Opening the door to change

In Opening the door to change the Care Quality Commission (CQC) looks at NHS safety culture around avoidable medical mistakes which it calls ‘never events’. It’s primarily focused on secondary care, but there are lessons for primary care here too. We look at what practices can learn from this key report

The NHS has an impressive record on ensuring that patients receive the highest quality of care, successfully treating millions of patients every day. In secondary care, when things go wrong, patients’ lives can be on the line.

In 2017-18 there were 21,500 reported serious incidents in the NHS, with approximately 500 of these classed as ‘never events’. These are situations that shouldn’t occur but, sadly, do; what makes them stand out is that they are entirely preventable. This means that, in the previous year, over 500 patients were unnecessarily harmed by the system that should be helping them.

Every never event is a cause for concern, but it is also an important learning point – offering an opportunity to ensure that the mistakes that caused the unfortunate incident are never repeated.

Every never event is a cause for concern, but it is also an important learning point – offering an opportunity to ensure that the mistakes that caused the unfortunate incident are never repeated.

In Opening the door to change the CQC brought together healthcare staff with experience of managing safety issues and safety experts from other safety-critical industries to explore the culture of safety and how the NHS can improve. While the report focuses on secondary care, there are important learning point for primary care too.

Patient safety challenges

Pressure in secondary care is affecting the ability of staff to focus on patient safety issues, with the CQC reporting that, ‘Patient safety alerts can be seen as just one more thing to do, and can lead to staff taking a mechanistic and ‘siloed’ approach to implementation.’ When this happens, never events can occur.

The cascading of information through teams in healthcare is a challenge in all areas, with the CQC suggesting that greater standardisation of processes, like those adopted in other industries, may be beneficial. Driving the patient safety culture requires strong leadership, and rigid hierarchical structures within secondary care are identified as potential barriers to communication and as acting as an impediment to the introduction of new, and potentially safer, practices.

Across the healthcare system, the CQC notes that all the bodies involved in setting the patient safety agenda – CQC, royal colleges and professional regulators – have a ‘substantial’ role to play in leading patient safety, but that the current system is complex and confused; it can be difficult, in these circumstances, for healthcare providers to prioritise the most important safety-related issues.

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Primary care interface

On the relationship with primary care, the trusts engaged were ‘generally positive’ about the support given by clinical commissioning groups (CCGs) following the publication of an alert, or after a never event; however, there was some variation.

‘Some CCGs were comprehensive and collaborative in their approach, visiting trusts to observe how they implemented guidance, talking with staff and patients and having frequent meetings with trust leaders’ ,the report concludes. However, ‘Some saw assurance and monitoring as simply checking what trusts are doing administratively, without getting involved.’

Training and development is essential to maintaining and improving patient safety within the health service but, for many staff, the perception was that safety education wasn’t a priority for leaders. This is in contrast to other industries where ongoing training is considered ‘crucial’ to preventing the development of potentially damaging, ‘habitual’ behaviours.

Future steps?

Learning from other industries, the CQC proposes training in human factors – the interaction between humans and systems – to help improve learning. Training should also be conducted alongside other colleagues in multi-disciplinary teams, not separately in individual clinical groups or specialities. This approach can help to identify – and plug – any potential gaps in communication that could lead to patients experiencing harm.

While not a particular focus for the study, the CQC acknowledges that patient involvement is important, but believes that it’s not done consistently well across systems.

The CQC acknowledges that patient involvement is important, but believes that it’s not done consistently well across systems.

A commitment to quality of care should be assumed among a group of staff whose entire purpose is to make people better; it provides a solid basis on which to introduce a more comprehensive, and engaging, culture of patient safety improvement.

In the future the CQC will use the findings of this report to improve the way it assesses and regulates safety, in order to ensure that the entire NHS workforce – not just those in hospital trusts – has a common understanding of leadership and just culture, as well as the skills and behaviours necessary to make safety a priority.

The CQC is proposing seven recommendations. You can read these, and a full copy of the Opening the door to change report, here.

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