Safety management systems: an introduction for healthcare (HSSIB, 18 October 2023)

Summary

Safety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this.

See also HSSIB's video Introduction to safety management systems.

Content

The purpose of an SMS is to ensure that an industry achieves its business and operational objectives in a safe way and complies with the safety obligations that apply to it. HSSIB note that there are four recognised areas associated with SMS frameworks:

• Safety policy - establishes senior management's commitment to improve safety and outlines responsibilities; defining the way the organisation needs to be structured to meet safety goals.
• Safety risk management - which includes the identification of hazards (things that could cause harm) and risks (the likelihood of a hazard causing harm) and the assessment and mitigation of risks.
• Safety assurance - which involves the monitoring and measuring of safety performance (e.g., how effectively an organisation is managing risks), the continuous improvement of the SMS, and evaluating the continued effectiveness of implemented risk controls.
• Safety promotion - which includes training, communication and other actions to support a positive safety culture within all levels of the workforce.

Findings

Exploring this topic, the report identifies three opportunities for an organised approach to safety management in healthcare:

1.    SMS development in healthcare

•  There is an opportunity to improve safety activities in healthcare to increase proactivity and coordination across and within organisations.
• In other safety-critical industries an SMS is mandated in regulation, but healthcare organisations are not required to have all four areas of an SMS.
• There is an opportunity to improve standardisation in the coordination of safety activities within and between different organisations across healthcare, in terms of how risks are escalated and managed.
• An effective safety system and culture requires a shared understanding of safety management principles.
• There is variability in the current language and definitions that describe the safety activities, functions and processes already common across healthcare.

2.    Safety accountability frameworks across healthcare

• For effective safety management, clear lines of accountability and responsibility are needed. Within an SMS, everyone has some measure of responsibility, such as reporting unsafe conditions. Accountability takes responsibility to another level. When someone is accountable, they are responsible for systems and processes that assure safety.
• If there is no co-ordinated approach in place, accountability and responsibility can become misaligned, leading to gaps in the oversight of safety management.
• While there are clear accountabilities for safety at provider level through the Care Quality Commission regulation, there is no multi-level framework that specifies who should be accountable for the management of safety risks across the healthcare system.
• There is consensus within other safety-critical industries that effective safety management is only possible when there is a clear accountability framework that underpins the process.

3.    Safety maturity assessments across healthcare

• The term safety maturity is used to describe how far an organisation has developed and embedded its SMS.
• Existing maturity frameworks in healthcare do not promote the principles of SMSs, do not define the key components of a healthcare SMS, and do not provide organisations with a road map for incremental development of their safety activities.

Future work and recommendations

Considering what would be needed to explore applying the SMS approach to healthcare, HSSIB suggest that this could involve:

• Mapping current safety management activities in healthcare to SMS principles and identifying opportunities for improvement.
• Determining if planned and ongoing changes to the way safety is managed in healthcare would be usefully guided by SMS principles.
• Further understanding how an accountability framework could support an SMS approach in healthcare.
• Understanding how safety issues and risks for inclusion health groups are identified and then managed through an SMS approach.

It makes the following safety recommendations:

• HSSIB recommends that NHS England explores, and if appropriate, supports the development and implementation of safety management systems (SMSs) through an SMS co-ordination group. This should be in collaboration with regulators, relevant arm’s length bodies and national organisations, academics, patient representatives and safety leaders from other safety-critical industries.
• HSSIB recommends that the Care Quality Commission is responsible for ensuring that its regulatory assessment approach effectively assesses safety management activities.

It also makes the following safety observation:

• The oversight of safety management can be improved if relevant bodies, such as providers, commissioners and regulators, adopt a multi-level safety accountability framework.

Related reading

• Five Cornerstones to an Effective Safety Management System (Andrew Ottaway, 2 August 2021)
• The involvement of patients and families in a healthcare safety management system: In conversation with Jono Broad (21 February 2023)
• What is a ‘safety management system’? A blog by Norman MacLeod (3 October 2023)
• Why healthcare needs to operate as a safety management system: In conversation with Keith Conradi (24 October 2022)