Healthcare Commission patient safety reports focus on board responsibilities

The Healthcare Commission has published three separate, but linked, reports on patient safety and highlights the role of boards in improving the safety of NHS care.

According to the Healthcare Commission, “Safety is clearly the responsibility of NHS trust boards. It should be one of their highest priorities. Trusts are telling us that safety has moved up the agenda, but that priorities vary between organisations and from time to time, depending on local circumstances. The evidence gained through our assessment and inspection activities raises concerns over the extent to which some NHS trust boards are effectively discharging their roles and responsibilities, to ensure that the services they commission and provide are as safe as they could be for patients, staff and visitors.”

“Our research with selected trusts also indicates that some boards are indeed struggling with how, and the extent to which, they should become engaged on this topic. The key issues were:

• Safety is not always first on everyone’s agenda.
• There is a need to do more to embed a widespread culture of safety and to genuinely learn when errors are made, or when things are not done that should have been done.
• Governance arrangements for safety need to be broadened beyond national targets, to include monitoring of all key outcomes, drivers and risks.
• There is incomplete and/or inconsistent recording and reporting of incidents.
• There are variable rates of implementation of national safety alerts.
• There is limited engagement with patients to improve safety.
• There is a lack of clarity and understanding of what should be reported to the board on a regular basis. (The Healthcare Commission provides, in appendix 4 of the report Safe in the Knowledge – see below – recommendations for the ideal range of information that boards should consider including in their governance framework.)
• There are difficulties in establishing effective mechanisms and measures to help drive improvement in safety via the
commissioning process.
• There are some substantial barriers to measuring performance on safety, such as lack of appropriate IT support, data quality, under-reporting, and problems tracking outcomes along care pathways.

The Commission also “found that some boards are struggling with how, and the extent to which, they engage with the issue of safety. The information that they receive needs to be broadened to address all key outcomes, drivers and risks in relation to safe care. Real and sustained change will only be achieved if boards ensure that safety and quality is at the heart of what  they do, and the [Safe in the Knowledge] report makes a range of suggestions for how they can do this.”

As mentioned above, the Commission has published three reports. They are:

Safe in the Knowledge – How do NHS trust boards ensure safe care for their patients?

Research on assuring the Board that the care provided to patients is safe. A report prepared for the Healthcare Commission by an external organisation.

Safely does it – Implementing safer care for patients.

All three patient safety reports can be downloaded here.


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