The golden thread: patient safety consultation

The Patient Safety Commissioner’s public consultation on new principles of better patient safety seeks views from patients, providers, regulators and commissioners. The principles are designed to act as a guide for senior leaders in how to design and deliver safer care for patients and reduce avoidable harm. They are relevant for healthcare providers, commissioners, regulators, manufacturers, and the broader supply chain, including those that provide services, medicines, and medical devices to the NHS.  

The launch of the consultation arrived at an interesting point, coming as it did a couple of days before the publication of Dr Dash’s interim report on the operational effectiveness of the Care Quality Commission and the Government’s response asking Dr Dash to review the effectiveness of all patient safety organisations.

Seven principles of better patient safety

The PSC would like to see the following draft principles adopted across the health and care system:

1. Create a culture of safety

This refers to leaders having responsibility to lead by example to “inspire a just and learning culture of patient safety and quality improvement”. This principle sets out to keep people safe, supporting continuity of care, and nurturing a culture of compassion, listening and restorative practice.

2. Put patients at the heart of everything

Ensuring leaders consider the needs of patients, work with them to identify risks and deliver person centred care. Leaders need ensure that the patient voice is central to informed consent and shared decision making.

3. Treat people as equals

Ensuring that patients are treated with “fairness, respect, equality and dignity”. Leaders are encouraged to actively seek and capture meaningful feedback from patients, families and staff. Feedback must be acted on to ensure the patient voice is heard.

4. Identify and act on inequalities

Health inequalities and the drivers of health inequalities need to be identified and acted upon at every stage of healthcare design and delivery.

5. Identify and mitigate risks

Patient safety risks need to be identified and action directed to mitigate those risks. Leaders need to escalate new and existing risks to healthcare commissioners and regulators. Staff must be empowered to proactively identify risks, hazards, and improvements.

6. Be transparent and accountable

Creating a culture where there is “honest, respectful and open dialogue and where candour is the default position”. This will enable a continuous improvement cycle and ensure patients do not face avoidable harm due to a culture of cover up.

7. Use information and data to drive improved care and outcomes for patients and help others to do the same

This principle is focussed on using good quality data for all work types to improve patient care with best practice shared widely.

Comment

Some of these principles resonate with the recommendations of the Infected Blood Inquiry report (read our collection of articles on key findings, lessons to be learned, risk management recommendations) and other inquiries, such as risk identification and learning from incidents.

So, while progress on patient safety has been made with the NHS Patient Safety Strategy and the appointment of the Dr Henrietta Hughes as the Patient Safety Commissioner in 2022, the need for these seven principles is clear. Dr Hughes says that despite the progress that has been made, patients still tell her that their voices are going unheard and that decisions about healthcare design and patient care are being made without reference to their views. Healthcare leaders also share concerns that while they want to focus on safety decisions higher up the chain prevent them from doing so. It is in this context that she has developed a draft set of principles to guide decisions across the sector.

This consultation is relevant to all in the health and care sector. You have until 6 September to respond to the consultation here.