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Every day, frontline staff identify opportunities to improve patient care, streamline processes and enhance the way services operate. Yet many of these ideas never progress beyond conversations within individual teams. This practical webinar explore how NHS organisations can create the conditions for continuous improvement, where everyday insight becomes meaningful organisational change. During this practical session we'll explore: Why many improvement programmes lose momentum after an enthusiastic start The hidden cost of lost frontline ideas How high performing NHS organisations sustain continuous improvement A practical framework for capturing, reviewing and implementing improvement opportunities How frontline insight becomes organisational intelligence Better ways to measure improvement beyond completed projects Five questions every Quality Improvement team should ask about their organisation A real NHS case study demonstrating continuous improvement in practice Why this matters: Every day across the NHS, thousands of opportunities to improve patient care are identified by the people closest to delivering it. Many are never captured. Many are never shared. Many are never acted upon. The organisations that consistently improve aren't necessarily those running the most projects. They're the organisations that make it easy for staff to contribute ideas, learn from one another and continuously improve the way they work. This webinar explores how to create those conditions. Register

This week the new Quality strategy for NHS-funded care in England has been issued. This has been published by NHS England on behalf of the National Quality Board (NQB), the principle national forum for quality across the healthcare system in England. The NQB brings together leaders from NHS England, the Department of Health and Social Care (DHSC), arm’s length bodies and clinical leadership. In this article, Patient Safety Learning sets out its initial reflections on the new Quality Strategy. On Tuesday 14 July 2026 a new Quality Strategy was published by the NQB. This document is intended to provide a structured approach to making quality the organising principle for all NHS activity over the next 10 years. At Patient Safety Learning, we believe that improving patient safety in inextricably linked to this aim. The new Strategy builds on last year’s Review of patient safety across the health and care landscape in England. We agreed with the Review’s recognition of the need to coordinate and rationalise the patient safety landscape. However, we have also expressed concerns about some of its content. In particular, we contested its argument that patient safety has been significantly over prioritised in recent years at the expense of other aspects of quality. As noted in our response to the review, we do not believe the examples it gave provided compelling evidence of this. Furthermore, we strongly believe that you cannot build an effective, efficient and responsive NHS on an unsafe system. In the coming weeks we will publish a more detailed analysis of this new Quality Strategy; however, in this article we will share our early reflections on the direction and content. Where we agree and welcome its approach We welcome the publication of the new Quality Strategy and the opportunity that it presents to improve patient care, experiences and outcomes. Priorities We are supportive of the six priorities identified by the new Strategy, and particularly the inclusion of a specific reference to patient safety. The priorities are: Improving outcomes and reducing unwarranted variation across major conditions and priority groups through implementation of the National Cancer Plan and modern service frameworks. Making sustained improvements in maternity and neonatal services. Strengthening patient safety across all settings. Improving experience of care and restoring trust in NHS services. Reducing inequalities across safety, effectiveness and experience. Monitoring clinical and population health outcomes. Clarifying who is responsible and accountable for quality Given the number of organisational changes in recent years, we are pleased to see the Strategy provides a clear outline of roles and responsibilities for quality management among different parts of the health system. Identifying patient safety risks We welcome proposals to explore how artificial intelligence and other advanced digital technologies can help the NHS learn more quickly when things go wrong and identify emerging risks earlier. Updating the Patient Safety Strategy We await with interest the publication of a reviewed and refreshed NHS Patient Safety Strategy. Looking ahead to this: It is positive that there is a recognition of the need to integrate digital safety considerations into the updated document. We would echo comments made in by the Health Services Safety Investigations Body (HSSIB) about reviewing the Patient Safety Strategy with a view to bringing together quality management and safety management. The Quality Strategy rightly acknowledges these as different but connected approaches. We believe these should be brought together, as part of an integrated quality and safety management system. Where we have concerns Recognition and prevention of avoidable harm We are disappointed that in setting the context for this Strategy, the scale and persistence of avoidable harm is not mentioned. Given the findings of numerous public inquiries and rising clinical negligence costs, the omission of avoidable harm as a factor for consideration is a significant oversight in our view. We are also disappointed that there is also no explicit ambition to reduce avoidable harm, beyond the following statement: “Improving safety in healthcare involves reducing the risk of unintended and unexpected harm to patients, while recognising that all care carries some level of risk. It does not mean eliminating all risk or pursuing zero harm.” We have concerns that this could, understandably, be considered alarming by many, including those patients and families where harm is preventable but is not being prioritised. We also have concerns about how this approach sits along the statutory obligations of providers to provide safe care and treatment (set out in the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014). National learning and improvement Patient Safety Learning believes that there needs to be structured systematic approaches to learning about the cause and contributory factors of avoidable harm. We need to better understand the action that is needed to develop solutions and improvement action in the NHS. Accompanying this, there should be capacity at a national level to: Share widely learning from investigations and learning responses to patient safety incidents. Intervene if necessary for the purposes of improvement. Develop solutions to improve safety and share these systematically. The Strategy does not appear currently to envision any such role for either the Department of Health and Social Care (DHSC), NHS England or the National Quality Board (NQB). The absence of this national capacity is a gap we also highlighted in our responses to Penny Dash’s patient safety review and the 10 Year Health Plan last year. Culture We believe there needs to be a transformative effort and commitment to creating a safety culture in the health service. We are disappointed that this has not been given greater consideration in the Quality Strategy, despite the ambition being explicit in the NHS Patient Safety Strategy. There are significant changes needed to ensure that there is an open and fair culture, with a focus on learning and improvement that does not blame healthcare staff for systemic failings. Organisations need to actively foster a patient safety culture, tackle blame and fear, and promote a culture of safety improvement. Areas we believe need further consideration Involving and engaging with patients and families We believe there is room to develop in this Strategy greater detail on how patients and families can be supported and involved in improving quality and safety. The Quality Strategy tends to focus on the role of the new Directorate of Patient Experience in DHSC and better use of patient feedback mechanisms. We believe there should also be a greater emphasis on listening to patients, families, including bereaved relatives. Their concerns can often highlight risks that organisations have not identified or before they are aware of them. The Strategy puts on a welcome emphasis on increasing transparency. We believe this should be accompanied by stronger commitments to ensure openness and transparency when harm occurs. This includes honest communication with patients and families following safety incidents—an ambition often stated but not delivered. Coordination and improvement We would welcome further information about the roles of: Regional teams “co-ordinating involvement and intervention where necessary”. System Quality Groups supporting the management of quality across organisational boundaries by identifying early warning signs and “co-ordinating system action required to improve quality”. If these bodies are to take important roles in these areas we would expect to see plans to ensure they have the appropriate capacity and support to function in this way. This is particularly important in the context of the changing roles and reduced resources with the current NHS organisational changes Monitoring recommendations There remain significant questions around how the NQB will undertake its new role maintaining and monitoring national recommendations arising from reports, reviews, inquiries and investigations. We understand the development of a new “recommendations hub”, mentioned in the Strategy, is already underway, and we await to see what this will look like in practice. There remain unanswered questions about how this will work and what level of transparency there will be around which recommendations are prioritised for implementation. This will be important given concerns which have been raised about how the transfer of HSSIB’s functions to the Care Quality Commission may impact the independence of future investigations. Questions about implementation The new Quality Strategy contains a detailed list of requirements, opportunities, imperatives and suggestions. However, many questions remain about what its implementation will look like and the impact this will have on patient and staff safety. At Patient Safety Learning, we recognise challenges organisations face in implementing changes in quality and patient safety. We have been engaging with organisations through our “What Good Looks Like” for patient safety, drawing on our report A Blueprint for Action. We believe this framework could help to potentially underpin significant elements of the implementation of the broad commitments in the new Quality Strategy. While the existing Strategy does include some specific activities, with broad timescales, we would expect to see more developed plans subsequently setting out how this will be delivered. This should be accompanied with details on the initial areas that will be prioritised and what key success criteria will be for delivering quality and safety improvements.

Earlier this year, Clare Collins from Northumbria Healthcare NHS Foundation Trust gave a presentation at the Patient Safety Management Network (PSMN) meeting on how their Trust has aimed to improve patient safety though a project to remove caffeinated drinks. In this blog, Clare shares their journey and what they have learned about implementation, engagement, organisational readiness and sustainability.  From a practical idea to a patient safety movement What started as a simple question: “Could changing the type of tea and coffee routinely served on our wards improve patient safety?”, has evolved into a growing quality improvement programme with local, regional and international interest. As a team, we wanted to explore whether a small and practical change to everyday care could contribute to safer, calmer and more restorative ward environments. At Northumbria Healthcare NHS Foundation Trust, we developed the Decaf by Default initiative to explore whether routinely offering decaffeinated tea and coffee to patients could help reduce toileting related falls, improve sleep and hydration, and support calmer, safer ward environments. The project has since expanded across multiple inpatient settings, generated strong staff engagement, and prompted wider conversations around organisational readiness for cultural change in patient safety. Why consider going decaf? For many years, staff across our wards routinely offered caffeinated hot drinks to patients as the default option. While this was often seen as a normal part of care and comfort, emerging conversations within our Care for the Older Person community raised questions about whether this practice unintentionally contributed to avoidable harm. Several factors prompted further exploration: NICE guidance recommends reducing caffeine intake in relation to urinary incontinence and pelvic organ prolapse in women. Caffeine can increase urinary urgency and frequency, potentially increasing the risk of toileting-related falls. Caffeine may negatively impact sleep and contribute to agitation. Non-caffeinated drinks can support hydration, rest, recovery and overall wellbeing. A review of Datix reports also identified that approximately 25% of inpatient falls over a one-month period were related to toileting activities, particularly within older people’s services. This led us to consider whether a relatively small environmental and behavioural change could contribute to safer care. Building the foundations: organisational readiness and engagement One of the strongest themes highlighted through discussions at the PSMN meeting was that success depended less on the decaf itself, and more on organisational readiness, staff engagement and shared ownership. From the outset, we did not approach this as a top-down instruction. Instead, the project focused on creating curiosity, shared ownership and practical collaboration. With senior nursing support, we established a quality improvement multidisciplinary community to explore the issue collectively. Staff from a range of professions and settings contributed ideas, concerns and learning throughout the process. Importantly, we also connected with University Hospitals Leicester, who had previously undertaken similar work. This external collaboration provided valuable insight, reassurance and practical learning. Several factors helped support implementation: Clinical ownership Ward teams were encouraged to shape how the initiative worked within their own environments rather than applying a rigid model. This helped improve engagement and sustainability. Preserving patient choice The initiative was never about removing patient choice. Patients could still request caffeinated drinks if preferred. A Taste the Difference challenge helped staff and patients explore perceptions around decaffeinated drinks. While around 55% of participants noticed a taste difference, approximately 85% said they would be willing to switch once they understood the potential benefits. Consistent messaging Simple, practical education materials were developed for staff, patients and carers, including posters, conversations at ward level and patient information leaflets. For example, digital teams looked at incorporating brief health promotion messaging into discharge documentation: “While in hospital, you were given decaffeinated tea and coffee. It may help to continue this at home.” This will reinforce the intervention beyond admission and encourage patients and carers to consider whether continuing reduced caffeine intake at home might support sleep, continence, anxiety management or falls prevention. Communities of interest One of the most important learning points was the value of building communities of staff who were genuinely interested in improving patient safety. Enthusiasm and local leadership often became stronger drivers than formal instruction. As discussed during the PSMN presentation, staff ownership proved critical to successful implementation. Challenges and learning The project generated important discussions and learning. Questions raised during the PSMN presentation included whether rapid caffeine withdrawal effects had been observed. While no specific reports had been identified, the team acknowledged that individual caffeine intake prior to admission is often unknown. Alternative approaches, such as limiting caffeinated drinks to mornings only, were explored and trialled in one location by a member of the PSMN but were not found to be sustainable in practice. Another PSMN member reported that in their care home, although they had adopted the change successfully, they had not seen a reduction in toileting-related falls. This highlighted the importance of local context, fall data and ongoing evaluation over a longer time period. From local project to wider movement Following pilot work in 2024-2025, Decaf by Default was adopted Trust-wide in December 2025. Since then, interest has continued to grow across the region and beyond. The project is now being explored more widely through collaboration with: the regional NHS Alliance the North East and North Cumbria Integrated Care Board patient safety networks and quality improvement communities. There has also been increasing international interest in the concept as organisations look for low-cost, scalable interventions that may contribute to safer care environments. Alongside the Trust-wide rollout, work has also begun to extend the learning into care homes across Northumberland and North Tyneside. This has created opportunities to explore how similar approaches may support resident wellbeing and reduce risks associated with continence, sleep disturbance, anxiety and falls within community-based settings. A small community pilot project has been developed involving community nurses and Allied Health Professionals (AHPs). Participating staff carry supplies of decaffeinated tea and coffee within their clinical bags and are able to offer this as part of broader lifestyle conversations and personalised care interventions. The aim is not simply to replace drinks, but to encourage wider discussion around hydration, sleep, continence, falls prevention and anxiety management in a practical and accessible way during routine community contacts. What has perhaps resonated most strongly is that the project demonstrates how a relatively small cultural and environmental changes can stimulate wider conversations about patient safety, prevention and personalised care. Key reflections Looking back on the journey so far, several lessons stand out: Small changes can create meaningful conversations about patient safety. Organisational readiness matters as much as the intervention itself. Staff ownership and engagement are essential for sustainability. Preserving patient choice supports acceptability. Quality improvement requires curiosity, testing and adaptation. Simple interventions may have wider wellbeing benefits beyond their original aim. Most importantly, the initiative has highlighted the value of frontline teams identifying opportunities to improve care through practical, evidence-informed innovation. Related resources Go decaf! How a simple change on our wards could reduce falls, slips and trips What happened when we went decaf – the story so far How going decaf could boost patient safety by reducing falls in hospitals Patient flyer - go decaf How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Do you have a patient safety initiative you would like to share more widely. We'd love to hear from you and share it on the hub. Share here (you will need to be a member of the hub and signed in) or email [email protected].

While traditional methods such as Failure Mode and Effects Analysis (FMEA) are well-established, they often reach their limits in clinical practice. This is due in particular to the subjectivity of fault identification. I would like to propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. HAZOP offers a structured, systematic approach to risk identification and assessment, particularly suited to analysing process risks and human factors. Unlike FMEA, HAZOP uses guide words (e.g. NO, MORE, LATE, LESS, OTHER THAN) to explicitly identify and analyse potential deviations from tasks and procedures.  A systematic approach to identifying and assessing clinical risks Despite the implementation of risk management systems, practice often falls short of expectations. This is due, among other factors, to the complexity of clinical processes, the dynamics of the work environment, and interprofessional interfaces, which make a holistic risk assessment difficult. Although traditional methods are widely used, they reach their limits in clinical practice: Subjectivity: When using traditional methods such as FMEA, which rely on the team’s spontaneous fault detection and experience, critical risks are easily overlooked as they are not recognised as ‘failure modes’. Monocausality: Traditional failure-mode-based approaches lead to a monocausal derivation of causes and effects. Human factors as ‘operator error’: Human errors are easily classified as ‘user problems’ without questioning the systemic causes (e.g. time pressure, unclear responsibilities, inadequate communication). Against this background, I propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. The HAZOP method was originally developed in the aviation industry and has established itself there as the gold standard for analysing risks in highly complex, safety-critical environments. HAZOP enables the approach required by ISO 31000 as a structured, step-by-step approach: Risk identification Risk analysis Risk evaluation Risk identification using guide words The method uses guide words as a heuristic to systematically identify potential process deviations as a starting point for the risk analysis. These guide words are adapted to clinical reality and enable a comprehensive risk analysis: Guide Word: Possible deviation. No: Failure to perform a task. More: Excessive performance of a task. Less: Inconsistent performance of a task. Late: Delayed performance of a task. Other than: Incorrect execution of a task. Using guide words as a starting point for risk identification also helps to involve those with little experience in risk management in the process. A list of guide words can and should be adapted to the specific requirements of the specialist department. Practical application: Example 'documentation of vital signs' Task: Recording and documenting vital signs in the intensive care unit. Guide word: Possible deviation No: Blood pressure is forgotten. Late: Documentation is delayed, delaying further diagnosis. Less: Not all vital signs are measured. Other than: A mix-up of patients in the documentation. Risk analysis The identified risks can be assessed using a two-dimensional risk matrix, like in other risk tools: Probability of occurrence (scale: ‘almost impossible’ to ‘almost certain’). Impact (scale: ‘no health consequences’ to ‘life-threatening consequences’). This commonly used and well-known assessment method enables measures to be prioritised and helps hospitals to proceed in a resource-efficient way. Risk evaluation and identification of measures Preventive and corrective measures are developed during interprofessional workshops, in which representatives from all relevant professional groups (doctors, nursing staff, administration, IT) work together to evaluate risks and propose solutions. Typical measures include: Process optimisations (e.g. standardisation of documentation procedures). Training to raise awareness of human factors. Technical adjustments (e.g. introduction of digital checklists). Clarification of responsibilities (e.g. through clear SOPs). Discussion The HAZOP method offers several key advantages that are particularly relevant to clinical patient safety: The use of guide words enables risks that are often overlooked to be systematically identified. This reduces subjectivity in error detection and enables more objective prioritisation of measures. The method allows for the analysis of human and organisational factors. This enables a holistic view of incident causes and supports hospitals in developing systemic solutions. HAZOP can be seamlessly integrated into the SEIPS 2.0 approach, which enables a coherent risk assessment that accounts for all relevant factors. The approach promotes collaboration among professionals from different disciplines. This strengthens the learning culture and helps to close governance gaps. Thanks to the structured approach and the use of guide words, risk analysis can be carried out more quickly and efficiently. Conclusion The HAZOP method, with its guide words, is a proven, systematic and evidence-based tool for improving clinical patient safety. It enables a comprehensive risk analysis that takes into account technical, procedural and human factors. Do you use the HAZOP method? We would love to hear from you if you're using HAZOP in a clinical setting so we can share real-life examples of its use. Email us at [email protected] or comment below (you need to be signed into the hub; sign up here, it is free and easy to do).

This online session will look at the essential role of robust data and learning from audit in helping identify risks, prevent harm, and build safer systems of care. Drawing on practical examples, the session will explore how data from audits and registries can be used to detect safety signals, understand where harm is occurring, and support action to reduce risk and improve patient safety. This session includes: Welcome from the Chair: Dr Jacqueline Andrews, Executive Medical Director, Harrogate and District NHS Foundation Trust and HQIP Trustee Using data for safety – A perspective from the Patient Safety Commissioner: Professor Henrietta Hughes OBE, Patient Safety Commissioner The role of the National Joint Registry in patient safety: Chris Boulton, Director of Operations, National Joint Registry Using national maternity data to drive patient safety improvement: Faith Sheils, Director of Midwifery, Northern Care Alliance NHS Foundation Trust From incident to improvement: using Epilepsy12 data to commission a safer first seizure pathway: Dr Colin Dunkley, Consultant Paediatrician, Sherwood Forest Hospitals, Epillepsy12 Clinical Lead Update from Patient Safety Learning: Clare Wade, Director, Patient Safety Learning Register here.

In February, Public Policy Projects (PPP) hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. A wide-ranging conversation between Penny Dash, Chair of NHS England, and the PPP Chair, the Rt Hon. Stephen Dorrell, offered a rare, candid look at the thinking behind the forthcoming National Quality Strategy and the complex trade-offs shaping it. The session was a live debate on the priorities, pressures and realities of improving care across the NHS. In this blog, Patient Safety Learning reflects on the key takeaways from this keynote session. A strategy nearing the finish line Penny Dash confirmed that the National Quality Strategy is in its final stages, with publication anticipated in April 2026. The process has involved extensive input from across the system, with the National Quality Board—co-chaired with the Care Quality Commission—playing a central role in refining the final draft. While the timeline reflects urgency, it also highlights the challenge of aligning political, clinical, and operational perspectives in a single framework. However, there was a concerning lack of focus on the NHS Patient Safety Strategy. Will it be updated or subsumed into the National Quality Strategy? This interview made it clear that while patient safety may have become less of a focus for NHS leadership, for the delegates in the room it was front and centre. During a panel session earlier in the day, Bola Owolabi (CQC Chief Inspector of Primary Care and Community Services) had a clear focus on patient safety, saying that we are all patient safety practitioners and that interfaces between episodes of care are the biggest patient safety risk, with many patients falling between the cracks. Did we witness a complete difference of opinion and priority between key senior NHS leaders and, if so, what hope is there for coherent strategies that will align to bring safer care and improvements? No surprises—but a sharper focus At its core, the strategy reaffirms three familiar pillars of quality: Effectiveness (outcomes). Safety. Patient and user experience. But what matters is how these are prioritised. Penny Dash was clear that improving life expectancy and healthy life expectancy is the overarching goal. That means focusing on major drivers of population health, particularly cardiovascular disease and cancer, while aligning with broader NHS reforms around prevention, community care and digital transformation. The big insight: effectiveness versus safety One of the most striking moments came when Dash revisited a controversial finding from her earlier review: Improving effectiveness could save ~100,000 lives per year. Improving safety could save between 1,000 and 10,000. Her message was clear: this is not a choice, but it does challenge how the system has historically prioritised safety over other aspects of quality and the outcomes from that; aspects of patient safety have not improved over the past 25 years. Audience members pushed back on this framing, arguing that safety and effectiveness are often intertwined in practice. Penny Dash agreed, acknowledging that quality cannot be meaningfully separated into silos and should instead be addressed as a whole. A system out of balance Penny Dash also pointed to a deeper structural issue: how resources have been allocated across the NHS. Over the past decade: Hospital spending has risen significantly. Primary care has seen modest growth. Community care funding has declined. At the same time, life expectancy and healthy life expectancy have fallen. The implication is stark: the system may be investing heavily, but not always in the areas that deliver the greatest long-term health impact, reinforcing the need to prioritise prevention, neighbourhood care and earlier intervention. The role of Integrated Care Boards Integrated Care Boards (ICBs) were highlighted as critical to delivering change. Their role is to: Plan services for local populations. Improve outcomes and reduce inequalities. Ensure value for money. Penny Dash emphasised that ICBs must take responsibility for entire populations, including underserved groups such as prisoners and the homeless, while being supported by national guidance and shared best practice. As ICBs implement more strategic commissioning, the performance management of the outcomes will fall to the regions. Given the current situation with resource reductions and redundancies, will anyone be focussing on ensuring the right staff are in place with the right skills to understand safety indicators and analyse the data? A lack of appropriate people in place who understand this agenda will leave a void, meaning we will see no progress in how the available data is used to review implementations, learn lessons and make improvements. Patient experience: leadership without mandates A major proposal within the strategy is the creation of a National Director of Patient Experience, aimed at strengthening how patient feedback informs decision making. However, this sparked debate around a broader theme: the approach of not mandating process and practice across the NHS. The perspective from Penny Dash was that too many mandates can stifle innovation and local responsiveness; however, too few can lead to inconsistency and inaction. Rather than imposing roles or structures from the centre, the strategy will lean towards defining best practice and encouraging adoption locally—a move that drew both support and scepticism from the audience. Patient Safety Learning has recently highlighted through our blogs the concerns that the patient voice is being dissipated given the structural changes resultant from the implementation of the Dash review. We will look to support initiatives strengthening the patient voice that might come from the new National Director of Patient Experience. Technology as a game changer Another key theme from the keynote was the role of technology, particularly through Modern Service Frameworks. Unlike traditional guidelines, these are envisioned as live, digital tools that will integrate with patient records with the ability to provide real-time prompts to clinicians. Early focus areas include cardiovascular disease and sepsis, with ambitions to expand into mental health, frailty and children’s services. If successful, this could mark a shift from static policy documents to dynamic, data-driven care pathways. Beyond healthcare: the wider determinants The discussion also touched on the limits of the NHS alone in improving health outcomes. Penny Dash highlighted the importance of social prescribing, housing and legal support, and community and mental health services. These 'non-biomedical' interventions are increasingly recognised as essential but require closer collaboration between the NHS, local authorities and public health systems. The mandate dilemma—still unresolved Perhaps the most persistent theme throughout the session was the unresolved tension between national consistency and local autonomy. As the chair noted, this is “as old as the health service” itself. Dash’s position was pragmatic: neither extreme work. The challenge is to find a balance that ensures high standards across the country while allowing local systems the flexibility to innovate and respond to their populations. Audience Q&A Members of the audience were given the opportunity to pose questions to Penny. Following a comment from her, that our collective focus should have been on quality rather than patient safety, there was a noticeable edge to delegate’s questions. People were surprised that patient safety appeared to have been downgraded in importance and others seemed to question whether NHS senior leaders are in tune with the reality of frontline work. Some felt this was not a positive demonstration of leadership in a time of significant change within the NHS. A system in transition The conversation made one thing clear: the National Quality Strategy is not just a document, it’s an attempt to reshape how the NHS thinks about quality, signalling a shift from safety alone → to broader outcomes, from central control → to guided collaboration and from static policies → to dynamic, tech-enabled systems. But it also exposes the scale of the challenge. Balancing priorities, reallocating resources, integrating services and maintaining public trust all while improving outcomes will require more than strategy alone. It will require sustained alignment across one of the most complex healthcare systems in the world. And as this session showed, that conversation is only just getting started. At Patient Safety Learning, we look forward to the publication of the National Quality Strategy. We will reflect and engage with our network members before publishing on the implications for patient safety. Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Safe systems, safe cultures: reflections from the Patient Safety Forum 2026 Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026

A good night’s sleep is essential for healing, yet, for many patients, it can feel almost impossible to be able to sleep or get rest during an inpatient stay. The Noise at night sleep pack project at Nottingham University Hospitals was a finalist at the Picker Experience Network 2025 Awards. In this blog, project lead Kelly Morley tells us why this initiative and a renewed focus on reducing noise at night was so important. Despite the dedication of staff and the comfort measures provided on our wards, night‑time noise remains one of the most common concerns raised through patient feedback and it was quickly identified as one of the top three patient experience priorities within our trust. At Nottingham University Hospitals (NUH), we know that sleep isn’t a luxury it’s a vital part of the fundamentals of patient care. Why night-time noise matters Hospitals are naturally busy environments. Even after lights dim, clinical activity continues as staff carry out observations, respond to emergencies, check medications and support patients who are awake or unwell. For patients, though, these unavoidable sounds can lead to: Interrupted sleep or the inability to fall asleep. Increased anxiety and stress. Decreased mental awareness. Higher pain sensitivity. Slower recovery times. Lower patient satisfaction. Complaints. Decreased uptake in rehabilitation exercises. Deconditioning. Longer patient stays. Many patients tell us that a noise is one of the most challenging aspects of their stay. Sleep is not just a comfort—it’s a critical part of recovery. Even as far back as in 1859, Florence Nightingale published her book 'Notes on Nursing', which contains lots of good advice about sleep in patients and these are still actions we would do well to take into consideration in modern nursing. “Unnecessary noise, then is the most cruel absence of care that can be inflicted on either the sick or well” (Florence Nightingale) What our patients were saying Through patient surveys, ward feedback and conversations with patients and staff, we regularly heard that noise from equipment, conversations, staff, bins, alarms and other patients would significantly affect their sleep. When asked the question: Do you have any suggestions as to how we can improve the quality of sleep for in-patients or any comments you would like to make? Patients responded: “Would be willing to try anything.” “I think the sleep pack should be mandatory and given to inpatients.” “Ask staff to speak quietly and answer the buzzers quicker—it sounded like they were moving furniture last night.” When we asked staff what they thought prevented patients from sleeping they reported: “Noise from other patients.” “Lighting.” “Observations/medications/investigations/turns.” "Noise from staff.” This feedback drove our improvement work. Sleep packs: small items, big impact To help patients rest better, many wards at NUH now offer sleep packs. These typically include: A sleeping well in hospital leaflet—this was designed by clinical staff with an interest in sleep and why it matters. The leaflet pulls together all literature that has been written in the Trust to date in regard to sleep and amalgamates this into one simple evidence-based leaflet. Earplugs—to soften unavoidable environmental noise. These are in singular packs and can be replaced as and when needed. Eye masks—to reduce disruption from lighting on the wards, particularly when nurses tend to other patients. Slipper socks—these ensure patients are not looking around for slippers in the night, opening lockers, looking under beds and, best of all, they are a simple measure that can also reduce slips, trips and falls. Sleep packs may seem like a small intervention, but patients consistently tell us they make a real difference—especially for those who struggle to settle in unfamiliar surroundings. The items are always used with the aid of clinical judgement, and it is reiterated that these items are not always suitable for everyone. Our aim is to ensure these packs are readily available and consistently offered, particularly to patients most likely to benefit. Post implementation, the feedback was very different: “Thank you for supplying the sleep pack. They have definitely made a difference.” “The mask was comfy and helped.” “Sleep packs, very beneficial. Sleep interrupted a lot as observations being taken regularly, but this is to be expected and not a criticism.” How our staff are supporting quieter nights Staff play a crucial role in creating a calmer night‑time environment. Across NUH a quieter hospitals group was formed to work on the problems that were identified during this project, including: Reducing unnecessary noise on wards: Lowering voices during night rounds. Limiting equipment noise where safe to do so. Closing doors softly. Using soft close bins/ doors. Having top tips poster for staff—reiterating the sleep leaflet guidance and making staff more aware. Planning care to avoid multiple disturbances during the night: Grouping non‑urgent tasks together (cluster care). Using soft‑close bins and quieter equipment where possible. Responding to patient needs: Offering sleep packs. Adjusting lighting levels where safe to do so. Addressing concerns quickly. This work is guided by patient experience feedback and in collaboration with ward teams who see first‑hand how important sleep is for recovery. Below is the feedback from the ward manager of one of our pilot wards, and they continue to see the benefits of these packs. “The ward can be noisy at night, and I think we had all just accepted that disturbed sleep is to be expected when you are in hospital, but this trial has changed that outlook. The sleep packs are really simple but very effective, they contain an eye mask, slipper socks, ear plugs and a leaflet with hints and tips of how to get a good night’s rest. Staff have been offering them to patients in the evening, feedback has been great with a few patients claiming ‘it’s the best night’s sleep they have had in years'. We will carry on with them after the study finishes.” (Amy, ward manager on sample ward for pilot – PDSA 2) How the community can help Support from families and visitors also plays a part in creating a restful environment. Simple actions can make a difference: Being mindful of noise during visiting times and remembering people are often sicker than they look and often need more rest. Avoiding phone calls late at night. Encouraging relatives to use call bells instead of raised voices. Bringing in comfort items that help patients relax. Sharing feedback so we can continue improving. Together, we can support better sleep in our hospitals for everyone. So what’s next? Improving sleep in hospital isn’t solved by one intervention alone—it’s a combination of thoughtful design, staff awareness, helpful tools like sleep packs, and ongoing feedback from patients and families. Our commitment at NUH is to continue: Listening to patient experiences. Reacting to feedback. Supporting clinical teams. Introducing practical solutions. Creating calming, quiet environments. Because a quieter night isn’t just about comfort—it’s about better care and better patient outcomes. Noise at night sleep pack presentation: Poster in wards:

The Cheshire and Merseyside Cancer Alliance (CMCA) were finalists in the 'Partnership Working to Improve the Experience' category at the Patient Experience Network 2025 Awards. In this blog, CMCA explain how patient stories are deliberately integrated into their governance, learning and pathway redesign, and how this approach transforms storytelling from passive listening into active improvement. Beyond data—listening to lived experience Modern healthcare systems are built on measurement. We track waiting times, referral-to-treatment targets, survival rates and performance indicators. These metrics are essential and tell us whether services are efficient, timely and clinically effective. Yet some of the most powerful drivers of improvement do not originate from a dashboard—they begin with a story. Cancer care is one of the most complex, emotionally charged and high-risk areas of healthcare delivery. A single cancer journey may span primary care, diagnostic services, multidisciplinary team (MDT) discussions, surgery, treatment, supportive services and palliative or end-of-life care. Along the way, patients navigate multiple appointments, handovers between teams and often life-altering decisions. Delays in diagnosis, unclear communication, fragmented pathways and missed escalation opportunities can have profound consequences. A cancer patient’s story does more than recount a sequence of clinical events. It reveals what mattered most to them in moments of uncertainty. It highlights where systems worked well—and where they did not. It brings into focus inequalities, access barriers and communication gaps. The question is no longer whether patient stories matter. It is how we use them responsibly, consistently and systematically to improve care. From patient story to structured improvement To create measurable impact, storytelling must move beyond powerful listening sessions. It must be embedded into structured quality improvement and safety culture. At CMCA, patient stories are deliberately integrated into governance, learning and pathway redesign. Stories are shared across meetings, events, training sessions and improvement programmes. Rather than treating stories as standalone testimonies, they are used to strengthen systems thinking. Each story prompts structured reflection: where were the faults in the pathway? what safety nets failed or were absent? how did workload pressures or process design contribute? were there missed opportunities to escalate concerns and could this scenario happen in our service today? This approach transforms storytelling from passive listening into active improvement. When patients see that their lived experience leads to tangible change, storytelling becomes partnership—not performance. On 23 May 2022, CMCA invited its first patient storyteller to a team away day. Hearing a personal cancer journey directly from someone with lived experience had a profound effect. It shifted conversations from abstract targets to real human impact. Since then, colleagues across the Alliance have increasingly invited patients to share their experiences to inform pathway redesign and programme development. Between 2022 and 2025, 73 patient stories have been shared. As a result, six significant changes have been implemented. These include improvements to the accessibility of diagnostic testing and the development of a patient engagement checklist for the pathology transformation programme. Other impacts are less immediately measurable but equally meaningful. Stories often leave a lasting impression, influencing how leaders think about service design long after the meeting ends. Empowerment through partnership For many patients, sharing their story is both courageous and empowering. Storytellers remain fully in control of what they share and how they share it. CMCA offers multiple formats—written narratives, audio recordings, video submissions or in-person presentations—ensuring that individuals can choose what feels safest and most authentic. One storyteller reflected: “Oh my word, it's always so amazing to know people hear what I say and take it in.” Another, a CMCA Patient Representative, shared: “Sharing a patient journey can feel daunting at first, but the team at CMCA have been empathetic, kind and supported me every step of the way. Knowing that my words can help others in some way gives me hope and helps me to heal.” Storytelling has also opened further opportunities for patient involvement. Some storytellers have joined project groups, contributed to service redesign or been connected to additional support services. What begins as a story can evolve into ongoing collaboration. Embedding the patient voice in leadership and education The influence of storytelling at CMCA has expanded beyond frontline teams. Patient stories are now a standing agenda item at Board and Diagnostics Board meetings, ensuring that strategic decisions remain grounded in lived reality. At one recent Board meeting, a storyteller who is both a wheelchair user and a cancer patient described the physical and systemic barriers they encountered across their pathway. The account was powerful and specific. It prompted Board members to commission a system-wide accessibility review—a direct example of lived experience shaping strategic action. Patient stories have also informed education. They became the foundation of the 123 Health Inequalities training programme, a CPD-accredited e-learning course developed by the CMCA Health Inequalities and Patient Experience team. Built from both staff and patient voice, the programme uses real experiences to illustrate how inequality manifests in everyday practice—and what professionals can do differently. As Jenny Brazier, Patient Engagement Senior Project Officer at CMCA, explains: “Listening to and acting on lived experience teaches us how to deliver better care and improve services for others. When we truly understand what matters most to patients and their loved ones, we create more equitable, person-centred care.” Conclusion: listening as a safety intervention In cancer care, success is often measured through survival rates, treatment standards and clinical outcomes. These are vital—but they do not tell the whole story. Safety is also about how patients experience their care. Did they feel heard? Were things explained clearly? Were they treated with dignity and supported during an incredibly vulnerable time? Patient stories are not just emotional accounts. They are practical tools for improvement. They help uncover risks that data may miss, reveal gaps in communication or coordination, and highlight where systems create barriers or inequalities. When listening is built into leadership and improvement work, it becomes a powerful safety intervention—helping ensure cancer care is not only effective, but truly centred on those who receive it. The Cheshire and Merseyside Cancer Alliance (CMCA) team. Further reading on the hub: How authentic patient stories can shift systems thinking and improve care Digital storytelling: Learning opportunity or reputational risk? Catching cancer early: what more can we do as GPs?

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The Green Nursing Challenge Showcase was held on 20 October 2025 celebrating the outstanding work of teams from hospital and social care settings—an award-winning leadership and engagement programme dedicated to transforming healthcare. One of the teams that competed in the Green Nursing Challenge was the Bladder, Bowel and Pelvic Health community team in Lewisham, London, with their project: ‘Trial without catheter (TWOC) using a structured approach’. The team have shared their project with the hub. The Centre for Sustainable Healthcare supported the Bladder, Bowel and Pelvic Health community team in Lewisham by undertaking a sustainable quality improvement project: a ‘Trial without catheter (TWOC) using a structured approach’. The team (consisting of the clinical lead, catheter lead nurse and a graduate management trainee) worked with the district nursing teams and urgent care service as part of the Green Nursing Challenge to improve care for patients, whilst saving money and carbon emissions. The challenge Indwelling urinary catheters are among the most used invasive medical devices in the UK, and an estimated 90,000 people in community settings require long-term catheter use. Evidence suggests that the longer a catheter remains in place, the higher the risk of infection, and around 2,100 deaths per year are directly attributed to catheter-related infections. The financial burden of catheter-associated urinary tract infections (CaUTIs) is approximately £2,000 per episode and the total annual cost of Foley catheter use estimated between £1 billion and £2.5 billion. A TWOC is conducted when a catheter, which is a tube inserted into the bladder to drain urine, is removed to determine if the patient can urinate normally without it. This procedure is essential for evaluating bladder function and ensuring that the patient can manage without ongoing catheterisation The team found that there was a lack of knowledge around standardised TWOC protocol, and a lack of clear evidence on how to manage the process. They identified problems with repeated catheter use, unnecessary district nurse visits, ambulance callouts and avoidable hospital stays. These inefficiencies not only compromise patient care, comfort and quality of life, but also generate considerable plastic waste from catheters, gloves, aprons and maintenance solutions. Removing catheters as soon as possible has many advantages, but it is vital that removals are planned and effective to prevent adverse events, unnecessary emergency call outs or attendances to the emergency department. Avoiding the cycle of failed TWOC and repeated catheter insertion is key. The Green Nursing Challenge helped the team in the successful implementation and evaluation of a project to develop a structured TWOC process, and measure the impact from a social, financial and environmental perspective. They implemented a classification system for TWOC suitability, together with corresponding TWOC strategies. The project saw the team training staff and evaluating their results across the community of Lewisham and the wider Trust. Results Monthly figures were collected before and after the project and showed clear improvements in the following: Reductions in: Catheter-related ambulance call outs by 25%, suggesting more timely community interventions. Catheter-related hospital stays (bed days) by 32%. Catheter-related hospital admissions by 12.5%, indicating fewer acute deterioration events. No catheter associated urinary tract infections were reported. Environmental sustainability The projected annual saving is 42,156.40 CO2e, equivalent to driving 124,026 miles in an average car. Economic sustainability On average, the initiative contributed to projected net annual savings of £441,708. Social sustainability The reduction in bed days meant that patients spent less time in hospital and more time at home which linked to improved emotional wellbeing. Reduction in staff pressures due to TWOC attempts and urgent visits for catheter-related complications. Increased staff confidence in catheter management contributing to a working environment that was less reactive and more focused on delivering high quality, consistent care. Improved integration, communication and patient pathways helped to ensure accurate referrals, faster and more effective communication. Next steps The team are continuing to develop their project hoping to see further improvements in emergency attendance, hospital stays, CaUTI rates, use of catheter materials and speed of catheter removals. They hope developing more comprehensive guidelines will lead to faster assessment and TWOC, or referral elsewhere, with the net result being a significant reduction in catheter usage overall. For more information please see Green Nursing Challenge Trial without catheter - a structured approach. Do you have a project you would like to share on the hub? We'd love to hear from you. Please email [email protected].