Care Quality Commission - Opening the door to change NHS safety culture and the need for transformation

Summary

This Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.

Content

Never Events are serious incidents that are considered to be 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. However, Never Events continue to happen despite the hard work and efforts of frontline staff: there were 468 incidents provisionally classified as Never Events between 1 April 2017 and 31 March 2018. The CQC examined the underlying issues in NHS trusts that contribute to the occurrence of Never Events and the learning that can be applied to wider safety issues. What makes it easier, and what makes it harder, for the different people and organisations in the system to prevent Never Events and deliver safe care more widely?

Findings in this report have led to the conclusion that this continual recurrence means that if healthcare staff are to give patient safety the priority it requires, the culture of the NHS needs to change to one that is orientated around safety.

Recommendations

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.