This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Judi talks to us about her experience of managing patient safety for a large healthcare provider, the importance of ensuring implemented safety standards are sustained and how crucial it is to professionalise patient safety.
About the Author
Judi has been a registered nurse for forty years and has held various NHS and independent sector leadership and executive director roles, in pre-hospital, primary, secondary care and strategic health authority settings.
Judi is currently the Divisional Vice President of Quality for HCA Healthcare UK and leads on all activities related to quality, patient safety and risk. She is also HCA UK’s nominated Patient Safety Specialist.
Questions & Answers
Hi Judi. Please can you tell us who you are and what you do?
I’m Judi Ingram and I am a registered nurse by profession, with over 40 years’ experience. I have worked in various specialities across the whole healthcare system including primary, secondary and tertiary care. My main area of clinical expertise was emergency care and orthopaedics and my last NHS role was as Chief Operating Officer for the East of England Ambulance Trust. I moved into the independent sector in 2010, working at Bupa and am currently Vice President of Quality for HCA Healthcare UK leading on the patient safety, quality and governance aspects of the care we provide.
How did you first become interested in patient safety?
Although I’ve always been intrinsically passionate about patient safety, my lightbulb moment was in 2004 when I worked for a GP consortium where there had been an unexpected patient death. The patient had been seen by a locum doctor who had been flown in from Germany, because there was a shortage of out of hours GPs. The doctor unfortunately mistakenly prescribed the patient the wrong drug. When it came to the inquest, many factors that contributed to the error became evident. I helped reframe their governance and patient systems to try and make them safer, working alongside the Care Quality Commission (CQC) who came in to do a focussed review. I was struck by the wide impact of this incident; on the patient and their family, the staff , the provider organisation and on out-of-hours provision.
I moved on from that role to become the Chief Nurse and Director of Clinical Governance for BUPA across their business units worldwide, which gave me another, different perspective on patient safety. I soon realised that ‘patient safety’ as a term can have a different meaning for each health system – and even each individual practitioner. My role involved leading on clinical governance and patient safety globally, and this can look very different depending on the safety culture maturity and approach of each system. It was quite a challenge to develop a patient safety framework with common themes that could be translated into effective country-specific implementation.
What was your approach to implementing patient safety across such a diverse range of systems and cultures?
It was important for me to actually see ‘work as done’, so I visited providers in different countries to try and understand each system. I also focused on building relationships with staff as I believe a fundamental principle of patient safety is that relationships are key—if someone doesn’t feel they can pick up the phone for advice or to discuss and share an incident, you don’t have a safe culture.
I found that there’s great examples of practice that happen across the world that we could look to emulate. As a collective we could be better at sharing the ‘good catches’. But it’s also really important to understand how different local cultural norms affect patient safety. I remember working with a team overseas and seeing how the culture made it much more difficult to speak up – at the time, if somebody reported an incident they could fear being dismissed. It made me consider the fact that each member of healthcare staff works within a wider cultural context, and we should always consider that when thinking about approaches to patient safety.
Which part of your role do you find the most fulfilling?
I love those lightbulb moments when you get great safety improvement traction and can put in place systematic changes that will make it safer for our patients and staff. I’m really immersed in the launch of the Patient Safety Incident Response Framework (PSIRF) at the moment—and what I love is how it brings together patient safety and quality improvement. Historically, patient safety specialists have tended to be experts in incident management and investigation, but not necessarily in implementation actions for improvement. I feel this part of PSIRF should be transformative—if we get this right it will make such a difference.
I recently held a learning seminar with some of our anaesthetic council members which included consultants, operating department practitioners and theatre managers who had been involved in a safety incident. We can get a unique perspective in the independent sector as many of our clinicians have an NHS base and often another private healthcare base so they bring with them their experience from a wide range of settings. We spent an hour brainstorming where they had seen best practice and safety processes done well. We learned more in that hour session than I ever have done from a root cause analysis report, which can take 60 days to prepare with the focus more on producing the report than taking the necessary safety improvement actions. It’s not always straightforward to do, but improving safety is all about getting the right people in the room, who want to do the best they can to find safety solutions that will stick.
What patient safety challenges do you see at the moment?
I believe our biggest challenge as a whole healthcare sector is establishing a sustainable approach to patient safety so that it’s easy for staff to do the right thing. We need improvement actions that can be followed consistently, so that when you go back and check next week, next month or next year, they are still embedded and sustained. In 2021, the NHS published a review of Enduring standards which looked at 140 National Patient Safety Alerts and analysed them to pull out the actions that should ‘endure’ and always be in place. An example of one of these enduring standards is making sure that for cardiac arrests, every hospital has 2222 as the number to call, with no variation between organisations. When these alerts come out, organisations are quite good at actioning them at the time, but we need to build a framework that assures us that these standards are being maintained over time. The temptation can be to go for quick fixes. It’s a natural part of working in healthcare that something else will come along to take your attention, but it’s really important that we work out how to make sure patient safety solutions endure beyond the immediate aftermath of an incident or safety alert being published.
One barrier to enduring standards can be high staff turnover. A few years on from a specific safety alert, the people who implemented and owned it at the time might not be there anymore. So, when we make changes we need to ask ourselves, “If I’m not here anymore, how do I know this safety action is still going to happen and stay in place?” Leadership at a local level is key to ensuring this sustainability, and that’s why patient safety can’t simply be a centralised, corporate function in an organisation.
I also think that understanding an organisation’s safety culture is so important, and I do think it should be mandatory for organisations to assess their patient safety culture and maturity on a regular basis. It’s so important that managers understand how their staff feel about their role in patient safety. It’s very easy to say you have the right values and behaviours in place, but having some hard data to look at allows you to then focus on what will make a difference to your staff and help improve patient safety.
What do you think the next few years hold for patient safety?
I think PSIRF is a real opportunity to raise the profile of patient safety and turn it on its head. This involves a huge transition in how we think about patient safety so I’m sure we will wobble for a while, but I think it’s OK to wobble as long as we are learning and improving as we go! Hopefully we’ll find ourselves taking a more systems-based approach, being much more curious and being more robust about testing new safety improvement actions on how effectively they can be implemented, and whether they’ll stick.
Just after his report into Mid Staffs, I remember Sir Robert Francis saying he didn’t want to see another action plan, as they were actually more like ‘inaction plans’. I often refer to this when I’m speaking to colleagues—if something isn’t right, fix it while you’re there or raise it with the Head of Department at the time. We need patient safety to be infused with energy and it is so important to ensure we create a safe space for people to share issues and solutions. The Patient Safety Management Network on a Friday is the most refreshing meet up and is one of the sessions I prioritise in my diary each week. It is led in such an engaging collaborative way, that people genuinely feel able to share and learn together.
If you could change one thing in the healthcare system right now to improve patient safety, what would it be?
I’m really passionate about professionalising patient safety. We so often see it as something you ‘have to do’ as part of the job, which is true, but we need to recognise patient safety as a specialism in its own right. We need to attract like-minded people to move patient safety forward. We really need to focus on building trust and credibility, clearly demonstrating how patient safety adds value. Safety is an integral part of our ‘business’, it’s a huge part of the reason doctors choose to practice with us and patients choose to be cared for by us.
Are there things you do outside of work that make you think differently about patient safety?
My mantra is ‘life is about relationships’ and I definitely bring that outlook to my role. Positive relationships are essential to creating a safe culture.
Can you tell us something about yourself that might surprise us?
I used to be a marathon runner, although I don’t run anymore! But I still love being outside and enjoy the freedom it gives me to think. There are great beaches and open spaces near where I live, so I spend a lot of time outside.