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CQC calls for a change in safety culture across the NHS to reduce avoidable harm
England’s chief inspector of hospitals is calling for a change in culture within the NHS to reduce the number of patients who experience avoidable harm.
In a national report published today, the Care Quality Commission (CQC) found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.
The CQC report, 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 Secretary of State for Health and Social Care 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, CQC is 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.
Professor Ted Baker, 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.
“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. NHS Improvement’s vision for a new patient safety strategy is a welcome development in achieving this aim.
“Everyone – including patients – can play a part in making patient safety a top priority and the recommendations we make today aim to achieve that. But there is a wider challenge for us all to effect the cultural change that we need, to have the humility to accept that we all can make errors – so we must plan everything we do with this in mind.
“This change in approach is essential if we are to create a just culture where learning is shared, and where solutions are created proactively to manage risk. Only then will we be able to reduce the toll of never events and the much greater number of other safety incidents.”
The review was based on evidence gathered by inspectors during visits to 18 NHS trusts, and through group discussions with frontline staff, patients, and experts from other safety critical industries.
CQC’s findings show a strong commitment from NHS staff to make the care of patients as safe as possible. But, the report also highlights the complexity of the current patient safety system; with trusts receiving guidance from a number of different bodies leading to confusion and a lack of clarity on which external organisations can provide information and support. Added to this is the impact of increasing patient demand and staff shortages which leave little time for staff to implement safety guidance effectively.
Although healthcare is by its nature ‘high risk’, the CQC review found that due to increasing pressures within the NHS, this is not consistently reflected in its culture and practice. In contrast, other safety critical industries accept that their work is high risk, ensuring that this approach informs everything that they do. While it is recognised that healthcare is different, there is still much the NHS can learn from these high risk industries to ensure risks are identified and managed proactively, with a greater understanding of team dynamics, situational awareness and human factors, and with safety protocols followed consistently.
The review identifies a need for a new programme of training to ensure the entire NHS workforce has a shared understanding of their role in patient safety from the moment that they start their first job in healthcare and throughout their careers.
Dr Aidan Fowler, National Director of Patient Safety at NHS Improvement, 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.
“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. Continuous learning and improvement must be at the heart of protecting patients from avoidable harm.
“The strategy proposes halving the number of patient safety incidents in key areas and introducing a national curriculum to standardise how incidents are reported and acted on.”
Following this 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 support a change in approach from all parts of the healthcare system. These recommendations have been presented to the Secretary of State for Health and Social Care:
- 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.
- 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.
- 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.
- 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.
- The National Patient Safety Alert Committee (NaPSAC) 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.
- 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.
- 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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- Last updated:
- 17 December 2018
Notes to editors
About the review:
Never events are serious incidents that are regarded as wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
Healthcare providers must report on the occurrence of never events and other serious incidents through the Strategic Executive Information System (StEIS), a system that assists the reporting and monitoring of investigations between NHS providers and commissioners. Provisional data between 1 April 2017 and 31 March 2018 shows 468 incidents were classified as never events.
In Autumn 2017, the Secretary of State for Health asked the Care Quality Commission in collaboration with NHS Improvement, to examine the underlying issues in NHS trusts that contribute to the occurrence of never events and thereafter the learning can be applied to wider safety issues. NHS Improvement’s patient safety team acted as specialist advisors on this review
The review focused on four main questions:
- How is the guidance (to prevent never events) performing?
- How do trusts implement this safety guidance?
- What do other system partners do to support trusts with implementation of safety guidance?
- What lessons can we ‘actually’ learn from other industries and other countries?