Over the last couple of weeks, the Clinical Audit Support Centre team have been updating our Root Cause Analysis training materials. Inevitably, as part of that process we have been looking at the new NHS Patient Safety Strategy that was published in July, available here. As many of you will know, this is a ‘once in a generation’ document building on the recent work of Francis, Berwick and many others. The new strategy is hugely ambitious with patients, and families at the heart of the document and repeated emphasis that future investigations must focus on system failures and not blame individuals. The National Reporting and Learning System (NRLS) will be replaced with a new system that makes reporting incidents and learning from them easier. The strategy focuses on developing a patient safety system and a patient safety culture built on three interlocking principles of insight, involvement and improvement. A new single patient safety syllabus will be introduced, research will be undertaken to reduce clinical negligence claims, a new streamlined system will be put in place to improve dissemination of patient safety alerts, etc.
The above is really the tip of the iceberg! The new 82-page strategy is a 5 to 10-year plan for making care in the NHS safer. And to under truly understand the strategy you’ll need to get to grips with the work of the HSIB, understand the role and purpose of the medical examiner system, familiarise yourself with Safety II and immerse yourself fully in the Patient Safety Incident Response Framework. From our perspective, if the new strategy can be effectively implemented and healthcare staff and patients buy into it, we will see a revolution in patient safety across the NHS.
While researching the strategy, we also came across a series of short films on You Tube that help bring the strategy to life. These have been created by NHS England and NHS Improvement and feature big-hitters like Aidan Fowler explaining the need for the new strategy here, Hugh McCaughey speaking on safety and improvement here, Lucie Musset specifying what will replace NRLS here, Suzette Woodward focusing on Safety II, here. All of the films are worth a watch as they bring the strategy to life via expert leaders who have lived and breathed this work. We encourage you to watch each film.
The problem is that to date, very few people have been watching. All the films were released over 6 months ago to coincide with the new strategy. To date (as of 20 November), Aidan’s film has been viewed 1,664 times, Hugh’s talk 974, Lucie and Suzette’s presentations both 583 (spooky!). Across the 4 films, there have been nine likes, no dislikes and two comments (one positive and one negative).
This astonishes us! Why are so few people tuning into these (actually very useful) films? At many different levels, improving patient safety relies on ‘getting the message out’ to as many people as possible. Are people choosing to read a rather dry 82-page strategy instead of watching films that bring this work to life? Are people just unaware that these films exist? Maybe we need to conduct a five whys or fishbone to better understand?
For those of us working in clinical audit and QI, there are lessons to be learnt. Getting our message out is vital and hopefully as a community we will use Clinical Audit Awareness Week, starting on Monday 25th November to do this. Hopefully we will see local audit teams showcasing their worth, lots of great examples of audits that have made a real difference, national leaders from NQICAN, HQIP, NHS England, national audits etc engaging with the masses, a healthy debate on the future of local and national audit and what needs to change, etc. Let’s use #CAAW19 to get our key messages out, but also make sure that we sustain this into December and 2020.
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