Patient safety: sharing intelligence

Patient safety: sharing intelligence

Published 13 diciembre 2017

The quest for ‘well led’ remains a work in progress with different elements of the UK health sector demonstrating different approaches to the energy they invest in data and how they rely on it for driving improvement.

There are some positive signs on leadership for safety – “but it is not yet standardised”, says DAC Beachcroft partner Corinne Slingo.

“There are defined, although diverse, reporting lines up to board level, but the survey reveals there is further work to do to achieve true leadership of safety data dissemination from the board to the operational staff/ward level.”

Slingo suggests it comes as a surprise to see how few organisations appear to use their own incident data to drive learning and improvements. And there is less focus than might have been expected on data around workforce levels and staff sickness rates to correlate across to safety.

“It was interesting that responses to open questions recognise that data might help inform safety and avoid recurrence – through sharing learnings across the sector. However, that sharing is still not happening consistently when it comes to disseminating information about significant events and near misses.”

DAC Beachcroft partner Anne Croft comments on the fragmented approach to data: “The concept of Accountable Care Organisations (ACOs) brings with it the possibility of a more consistent approach to patient safety processes. However, until ACOs are a reality, the STP/ACS structure is comprised of independent organisations with their own operating procedures and reporting structures, rather than common standards, and this results in a fragmented approach.

“In international examples of ACOs, reporting and clinical safety response is often driven by the funder, typically an insurance entity that is also responsible for meeting clinical negligence liabilities, which can incentivise a more aligned approach to responding to data.”

Sharing intelligence

Healthcare must learn more about safety from the oil and gas industry, and the aircraft sector, according to Professor Bewick.

It must also develop and offer specialist training so that non-executive board members have the confidence to interrogate clinicians. He recommends the creation of separate committees, directly reporting to the board about how the organisation receives, monitors and acts on patient safety data.

Professor Bewick also calls for more liaison with NHS Resolution and medical indemnity organisations to share their intelligence on medical error and clinical negligence, and for consistent and effective use of incident data.

Intelligence from national initiatives should be disseminated as widely as possible, adds Heather Durston-Hillyer. “It is a recurrent theme we hear from trusts that they want to benchmark themselves with similar organisations but the ability to do that just isn't there. GIRFT has been able to do that. The fact that the Department of Health through NHS Improvement is providing the funding to roll their programme out to all specialities is welcome news.”

She says there is a desire at all levels to use data and share learning within the patient safety arena, but it is being held back “by the challenges organisations face of having a plethora of sources and not having a clearly defined governance framework in place for capturing, analysing and disseminating the learning”.

Board members need to be trained to be confident about asking the right questions. Giles Peel explains: “There is a wealth of sources of information on clinical best practice that may not be visible to the vast majority of non-executives. For example, clinical networks – neonatal or stroke – which signpost best practice and new developments. How do we get the debate around best practice reorganised in a way that means that people can have a view on it? Given where we are within the wider world of information technology, it is a worry that individuals can still say 'I know best'.

“In business, in the oil and aviation industries, these independent boards usually have fewer inhibitions in challenging experts. There is still a reluctance for non-clinicians to challenge clinicians – a historic hangover from the old days of doctor knows best.”

Whilst the cultural challenges in the sector are clear, what is also evident is the ambition to position patient safety at the forefront when it comes to decision-making. The sharing of intelligence will likely drive forward developments here; acquainting organisations across the health sector with best practice in identifying the most useful data channels and, crucially, managing the flow of learning from board level to the point of delivering care.

We would be very happy to discuss any aspects of this report with you – please feel free to contact us at cboston@dacbeachcroft.com or call +44 (0)117 918 2467.

Download the full report here.

Authors

Corinne Slingo

Corinne Slingo

Bristol

+44 (0)117 918 2152

Anne Crofts

Anne Crofts

London - Walbrook

+44 (0)20 7894 6531

Heather Durston-Hillyer

Heather Durston-Hillyer

Winchester

+44 (0)1962 705513

Key Contacts

Corinne Slingo

Corinne Slingo

Bristol

+44 (0)117 918 2152

Anne Crofts

Anne Crofts

London - Walbrook

+44 (0)20 7894 6531

Heather Durston-Hillyer

Heather Durston-Hillyer

Winchester

+44 (0)1962 705513

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