Sixth Global Ministerial Summit on Patient Safety: Bringing and sustaining changes in patient safety policies and practice

Summary

On 17 and 18 April 2024, government ministers, high-level representatives and health experts from all over the world gathered in Santiago, Chile for the Sixth Global Ministerial Summit on Patient Safety. In this long-read article, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the key themes and issues discussed at the event.

Content

Global Ministerial Summits on Patient Safety aim to drive forward the global patient safety movement. Beginning in 2016, they have helped keep patient safety high on policy makers’ agendas and built the momentum needed to create the first World Health Organization (WHO) Global Patient Safety Action Plan, published in August 2021.

Last week I attended the sixth of these summits in Santiago, Chile. The event focused on how countries are approaching implementing their patient safety strategies within the framework of the Global Patient Safety Action Plan. Participants included clinicians, policymakers, leaders in the fields of quality improvement and patient safety and patients (though not as many of the latter as there should have been, in my opinion).

I am sure the Summit organisers will produce a formal report, but for now I thought it might be interesting to share my personal reflections on the sessions I attended, and the key take away messages.

“Patient Safety is not an aspiration, it is a commitment”

This statement in the opening address was a theme that resonated throughout the Summit, and many attendees I spoke with expressed this sentiment. There was a consistent message that patient safety shouldn’t be seen as just a technical programme of activities, but instead as a moral and ethical imperative. This is a perspective that we share at Patient Safety Learning—that patient safety should be seen as a core purpose of health and social care. 

The scale of the challenge we still face was highlighted in a video address given by Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. He set out that over three million people a year die from unsafe care, 50% of which is preventable. While noting that the impact was much greater in low- and middle-income countries, this remains significant challenge everywhere, even more so in a post-Covid world. 

This point was also identified by Dr Aidan Fowler, National Director of Patient Safety in England, in a roundtable discussion with leaders from each country that has previously hosted a Global Patient Safety Summit. He reflected that the pandemic had emphasised the importance of responding to events in real time and that patient safety is not something we can do “driving looking in the rear-view mirror”. Panellists also discussed the importance of safety science and human factors, as well as how to tackle emerging patient safety challenges such as delays in access to care and an overstretched workforce.

Talking specifically about the NHS in England, Dr Fowler noted that much greater emphasis was now being put on improving patient flow because of increased demand faced by the system. He also highlighted various new patient safety initiatives, including:

• the introduction of Martha’s Rule.
• the new Patient Safety Incident Response Framework (PSIRF).
• the creation of the Patient Safety Commissioner for England and the Health Services Safety Investigations Body (HSSIB).

From the “knowledge gap” to the “implementation gap”

Many speakers reflected that, while there have been significant improvements in patient safety in the last few decades, it is important to clearly evidence them. Alongside this, we need commitment to effective implementation. There were reflections that while globally we are making significant progress in addressing the “knowledge gap” for patient safety, greater effort is needed to tackle the “implementation gap”. In other words, there is a difference between what we know improves patient safety and what is done in practice. 

This patient safety challenge affects all countries, and at Patient Safety Learning we looked at this issue in England in our 2022 report Mind the implementation gap: The persistence of avoidable harm in the NHS. We also raised this again as part of a review by the Expert Panel Report of the House of Commons Health and Social Care Select Committee this year. The review looked at the UK Government’s implementation of patient safety recommendations and found that its work “requires improvement”.

Implementing the Global Patient Safety Action Plan

As mentioned earlier, a central focus of the Summit was the implementation of policies and strategies to support the Global Patient Safety Action Plan. Following on from an interim report last year, it was announced that WHO will shortly publish a report on the progress that has been made against the Plan by member states. I look forward to seeing this report in due course—hopefully it will shine a light on improvement opportunities being acted on in different countries and enable us to learn from successes and identify the barriers that are still to be overcome.

In a keynote plenary session, Dr Neelam Dhingra, Unit Head of WHO’s Patient Safety Flagship, highlighted several areas where insights have already been gathered:

1. Variation

She noted that WHO had found a diverse range of patient safety policies and strategies, not just amongst member states but also individual organisations within states, each at different stages of development.

This point made me reflect on the fact that many organisations do not have patient safety strategies which feature explicit and measurable goals for improvement. Here in the UK, there’s no requirement for this.

At Patient Safety Learning, we believe that organisations need to design for safety with clear ambition and an honest understanding of their baseline performance, to inform the development and implementation of patient safety improvement programmes. This was something I discussed with Dr Sanjiv Sharma, Medical Director at Great Ormond Street Hospital (GOSH), who was also in attendance at the Summit. We have been working in partnership with GOSH as they apply our Patient Safety Standards in their patient safety transformation programme.

2. Safety culture

Dr Dhingra also reflected on the importance of seeking to build safety cultures across healthcare facilities and health systems, and the difficulties in achieving this.

At Patient Safety Learning, we have recently looked at this in our recent report on the NHS Staff Survey results in England. This is another area where there is significant knowledge of the problem but an “implementation gap”. Our report outlines that much more work is needed to realise the aspiration of a just and fair culture with strong psychological safety for staff and patients.

3. Patient engagement

Another key issue noted was the importance of ensuring patients have a greater role in improving patient safety. This was the theme of last year’s World Patient Safety Day and one of the six foundations of safer care that Patient Safety Learning identifies in our report, A Blueprint for Action.

Later in the day there was an excellent session on this subject that:

• provided data and evidence of patient involvement in their own care.
• noted that safety is well known to be greater when patients are involved in medicine reconciliation, for example, in anti-coagulant care and for people with long-term health conditions.
• highlighted that when patients have access to their own medical records and diagnostic tests they can better contribute to learning from incidents of unsafe care.

This discussion also reinforced that it is essential to have a culture of participation and collaboration between clinicians and patients. The research of UK based Jane O’Hara, Director of Research at THIS Institute was cited as part of this.

4. Political will

Another key challenge highlighted was ensuring that political will and leadership is in place to focus on patient safety, particularly considering competing priorities and financial constraints. This applies to all systems, even in high income countries like the UK. What resources are being made available for patient safety improvement?

5. Sharing learning

The need for greater collaboration between sectors and improved stakeholder engagement was also highlighted. Alongside this, Dr Neelam emphasised the crucial role that technology and new innovations can play in supporting shared learning, helping to both improve patient safety and efficiency in organisations. She also noted that there was significant interest in how the application of human factors and safety risk management principles in particular can be employed to improve patient safety.

At Patient Safety Learning, we believe that sharing learning is key to improving patient safety. Our award-winning online platform the hub is an increasingly significant contributor to this and over 40% of people accessing our 15k resources are not based in the UK. Introducing myself to delegates, I was delighted that many of them said that they are members of the hub, welcome the resources and follow our activities. There was much interest in the patient safety networks that we support, such as the Patient Safety Management Network (PSMN). It left me considering whether we need a similar frontline community of practice for patient safety globally, taking a similar social movement-approach towards peer support and dissemination of good practice.

6. Capacity for patient safety improvement 

Finally, another issue raised was the sheer workload challenges faced in healthcare systems. There were many conversations noting the importance of allocating time and resources to make patient safety improvement activities a success.

This is something we have also discussed at a recent meeting of the PSMN, considering how NHS England is aiming to strengthen the guidance on patient engagement for patient safety. Members highlighted lack of resources as a challenge, as well as variation in operating models and approaches. We need a better idea of ‘what good looks like’ from the patient and family perspective and how patient safety staff and organisations can deliver this.

Key themes: Safety systems, staff wellbeing and patient engagement

I want to highlight some of the other key discussions that took place at the Summit.

Safety systems

One theme that ran through many sessions was the importance of healthcare operating as a safety system. Sir Liam Donaldson, WHO’s Patient Safety Envoy, led a panel session on lessons learned in building and sustaining high reliability health organisations that protect patients from harm. This focused on:

• developing and sustaining safety cultures.
• developing clinical and managerial leadership capacity and capability.

Dr Rosie Benneyworth, Chief Executive Officer of the Health Services Safety Investigations Body (HSSIB) spoke at this session, as well as giving a well-received presentation on the role and work of HSSIB, and the importance of healthcare considering and adopting a safety management system approach. She spoke about how HSSIB is working with other national bodies to create an international network for patient safety investigation.

Dr Dafni Kaitelidou from the University of Athens presented the results of the resilience testing process being adopted in Greece, led by the European Observatory on Health Systems and Policies, WHO and OECD. She also spoke about the launch of a WHO project on Human Resources for Health and Quality of Care.  

There was also a fascinating session on the measurement of patient safety culture in Latin America, to learn, train leaders and drive change with evidence-based actions. From surveys, Dr Alejandro Arrieta reported very significant findings and conclusions:

• Leadership is crucial. The findings highlighted the disconnect between hospital administrators and clinical leaders and between leaders and frontline workers.
• Hard and soft regulation can strongly influence safety culture.
• The opportunity to learn from other industries is not being exploited in a way that enables healthcare to make a difference—having a safety management system is crucial.

National workforce experiences and staff wellbeing

The safety system theme was also drawn out in an excellent session on creating a culture of wellbeing for staff, led by Professor Albert Wu from Johns Hopkins School of Medicine and Jeffrey Salvon-Harman from the Institute for Healthcare Improvement (IHI).

They spoke about the context of workforce burnout and recruitment and retention crises globally, and the need to be better at prioritising staff wellbeing. Without motivated, trained and supported staff, we won’t be able to deliver safe care. We need to shift focus from individual resilience to system resilience, think about the causal factors and redesign systems. This includes addressing the impact on staff of moral injury related to unsafe care and designing systems that enable them to do their jobs safely and effectively; many information systems are hugely burdensome and don’t benefit patient care.

Patient engagement

Unfortunately, I missed Dr Henrietta Hughes, Patient Safety Commissioner for England, participating in a workshop looking at how events experienced by individuals can be transformed into effective national and international measures to protect patient safety.

I heard many at the Summit reflecting on the Patient Safety Commissioner as a new and innovative leadership role. I wonder whether other healthcare systems outside the UK will champion patient engagement in patient safety in this way in years to come? Henrietta and I had a great discussion about a recent workshop for Patient Safety Partners and ‘what good looks like’ in their recruitment, selection, induction and impact in the NHS in England. This is something we’ll share more about soon. 

Diagnostic safety

Just before the Summit began, WHO announced the theme of World Patient Safety Day 2024 which will take place on Tuesday 17 September: “Improving diagnosis for patient safety.” This was also the focus of what I found to be one of the most interesting sessions, discussing successful experiences with national plans and programs for diagnostic safety. This session featured a panel made up of Sir Liam Donaldson, Dr Hardeep Singh from the Center for Innovations in Quality, Effectiveness and Safety and Sue Sheridan from Patients for Patient Safety USA. 

The session looked at several issues, including:

• patients’ rights to timely diagnosis.
• the valuable impact that diagnostic technology that can have.
• the sheer scale and complexity of diagnostic decision making.
• how little progress has been made in improving diagnostic safety since the Institute of Medicine report on diagnostic safety.   
• the devastating impact that diagnostic safety can have on patients and how collaborating with patients can lead to significant improvements, such as reducing the number of patients ‘lost to follow up’ that delays access to care.
• common health problems being missed due to poor basic clinical skills, poor clinical decision making, poor data and information systems.
• the importance of changing the power dynamic between healthcare professionals and patients and ensuring that the sharing of information meets patients’ needs in terms of timeliness and understanding.
• the fact that diagnosis is not a single action but a process.
• the role of patients, carers and family members as ‘quarterbacks’, recognising their role in feedback and learning loops.
• the importance of critical thinking skills and humility. Asking questions like, “Why is the patient coming back?” “Why haven’t we answered their concerns?”
• the need for a structured approach to disease-agnostic systems.
• the need to increase awareness of tools such as the Safer DX checklist, available on the IHI’s website.

My take home messages from this session were that harm from diagnostic errors can be profound, and that we need to embrace the wisdom of the patient community and listen and learn from patients. I would also encourage healthcare organisations to check out the IHI's Safer Dx checklist when seeking to understand the current state of their diagnostic practices.

There are many resources on the hub about diagnostic safety and we will promote and share more as WHO and global partners address this safety challenge. 

Closing the summit: a strong message to Ministers on safety systems

The final session by Sir Liam Donaldson was as profound as it was moving, closing the Summit and inspiring those in attendance to think about safety systems at the clinical, organisational and system level.

Sir Donaldson's concluding challenge was for Ministers to:

• create industry wide standards for patient safety (something Patient Safety Learning has developed a tool for, to inform patient safety self-assessment and improvement).
• unleash the power of design.
• demonstrate that a source of harm can be eradicated worldwide.
• bring patient safety out of its silo.
• build solidarity with victims of harm.

New initiatives launched at the Summit

New Patient Safety Rights Charter

The Summit marked the official launch of a new Patient Safety Rights Charter. The Charter covers 10 patient safety rights crucial to mitigate risks and prevent inadvertent harm: 

1. Timely, effective and appropriate care
2. Safe health care processes and practices
3. Qualified and competent health workers
4. Safe medical products and their safe and rational use
5. Safe and secure health care facilities
6. Dignity, respect, non-discrimination, privacy and confidentiality
7. Information, education and supported decision making
8. Access medical records
9. To be heard and fair resolution
10. Patient and family engagement.

Perhaps we all need charters in our healthcare systems and organisations that cover these rights? The Charter is highly valuable, but maybe patient and family engagement should have been higher up the list? Patient engagement is something every health system and organisation needs to support and promote.

Coming soon: A new consortium of international and national patient safety agencies 

The Summit was also the host for an exciting new initiative by several international and national patient safety agencies. Together, we are creating a consortium to reinvigorate patient safety, ensuring it is a core value of an open and fair culture and a leadership priority in healthcare systems globally. More details will follow soon!