The patient safety collaborative programme: opportunities for physician engagement

Background

In 2012, the report Innovation, health and wealth highlighted the need to accelerate the adoption of innovation in the NHS.¹ In 2013, 15 Academic Health Science Networks (AHSNs) were established across England to help meet this ambition, to spread innovation at pace and scale, improve health and generate economic growth. Each AHSN works across a distinct geography, connecting NHS and academic organisations, local authorities, the third sector and industry to facilitate change across whole health and social care economies to improve outcomes for patients. Funded by NHS England, NHS Improvement and the Office for Life Sciences, a diverse range of programmes and activities provide a unique opportunity for physician engagement; one of these programmes is the Patient Safety Collaborative (PSC), which was established to accelerate improvements in patient safety across England.

Emergence of patient safety

Patient safety is a relatively recent phenomenon. As recently as 25 years ago, harm caused by healthcare, such as healthcare-acquired infections, was generally regarded as an inevitable consequence of healthcare.² Today, such problems are seen as both unacceptable and preventable, and it is this intolerance of harm that has driven a number of significant improvements and achievements in patient safety. For instance, due to the concerted efforts of staff and the impetus provided by national campaigns, cases of methicillin-resistant Staphylococcus aureus and Clostridium difficile decreased dramatically between 2007–2010.³

However, advances in technology, evolution of our understanding of harm, ever-increasing expectations from patients and the drive for care to be delivered in non-clinical settings and by patients and carers themselves, means that patient safety is never finished; it is a never-ending pursuit, where standards continue to rise but where more needs to be done. There is a growing feeling that there needs to be a step-change in how safety improvement is approached to make further improvements.⁴

The PSC programme

In 2013, a national review of patient safety in England was conducted by Prof Don Berwick in the light of the failings at Mid Staffordshire NHS Foundation Trust.⁵ The Department of Health and Social Care responded to a recommendation in the Berwick review to establish regional expertise that could help NHS organisations build capacity and capability to improve patient safety.⁶ In October 2014, the PSC programme was launched, with the following underpinning principles:

• securing local engagement through structured quality improvement (QI) initiatives leading towards transformational change

• building system-wide capability for staff and patients in quality and safety improvement

• spreading QI interventions both within and across AHSN regions

• actively contributing to national sharing and learning.

Each of the 15 regional PSCs, hosted by their respective AHSN, was encouraged to build upon existing initiatives or instigate new areas of work in areas identified to be of local importance, using a range of QI tools and techniques. In 2017, the work of each regional PSC was realigned around a smaller number of national priorities to focus efforts and achieve greater impact in the following areas:

• fostering a positive safety culture

• improving the identification and management of deteriorating patients (Box 1)

• improving safety in maternal and neonatal services.

Using QI to improve patient safety

The work of the PSC is underpinned by a methodological approach – to use QI as part of collaborative structures to drive continuous improvements in patient safety. There is no single definition of QI, nor a single way to approach it.¹³ Drawn from techniques in other industries, the Institute for Healthcare Improvement's (IHI's) Model for Improvement is perhaps the most commonplace in healthcare and is used extensively as part of the PSC.¹⁴ It is not a panacea, but it has the advantage of enabling frontline teams to use practical techniques to understand the nature and scale of the problem being tackled, introduce small tests of changes to address the problem, and measure the impact of those changes in almost real time.

Utilising the IHI methodology, the PSC makes particular use of the QI collaborative method, which is an organised, multifaceted approach involving teams from multiple healthcare sites to learn, apply and share improvement methods, ideas and data in a given area or topic.¹⁵ Teams are supported by a central team who provide additional coaching to help teams apply QI methods in their own work environment, and to measure the effect of the changes introduced.

Such approaches are based on the principle that healthcare teams can make changes more quickly and more effectively when working together, rather than in silos. This can be for several reasons: first, because improvements in safety and quality often necessitate multidisciplinary or multi-agency engagement, for instance, if trying to reduce emergency admissions to hospital by equipping community teams to better identify and manage deteriorating patients; second, because it is often the case that a safety or quality challenge faced by one healthcare team has already been tackled by another; third, because collaborative approaches can enable change to be made on a larger-scale; fourth, because they can facilitate the standardisation of practice where appropriate, such as in the adoption of improvement interventions like care bundles and checklists; and fifth, because they can help to engage clinical teams at a regional level to support the implementation of national policies and initiatives.

QI collaboratives are, however, not without their challenges. Like other change or improvement methodologies, their effectiveness relies on a number of social, technical and contextual factors. Dixon-Woods and Martin also identified that, to maximise the effectiveness of QI efforts, healthcare needs to act more like a system rather than hospital-by-hospital or care home-by-care home. The PSC has embraced this through its work to standardise the approach to, and develop a common language for, the identification and management of deteriorating patients (see Box 1), complemented by having a common aim and carrying out work to build the skills of staff to implement and measure change (see supplementary material S2).¹⁶

A core advantage to the collaborative approach is that it allows highly pressured frontline teams to come together, giving them the necessary time, space and support to plan and deliver improvement work. This is most effective when individuals have explicit support from a senior colleague and protected time to participate, something which is increasingly challenging given the current pressures on the health service, even though taking part in quality improvement activities to improve safety is now explicitly required within Good medical practice.¹⁷

Local efforts can have a national impact

The traditional way of trying to achieve change at scale within healthcare has invariably involved a top-down approach, with mixed results.¹⁹ The PSC programme has benefitted from national policy drivers to support change in areas, such as the introduction of NEWS2 (see Box 1), ranging from financial incentives to issuing patient safety alerts. However, frontline teams have benefited from having a regional PSC to act as a buffer to these directions, providing improvement support to help teams meet their obligations and creating opportunities for clinicians to engage with peers from other organisations to share their learning and knowledge.

Current and future programmes of work: opportunities for physician involvement

The PSC programme consists of the following current and upcoming programmes of work. They are multiprofessional in nature, but rely heavily on physician engagement in both the planning, design, delivery and wider adoption of the interventions being implemented.

• Improving the identification and management of deteriorating patients: which includes the recognition, communication and escalation of deterioration across all sectors and specialties. Future work will focus on supporting the adoption of NEWS2 right across the health and care system.

• Improving safety in maternity and neonatal care: this programme supports the NHS ‘better births’ programme, which has the ambition to reduce harm by 50% by 2025.²⁰ All units in England have access to PSC-facilitated networks, known as local learning systems, to bring clinicians, mothers and system leaders together to drive improvements across local regions.

• Improving the safety of medicines administration in care homes: this programme will support improvements in the administration of medicines in care homes, a significant source of risk for our elderly and frail population. This will require the support of clinicians from hospital to the community in the review of the medicine burden.

• Supporting the adoption and spread of tested patient safety interventions: each regional PSC is supporting local clinical teams to implement, and drive more effective use of, a number of improvement interventions. These are:

  • emergency department (ED) patient safety checklist: a time-based framework outlining the clinical tasks that need completing for each patient in the first four hours of their admittance to the ED

  • Emergency Laparotomy Collaborative: supporting adoption of an evidence-based set of interventions to improve outcomes for patients

  • Prevention of Cerebral Palsy in the Preterm Infant (PReCePT): reducing the incidence of cerebral palsy by offering magnesium sulphate to eligible women during preterm labour

  • chronic obstructive pulmonary disease hospital discharge bundle (see Box 2).

Summary of key practice implications

• Physicians should contact their local AHSN's PSC to discover opportunities to develop and test patient safety innovations, and lead or participate in large-scale patient safety improvement programmes across a range of clinical areas spanning entire health and care systems.

• The PSCs based within the 15 AHSNs can be contacted at www.ahsnnetwork.com/contact-the-ahsn-network.

• The information about current and future programmes of work for the PSC was correct at the time of writing but subject to change given the emerging COVID-19 crisis. The programme now includes work to improve the safety of tracheostomy care. For further information, please visit www.tracheostomy.org.uk.

Supplementary material

Additional supplementary material may be found in the online version of this article at www.rcpjournals.org/clinmedicine:

S1 – Summary of the UCLPartners sepsis and acute kidney injury improvement collaborative 2015–2017.

S2 – Patient safety collaborative activity between September 2016 and December 2018.