Levers and initiatives: national patient safety strategy in England
| Lever | Examples of current initiatives |
|---|---|
| Regulation and inspection | Development of national healthcare standards as the basis for inspection to be undertaken by independent scrutineers, the Healthcare Commission. Patient safety has been identified as a specific domain of the standards. Work is ongoing to identify criteria by which safety performance should be assessed in relation to these standards to identify both poor performing and high performing services. |
| Purchasing and design | Use of NHS purchasing power via a single national purchasing agency to increase safety of products supplied to the NHS and the design of interventions—for example, a toolkit to help hospitals review and improve their decision making about purchase of infusion devices with patient safety as a key consideration. |
| Market incentives | Articulating the business case for local organisations to invest in patient safety within national solutions development—for example, tools which help organisations systematically to assess the cost benefit of implementing better management systems for infusion devices or the introduction of alcohol gel at the hospital bedside to improve hand hygiene. In future, provision of comparative safety profile information to guide consumer choices. |
| Professional ethos and commitment to improve | Harnessing the commitment of professional Royal Colleges to improving patient care through the appointment of patient safety champions across a range of clinical specialties. |
| Rolling out a national programme of root cause analysis training to improve skills in incident investigation among frontline staff. | |
| Working with higher education providers to develop safety components within professional education and training. | |
| Measurement and system learning | Implementation of a “national reporting and learning system” to nationally aggregate and analyse patient safety incident reports in conjunction with other sources of information. Feedback and publication of results. |
| Organisational governance and development | Disseminating national guidance on actions to be taken by healthcare organisations to support patient safety improvements. |
| Developing tools to support Boards in governance of patient safety including safety training programmes—for example, dissemination of policies to reduce punitive outcomes for staff following patient safety incidents and the development of tools to measure “safety culture” within NHS organisations. | |
| NHS infrastructure | Mobilising NHS infrastructure in the cause of patient safety by building safety considerations into NHS-wide information management and technology developments |
| Influencing the estates strategy by emphasising patient safety as a parameter of good design, particularly for new capital developments | |
| Public and patient involvement | Ensuring that patient experience feeds into the development of national safety solutions—for example, patient experience reference groups |
| Developing national guidance on staff and organisational openness with patients and carers following a patient safety incident | |
| In future, supporting members and public governors of foundation hospitals with information about safety |