Patient Safety Management Network – the time is now (25 October 2021)

Summary

In this blog, Claire Cox, Quality Improvement and Patient Safety Manager at Guys and St Thomas' Hospital NHS Foundation Trust, explains why and how she developed the Patient Safety Management Network. She looks at why the network is needed, what it has achieved so far, its aims for the future and how patient safety managers can get involved.

Content

Belonging to a group, a tribe, is important to me. Shared challenges, shared purpose, shared experiences and shared knowledge in what I do - these are the reasons why it’s important to me. Alone, we are not able to reach our full potential, but together we are strong and are able to stand on the shoulders of giants.

Why do we need a network?

For the past few years, a perfect storm has been brewing. The need for a network of patient safety managers has never been more evident.

There were three themes playing on my mind - each one was troubling me and affecting the way I was performing at work:

1. Recurring harm
Every year, avoidable harm leads to the deaths of thousands of patients, each an unnecessary tragedy. Unsafe care also causes the long-term suffering of tens of thousands and costs the health service billions of pounds.

Many people have been doing good work over the last 20 years, but patient safety remains a persistent problem.[1] This was evident during my Darzi Fellowship. Understanding why learning from incidents was not shared between trusts, departments and wards was fascinating. There are many barriers to why we don't share, some of which are deep-rooted in ‘the way things are done around here’ - the organisational culture and unwritten rules. But the overriding barrier was that there was no mechanism to share.

If there was a mechanism to share, would it even make any difference? The only way to find out was to try, so in 2019 Patient Safety Learning launched the hub, a free platform to share learning for patient safety. A knowledge repository with open access for all. So far the hub has had 10,000 resources uploaded and has had 637,000 page views from over 200 countries, with communities of interest for people to discuss patient safety concerns and how to address them. the hub is a fantastic resource, but what we need is more of the human element - human interaction where tacit knowledge is shared.

2. Isolation
I started my first patient safety management role in September 2020, as we were coming out of the first wave of the pandemic and heading straight into the second. Times were turbulent. I wasn’t based in the office and working from home made forging relationships tricky. The feeling of isolation was particularly challenging for me. The need to reach out was strong.

When working clinically as a nurse, the bond with my colleagues was strong. As nurses, no matter where we work, we understand each other. We understand each other’s challenges, we are able to support each other and we know we are not alone. There are also many of us, so it’s not too difficult to find another nurse where you work to debrief, learn from each other and gain support.

Coming from working clinically to now working as a patient safety manager, I miss the sense of belonging. I no longer fit into the ‘nurse’ box, at least that’s the way it feels to me. There are fewer peers around me that I can debrief, share and learn with.  

3. Roll out of Patient Safety Incident Response Framework (PSIRF)
Currently, we are stuck on a hamster wheel of investigating; investigating in such detail and at such volumes that we have no time for organisational learning, implementing robust actions or involving families and patients.

The PSIRF is a key part of the NHS Patient Safety Strategy published in July 2019.[2] It supports the strategy’s aim to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This strategy gives permission for the healthcare system to ‘do safety differently’.

I know I am very excited about the new framework. The whole reason I came into patient safety was to make it easy to do the right and safe thing, but there are still so many questions about PSIRF: How will it work? What do I need to do to start making changes? What methodologies do I use? What training do I need? Where do I start?

To test the PSIRF, NHS England is first working with a small number of early adopters who are using an introductory version of the framework in their organisations. My Trust is not an early adopter, so we remain using the existing Serious Incident Framework.[3]

Each trust has nominated Patient Safety Specialists (PSS) - in my Trust, they are the directors of patient safety. They will have the responsibility of leading the changes, whereas I will be implementing their strategy. There is a PSS network which has been created by NHS England to keep trusts abreast of how the early adopters are proceeding and provide updates on implementation timelines. However, I am unable to join this network as I am not a PSS. This network does not include my peers.

I want to reach out to others on what I would call the ‘nuts and bolts’ of patient safety: how to reduce pressure damage, how to capture Duty of Candour, how to interview staff after a serious incident, how others involve patients and families.[4] The PSS network certainly isn’t the right forum for that.

How did the network evolve?

Scoping what was out there and identifying need
After realising that the PSS network was not aimed at people like me, I looked at what was around for patient safety managers. Some of us are clinical, some of us are not, so a platform that we could all access was non-existent. There were forums on specific issues such as falls and tissue viability, but I couldn't find anything that encompasses patient safety and the management of patient safety.

I knew I wanted to reach out to others, but were others ready to reach out too? By putting out a call on social media, it became acutely evident that I wasn’t alone. A poll that I put out on Twitter came back with a resounding, "Yes – we want a network!"

Developing shared purpose
Having a shared purpose for the network was the key to success, so we decided on these aims:

1. To facilitate and nurture private conversations between a community of like-minded individuals.
2. To share our insights and lessons learned so that all may benefit from our collective wisdom.
3. To provide peer support when others in our community are in need of help.
4. To collaborate on new ideas, solutions and research that might lead to improved patient safety.
5. To introduce new thinking from both within and outside health and care that could accelerate patient safety improvements within our own organisations.
6. To gain a better, shared understanding of new policies, guidance, directives and regulations that impact our work.
7. To share knowledge resources that others might use in striving to improve patient safety within their own organisations.
8. To enable PSMN members to influence relevant regional and national policies and add their voices en masse to campaigns that seek to improve patient safety for all (either directly or indirectly).

Ensuring a safe space
One of the barriers to sharing concerns and stories is that we are unsure who we can share with. Sharing non-patient identifiable information is OK. Sharing policies, process and action plans is acceptable. But the narratives behind these policies and action plans are far more insightful - however, to get this information you need to speak to people face to face. In a funny way the pandemic did us all a favour, as we are now all experts in using Microsoft Teams and managing online meetings (although I still forget to unmute myself – there's always one!) We know and trust Teams, so it's been a great way of getting people from across the UK together cheaply and easily.

To ensure we have ‘real’ patient safety managers there is a process for joining the network. Firstly, applicants need to be a member of the hub. Once they have signed up they are screened by me and when we know they are a ‘real’ patient safety manager, they gain access to the meeting links and the private community page on the hub

I’m really grateful to Patient Safety Learning for hosting the network on the hub and helping us capture discussions, such as this latest blog about the amazing work of the Patient Safety team in Sussex Community Foundation Trust. And to BD for providing Patient Safety Learning with some tech set-up funding for the forum on the hub.

Deciding on a structure
"Not another meeting!" No, it’s not just another meeting. In our private community we have:

• no agenda
• no action log
• an informal setting
• no hierarchy 
• cameras on
• no recordings
• drop in, drop out
• a summary note on the dedicated hub page for those that can’t attend.

Progress so far
The network launched on 25 June 2021 and so far:

• we have had 17 meetings.
• we have 150 members (and growing fast).
• we have had 10 external speakers including NHS England, early adopters and the Healthcare Safety Investigation Branch.
• we have discussed what is important to us, including subjects like human factors and investigation, involving families, medication errors and duty of candour.

Measuring success and impact
The impact this group has had on patient safety has not been measured, and would be difficult to measure. Getting caught up in trying to measure and justify the network isn’t my priority; my priority is to keep the network going. If people continue to attend the meetings, continue to share their ideas and continue to find solutions from each other – then the network is serving an important purpose and will continue.

The future and vision

In the future I see a national patient safety management network with sub-groups – one for community, one for mental health, one for acute care, one for primary care, one for care homes and one for ambulance services. Each of these sub-groups would feed up to the national group for a yearly conference where we would share and discuss learning across all groups.

Currently, I convene the meetings. However, I work full time as a patient safety manager and it would require a full-time person to run the network for it to reach its full potential. But for now – we have a fledgling network with passionate people who want to make a difference and get it right. We have made a start and we are trying!

How to get involved

Are you a patient safety manager interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email claire@patientsafetylearning.org

References

[1] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019
[2] NHS England and NHS Improvement, The NHS Patient Safety Strategy, 2 July 2019
[3] NHS England and NHS Improvement, Serious Incident framework, Last Accessed 25 October 2021
[4] Care Quality Commission, Regulation 20: Duty of candour, Last Accessed 25 October 2021