This article originally featured in the Summer 2018 edition of the Care Home Nursing Journal (CNJ), produced by Four Seasons Health Care for nurses.
Patient Safety is a well-recognised concept in acute healthcare, but the idea of “resident safety” as a defined area of study and improvement in adult social care is less prevalent. This needn’t be the case though, and those providing care in nursing and residential homes can capitalise on the large body of existing patient safety work.
Acknowledging the Problem
The idea of Patient Safety is now firmly embedded in the NHS, having had many years to take root and demonstrate positive outcomes. A famous line by Florence Nightingale – “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” – is frequently quoted in review articles, but the perception that errors in clinical care might be widespread still took many decades to become widely acknowledged. In 1999, the US Institute of Medicine published a report titled “To Err is Human”. This was the first to openly discuss and publicise the scale of harm to patients in the United States, and suggested that harm could be best reduced by changing the systems involved rather than blaming individuals. This is a topic which arises again and again in subsequent years. In the UK, the Department of Health released a report by Sir Liam Donaldson in 2000 addressing similar issues. “An Organisation with a Memory” proved to be a landmark piece of work, identifying a number of additional reasons why patent safety was so important, beyond the harm sustained by patients. These included hospital-acquired infections costing almost £1billion per year, and almost 30,000 written complaints regarding clinical care in hospitals.
“Building safety into processes of care is a more effective way to reduce errors than blaming individuals. The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.”
To Err is Human, IoM, 1999
More importantly, the report considered the mechanisms by which improvement could take place. The National Patient Safety Agency (NPSA) was established the following year, with the aim of learning lessons and minimising avoidable harm to patients across the UK.
“Activity to learn from and prevent failures […] needs to address their wider causes. It also needs to stretch beyond simply diagnosing and publicising the lessons from incidents, to ensure that these lessons are embedded in practice.”
An Organisation with a Memory, 2000
The NPSA did important work in raising the profile of patient safety throughout the health and social care professions, including publishing “Seven steps to patient safety”, which gave advice on how to create an entire safety ecosystem in healthcare.
Seven steps to patient safety
1. Build a safety culture.
2. Lead and support your staff.
3. Integrate your risk management activity.
4. Promote reporting.
5. Involve and communicate with patients and the public.
6. Learn and share safety lessons.
7. Implement solutions to prevent harm.Seven Steps to Patient Safety, 2004
Where does nursing in care homes fit in?
The principles outlined in An organisation with a memory specifically focused on “NHS organisations”, while Seven steps to patient safety referenced private healthcare but beyond that did not particularly engage with the sector. Quality and safety in independent providers are monitored via a number of means, including mandatory information returns to regulators, and associated inspection visits, along with contract monitoring by commissioners and investigations by local safeguarding teams. However, the demise of the NPSA, and the commercial aspect of operations, means that there is no central organisation or forum promoting or coordinating resident safety in the care home sector. This can make it hard for clinical staff to find resources and examples of good practice.
Care homes also face different problems to acute hospitals and primary care. The Department of Health report into abuse at the Winterbourne View care home gave recommendations relating to safeguarding, compliance with the Mental Health Act, and medication, but contained few wider-ranging recommendations applicable to more varied incident types. More recently, however, the Care Quality Commission (CQC) published its Quality Matters document (2017), specifically aimed at the adult social care sector in England. The document states that it aims to “bring the adult social care sector together in support of the agreed principles that underpin good quality adult social care. It […] sets out clear action plans that support the delivery of priorities for improving quality[…]. Crucially, it highlights that quality is everybody’s business.” A number of workstreams are under way to help deliver this, including under the heading “Our shared view of quality”, which aims to ensure that “People are protected from avoidable harm, neglect and abuse. When mistakes happen lessons are learned.”. Clearly it is critical that lessons are then shared within organisations and externally, to maximise the impact of the learning. Whether the majority of independent operators will engage with these concepts without legislative persuasion remains to be seen.
Finally, the commercial imperative to improve resident safety should not be underestimated. By demonstrating to residents, commissioners and regulators that they operate safely, organisations can make themselves the ‘provider of choice’ and secure vital business. This extra income can help further improve safety if invested in the modernisation of processes and infrastructure (such as the implementation of electronic care records, or new clinical equipment). There can be a temptation to shy away from the fact that commercial operators ultimately have a duty to make money on behalf of, for example, shareholders. However, this freedom from the well-documented bureaucracy of the NHS should also be seen as an opportunity to move quickly and make innovative changes which may not be possible in a more constrained environment.
How do we fix the problem?
An Organisation with a Memory stated that one of the barriers to improvement was organisational culture, particularly the idea of a ‘blame culture’. Far more prevalent nowadays is the concept, borrowed from the aviation industry, of a ‘just culture’ – if a nurse makes a genuine mistake then they are supported with training or mentoring, for example. If internal policy, or the law, is deliberately and knowingly broken then staff will be held to account. It is therefore essential that teams feel able to report incidents without fear of recrimination. Including this principle in policy is the first step, but the only practical way to achieve a just culture in practice is for clinicians and managers to lead by example, and focus on supporting staff and fixing system or process issues. Anecdotally, incident reporting is often seen simply as paperwork or an administrative burden, when it is actually the primary mechanism by which system failures are highlighted and accurately described. Teams need to feel confident that they will not be automatically blamed for an incident, and to see that action does actually result from the incident reports and development suggestions that they submit.
Becoming involved in investigations, beyond the initial incident report, gives clinical staff a direct opportunity to change ways of working, in a manner which has a positive effect on the care provided to residents. This also provides a means by which nursing staff are able to focus on driving improvement in their own areas of special interest, such as falls, pressure damage, or palliative care, developing their skill set in the process. All too often, investigations focus on the actions taken to deal with the individual incident in question – we should instead be asking “What actions will prevent the same thing happening again, to the same person or to anyone else?”. Coincidental with this is a duty on organisations to provide a corporate structure under which such actions can be completed as often as possible, with lessons shared to all.
Throughout these areas, the fundamental pillars drawn up in An organisation with a memory nearly 20 years ago remain vital:
- unified mechanisms for reporting and analysis when things go wrong;
- a more open culture, in which errors or service failures can be reported and discussed;
- mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice;
- a much wider appreciation of the value of the system approach in preventing, analysing and learning from errors.
An Organisation with a Memory, 2000
A crucial aspect of the development of the “more open culture” is the Duty of Candour legislation introduced in England in 2015, and in Scotland in April 2018. This arose primarily from the Mid Staffordshire NHS Foundation Trust Public Inquiry, published in 2013, and the subsequent Freedom to Speak Up review by Robert Francis. One of the Mid-Staffs findings was that patients were involved in serious incidents, but never informed about the incidents themselves, or the potential long-term effects. Involving residents in incidents provides a means of reassurance, but also presents an opportunity to gather important information about contributory factors. As well as the legal duty of candour in England and Scotland, nurses throughout the UK have a professional duty of candour under the NMC code.
Most recently, an NMC consultation started in April 2018 recognises the importance of learning lessons as a fundamental element of fitness to practise. The consultation document states that “We [the NMC] consider that effective and proportionate fitness to practise means putting patient safety first, and that an open, transparent and learning culture will best achieve this.”
Measuring the effects – is your organisation working safely?
Once staff are comfortable reporting incidents, and teams are carrying out effective investigations, their effectiveness can be assessed. Measuring whether a care home operator is working safely or not is difficult. Work in acute settings has identified that many incidents go un-reported (Lawton & Parker, BMJ Quality & Safety, 2002), and there is no reason to suggest that the situation is any different in care homes. It also should not be assumed that a large number of incident reports means an unsafe organisation – identifying lots of near misses enables action to be taken before they develop into incidents; clearly this is a desirable outcome. In addition, companies with operations across the various home nations of the UK may be asked to measure different metrics by different regulators and commissioners, stifling their ability to compare and contrast between individual services.
If such internal benchmarking is difficult, national benchmarking between private companies is all but impossible. In England, the National Reporting and Learning System (NRLS) is a system into which all patient safety incidents at NHS Trusts are automatically reported. It facilitates benchmarking between similar organisations, and allows its operator, NHS Improvement, to identify national trends. It also has the advantage that the CQC are able to query it directly, and therefore do not require manual forms to be submitted regarding notifiable events. However, the system does not currently capture information from independent providers. Work is under way to upgrade the system by 2020, to create a new Patient Safety Incident Management System (PSIMS). This includes input from private providers of adult health and social care, giving the potential to create the first national means of gauging the relative safety of individual independent organisations. The risk is that reporting is not currently planned to be mandatory, so commercial companies will need to be bold enough to start sharing potentially contentious figures in an effort to achieve the broader goal of improving quality. Outwith the NRLS, any other projects will need to establish not only which metrics are most important, but also how their measurement can be standardised given variations in number of beds, occupancy, resident acuity, and varying types of care (dementia, intermediate care, respite, etc.).
While not easy to aggregate into a single indicator, it is evident that resident safety needs to be measured so that improvement can be identified (there is little point sinking effort into initiatives which make no difference to resident care). The collection of accurate, timely data is fundamental to this process, and the need for accurate reporting – as discussed earlier in this piece – is critical.
Care homes can also take advantage of the excellent research carried out by UK universities. This has been, to date, rather sparse, but this offers the tantalising prospect that even apparently obvious ideas simply haven’t been explored yet. The involvement of individual care homes and nurses in collaborative research projects provides an opportunity to identify dedicated time in which to delve deeper into specific issues, often obtaining insights which would be otherwise missed. This is also valuable personal development for the team members involved.
Where next?
Patient safety remains a hot topic within the UK. In England in 2017 the independent Healthcare Safety Investigation Branch (HSIB) was formed to “improve safety through effective and independent investigations that don’t apportion blame or liability”. This is a significant development, with HSIB being analogous to the well-respected independent Air Safety Investigation Branch which has led so many safety improvements in aviation. The Scottish Patient Safety Programme continues to operate, while Patient Safety Wales has a presence but few resources targeting care homes.
While government may be slow to react, health and social care professionals, along with industry, continue to strive to improve. The pressure under which nurses operate mean that it can be difficult to step back and consider the wider circumstances contributing to an incident, rather than just fixing the immediate issue. However, the potential benefits of doing so are clear.
Alongside action by individuals, care home operators need to self-organise and capitalise on work already completed in the NHS. The particular needs of the sector will mean that inter-organisation sharing of aggregate data and topic-specific lessons will become increasingly important.
A combined approach from nurses, carers, governance teams, and entire companies has the potential to deliver vast improvement in the standard of resident care. Much of that work will entail new and exciting developments; those involved in improving resident safety should be proud of their achievements, and shout about them from the rooftops.
About the author:
Haydn has 15 years of experience working in patient safety in acute NHS hospitals and private-sector care homes. His PhD at the University of Nottingham investigated protein folding in the formation of Alzheimer’s disease amyloid plaques.
Resources:
Patient Safety hub – NHS Improvement – https://improvement.nhs.uk/improvement-hub/patient-safety/
Patient Safety Timeline – The Health Foundation – http://www.health.org.uk/patient-safety-timeline
Development of the Patient Safety Incident Management System project – NHS Improvement – https://improvement.nhs.uk/news-alerts/development-patient-safety-incident-management-system-dpsims/
Seven Steps to Patient Safety – NPSA, 2004 – http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/
Patient Safety First – http://patientsafety.health.org.uk/resources/patient-safety-first-2008-2010-campaign-review
Healthcare Safety Investigation Branch – https://www.hsib.org.uk/
“A public consultation on changes to our fitness to practise function” – NMC, April 2018:https://www.nmc.org.uk/globalassets/sitedocuments/consultations/2018/ftp/ftp-consultation-info.pdf
Freedom to Speak Up – http://freedomtospeakup.org.uk/the-report/
Duty of Candour – Nursing & Midwifery Council – https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/read-the-professional-duty-of-candour/
RCN Duty of Candour:
https://www.rcn.org.uk/get-help/rcn-advice/duty-of-candour
Patient Safety and Human Factors – Royal College of Nursing – https://www.rcn.org.uk/clinical-topics/patient-safety-and-human-factors
To Err is Human – US Institute of Medicine, 1999 – http://www.nap.edu/books/0309068371/html/
An Organisation with a Memory – Donaldson, 2000 – http://webarchive.nationalarchives.gov.uk/20130105144251/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4065086.pdf
Building a safer NHS for patients: Implementing an Organisation with a Memory – Department of Health, 2001 – http://webarchive.nationalarchives.gov.uk/20120106001900/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4058094.pdf
Transforming care: A national response to Winterbourne View Hospital – Department of Health, 2012 – https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry – Robert Francis QC, 2013 http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/
A promise to learn – a commitment to act: improving the safety of patients in England (Berwick Review into Patient Safety) – Department of Health, 2013 – https://www.gov.uk/government/publications/berwick-review-into-patient-safety
The Report of the Morecambe Bay Investigation – Dr Bill Kirkup, 2015 – https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
Quality Matters (Adult Social Care) – CQC, 2017 – https://www.gov.uk/government/publications/adult-social-care-quality-matters
Barriers to incident reporting in a healthcare system – Lawton & Parker, BMJ Quality & Safety, 2002;11:15-18 – http://dx.doi.org/10.1136/qhc.11.1.108
Just Culture: Balancing Safety and Accountability – Sidney Dekker, 2007
Human Error – James Reason, 1990