as is the case in other industries.
  4. NHS Improvement should work with professional regulators, royal colleges, frontline staff and patient groups to develop a framework for identifying where clinical processes and other elements, such as equipment and governance processes, can and should be standardised.
  5. The National Patient Safety Alert Committee should oversee a standardised patient safety alert system that aligns the processes and outputs of all bodies and teams that issue alerts, and make sure that they set out clear and effective actions that providers must take on safety-critical issues.
  6. NHS Improvement should work with professional regulators and royal colleges to review the Never Events framework, focusing on leadership and safety culture and exploring the barriers to preventing errors such as human behaviours.
  7. CQC will use the findings of this report to improve the way we assess and regulate safety, to ensure that the entire NHS workforce has a common understanding of leadership and just culture, and the skills and behaviours necessary to make safety a priority.



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