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In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback. The WHO Global Patient Safety Action Plan Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6] We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles: Treat patients and families as partners in safe care. Achieve results through collaborative working. Analyse data and experiences to generate learning. Translate evidence into measurable improvement. Base policies and action on the nature of the care setting. Use both scientific expertise and stories of care to educate and advocate. These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7] The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders. Tackling the implementation gap and sharing learning A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8] There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere. At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety. Building high reliability health systems and organisations The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9] We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives. We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes. Working with partners to bring about change The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners: Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11] Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise. International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list. How do we create a global patient safety movement? Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety. In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3] How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change. References 1. WHO, World Health Assembly Update, 25 May 2019. 2. WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020. 3. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020. 4. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020. 5. WHO, Patient Safety Fact File, September 2019. 6. National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018. 7. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. 8. Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016. 9. Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019. 10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020. 11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020.

WHO's definition of an After Action Review and resources Guidance for After Action Review After Action Review infographic 3 minute video explaining the AAR practice as promoted by WHO, including the definition, the different methodologies and available resources. After Action Reviews and simulation exercises

CAHPS surveys CAHPS surveys ask patients to report on their experiences with a range of health care services at multiple levels of the delivery system. Some CAHPS surveys ask about patients' experiences with providers, such as medical, groups, practice sites, and surgical centers, or with care for specific health conditions. Other surveys ask enrollees about their experiences with health plans and related programs. Finally, several surveys ask about experiences with care delivered in facilities, including hospitals, dialysis centers, and nursing homes. CAHPS databases For each survey, you can download formatted survey instruments, guidance for administering them, and information on analysing and using the results. Information in the guidance documents is based on the survey developers' extensive research into best practices in survey design and administration as well as analyses of data collected during the field testing of each instrument. AHRQ does not require the use of any surveys or the use of a specific methodology for sampling or survey administration. CAHPS Ambulatory Care Improvement Guide The CAHPS Ambulatory Care Improvement Guide is a comprehensive resource for health plans, medical groups, and other providers seeking to improve their performance in the domains of patient experience measured by CAHPS surveys of ambulatory care. Use this guide to help your organization: Cultivate an environment that encourages and sustains improvements in patient-centered care. Analyze the results of CAHPS surveys and other forms of patient feedback to identify strengths and weaknesses. Develop strategies for improving performance.

Actions the National Guardian's Office will take: Improve the office’s offer of support and guidance. Further enable existing guardians to support each other. Take positive action to support guardians in trusts with less positive speaking up cultures. Improve understanding of the impact of the guardian role, and Freedom to Speak Up culture in the NHS . Develop governance arrangements and explore further the office’s standing and role in the wider system. Increase reach into the primary care landscape. Join-up cross system drivers for improving freedom to speak up culture.

You can find out more about the Conquer Silence campaign and download a Communications Toolkit for Healthcare Providers and Leaders via the link below.

This version of the Framework is for: All NHS staff, including all clinical and non-clinical staff and senior leaders, to: provide a clear vision of how to approach feedback and complaints effectively set out how they should approach learning from complaints to improve services. Everyone who provides feedback or makes a complaint about the NHS, and the people who support, advise or advocate for them. It sets out what they can expect to see and experience when doing so. NHS staff who are being complained about. It will make sure they are supported and that the complaint is seen as a learning opportunity rather than a finger-pointing exercise. The Framework is built on the following four principles: Promoting and learning and improvement culture. Positively seeking feedback. Being thorough and fair. Giving fair and accountable decisions.

On this page you will find more about the work PSCs are doing around: Culture Deterioration Maternal and Neonatal Care

This is a slide set from Rebecca Lawton (Yorkshire and Humber Patient Safety Translational Research Centre) for the National Institute for Health Research and Yorkshire and Humber Improvement Academy, explaining what second victim is and how we can do better to support staff.

In this video, Senior Paediatric Intensivist, Adrian Plunkett from Birmingham Childrens Hospital UK, discusses positive reporting (as opposed to incident reporting) in improving morale and outcome in sepsis.

Social normalisation of deviance means that people within the organisation become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact they exceed their own rules for the elementary safety. People grow more accustomed to the deviant behaviour the more it occurs . To people outside of the organisation, the activities seem deviant; however, people within the organisation do not recognise the deviance because it is seen as a normal occurrence. In hindsight, people within the organisation realise that their seemingly normal behaviour was deviant. Diane Vaughan uses healthcare to illustrate why deviance is normalised in companies. She gives four major reasons why it happens: "The rules are stupid and inefficient." System operators will often invent shortcuts or workarounds when the rule, regulation, or standard seems irrational or inefficient. Knowledge is imperfect and uneven. System operators might not know that a particular rule or standard exists; or, they might have been taught a system deviation without realising it. "I’m breaking the rule for the good of my patient!" This justification for rule deviation is where the rule or standard is perceived as counterproductive. Workers are afraid to speak up. The likelihood that rule violations will become normalised increases if those who witness them refuse to intervene. Yet, studies show that people feel it is difficult or impossible to speak up. Solutions Vaughan offers the following suggestions for helping to prevent deviant behaviours from becoming normalised: Education is the best solution for the normalisation of deviance. Diane Vaughn states, "the ignorance of what is going on is organisational and prevents any attempt to stop the unfolding harm." Being clear about standards and rewarding whistleblowers is part of the education that should take place. A company must be transparent about their standards and consequences of not meeting them. Also, creating a culture that is less individualistic and more team-based is helpful to stop the normalisation of deviance. Each person should be looking out for the company and team as a whole. If it were more team-based, each person would feel like they were letting their colleagues down if they were to break the rules. A top-down approach is very important. If the employees see executives breaking rules, they will feel it is normal in the company's culture. Normalisation of deviance is easier to prevent than to correct. Companies must make sure they take the correct steps to prevent it.