Ian Trenholm, Chief Executive, Care Quality Commission
This first World Patient Safety Day is an opportunity to improve awareness of patient safety and to show how we are making health and social care safer. Everyone has a part to play in improving patient safety, not only clinicians, and everyone should be empowered to raise concerns when they believe there is a risk to patient safety.
CQC works across all sectors to drive improvement and we have seen time and time again that strong leaders who can establish an open and transparent culture alongside a workforce that is valued, well trained and supported to deliver safe, effective person-centred care are hallmarks of patient safety — they create the conditions for success.
This has been reinforced in the interim report of our thematic review on restraint, seclusion and segregation. Many of the people we visited during the review had little or no control over their day to day life and were not involved in decisions about their care. Some had been in hospital for a long time, often supported by people who did not have the right training and skills. We know that when people are located away from their communities and where employees are often unqualified, people are more at risk of harm.
It is vital that people working in mental health hospitals are supported to make every effort to enable a person to communicate their wishes and to be a full partner in decisions about their treatment, care and future. This requires expert and compassionate care from professionals with highly specialised skills and a culture that values the people they are caring for. Healthcare is delivered by people and people can make mistakes; that is why we need to ensure that leaders and the wider system put in place the conditions for success.
Having enough people with the right skills, in the right place, at the right time is key to patient safety. Our recently published web resource on effective staffing looks at what providers have done to address the challenge of providing safe, effective staffing in creative and flexible ways. They demonstrate the importance of team work, avoiding silo working, and developing professionals so they can support each other to ensure that patients have the smoothest possible journey on their care pathway. We know that simple changes such as checklists can have a significant impact. They are however just tools, and it also needs a sustained desire to improve and question everyday practice.
There is a great deal of experience out there, so part of creating conditions for success is about learning from others, including being open minded enough to learn things from other industries, and from patients themselves. We aim to support this learning, for example, through our ‘Driving Improvement’ series, we spoke to people working across a variety of care settings to explore how organisations improve the quality of care for patients. These case studies show just how important it is to have open, honest and visible leadership that engages and empowers people across all departments to contribute to improving patient care. But real change does not happen overnight — and the improvements made are a testament to the effort and determination of those involved.
We have seen this in East Lancashire Hospitals NHS Trust, who have adopted an integrated way of working which has seen health professionals being trained in social care skills. This approach has significantly reduced delayed transfers of care and was developed through collaborative training, multi-professional working, and a case management style approach.
We also know from the work we have done on how trusts have achieved significant improvements that the involvement of people working in the service is key. The chief executive of East Lancashire Hospitals told us that “improvement starts and ends with staff engagement. Getting staff to understand they had the answers and means to improve was critical”. When people are fully engaged and supported, they are more likely to raise concerns and admit errors, helping learning and driving improvement. When things go wrong we should always see this as an opportunity to learn, not something to hide. We have a duty to patients to explain when things go wrong and how we have learnt from it — that is sometimes uncomfortable but vital to do.
We are committed to encouraging good and outstanding practice and to sharing learning to support more providers to make safety improvements. Equally, patient safety cannot be compromised and where we identify safety concerns, we will require improvements to be made. Where improvements are not made, we will use our enforcement powers to protect people. One example is our recent prosecution of Avon & Wiltshire Mental Health Partnership NHS Trust for failing to provide safe care and treatment — resulting in avoidable harm to a patient who was seriously injured following a fall from a roof at the trust. We will continue to focus on encouraging improvement and sharing best practice — but we also have a legal duty, and a duty to families and loved ones, to use our civil powers or the powers we inherited from the Health and Safety Executive in 2015, to ensure that people are protected from harm. We will continue to use learning from enforcement action to feed back to individual organisations and the wider system so that care is improved and people are protected.
Everyone — including patients –has a part to play in making patient safety a top priority. Hearing from people about their experiences of care is an important part of our inspection work and contributes to driving improvements in standards of care. Everyone can play a part in improving care by directly giving feedback to services, or by sharing information and experiences with us so that we can take action when we find poor care and continue to highlight the many great examples of care we see. You can give feedback on your care on our website at any time.