What every healthcare board needs to understand about patient safety

February 2010

Harm done to patients by the healthcare system is as old as medicine itself. Understanding errors and addressing their causes provide a window into the efficiency and effectiveness of the whole healthcare system, and at a time when those on NHS boards are seeking to finesse better value for money and at the same time improve patient experience, there is a unique win-win to be had by putting safety first.

GGI Report on Patient Safety – February 2010

What every healthcare board needs to understand about patient safety
Andrew Corbett-Nolan, Chief Executive, Good Governance Institute
Jonathan Hazan, CEO, Datix

We have written this report for all members of boards of healthcare organisations, but particularly for non-executive directors and others who may not steeped in the world of patient safety. NHS boards hold the ultimate responsibility for the common law ‘duty of care’ for those who seek and use our services. The Health Act 1999 also applied a ‘duty of quality’ to all parts of the NHS and to all those who commission, provide or manage patient care. Under the Act, arrangements must be put in place for monitoring and improving the quality of the health care that health authorities and Trusts provide. Chief Executives are accountable for assuring the quality of NHS Trust services and must provide boards with regular reports on quality in the same way as they do for finance. This report aims to explain the importance of patient safety, the scale and nature of the epidemic of clinical errors, how the NHS has responded to this and what good governance practice is in relation to sustaining local improvement.

Harm done to patients by the healthcare system is as old as medicine itself. Healthcare is a high-risk industry, but surprisingly the scale of this harm has only really been understood within the past 20 years. Put simply, adverse events may account for the deaths of in excess of 30,000 NHS patients each year. This in itself is quite sufficient to make safety the prime duty of all on NHS boards, but there is more still to be gained from a better grip on safety than tackling this major public health issue. Understanding errors and addressing their causes provide a window into the efficiency and effectiveness of the whole healthcare system, and at a time when those on NHS boards are seeking to finesse better value for money and at the same time improve patient experience, there is a unique win-win to be had by putting safety first. We developed our thinking in a number of ways.

Both the Good Governance Institute and Datix have been involved in patient safety work for many years, and so we come to this task from having both a long-term commitment to the issue and having seen patient safety work in the United Kingdom develop over the last two decades. We have also considered the research base, the work of other organisations committed to improvement and the various national programmes aimed at helping boards institute better patient safety practice. We have also involved many from the NHS itself, and supported this work through a series of events looking at the issue from the perspectives of primary care, acute and community services, mental health services and commissioning. Our findings were reviewed at a symposium at the Royal Society of Medicine in London in January 2010.

We would like to record our thanks to all involved in shaping, testing and challenging our ideas and proposals and in particular Dr. John Bullivant who reviewed and quality assured the final draft of the report. We thus set our proposals for change in the context of how the patient safety movement has developed over the past two decades.

This report additionally starts to rehearse some of those things that are known to improve safety, and are within the gift of the board. This includes our suggestion for the kinds of things which boards should be keeping a firm grip on. We have also developed a patient safety ‘ready-reckoner’ or maturity matrix1 as a means by which a board can self-evaluate where its patient safety efforts stand in relation to our recommendations and what actions it could institute.

Co-Author: Jonathan Hazan, Datix


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Andrew Corbett-Nolan

Andrew Corbett-Nolan

Chief Executive (Partner)

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