Dr Ted Baker (HSSIB Chair) and Dr Rosie Benneyworth (HSSIB Interim Chief Executive Officer) were also emphatic that:
- no investigation topic will be ‘off-limits’ if it impacts patients
- all patient safety organisations must work together
- the voice of patients and families remains vital in providing safer care for all.
The comments were made at an event, held at King’s College London with 200 invited guests, to mark the formal establishment of the Health Services Safety Investigations Body (HSSIB).
Also speaking at the event were other key figures in patient safety, including Maria Caulfield MP (Minister for Mental Health and Women’s Health Strategy), Dr Aidan Fowler (National Director of Patient Safety at NHS England) and Dr Henrietta Hughes (Patient Safety Commissioner).
HSSIB replaces the Healthcare Safety Investigation Branch (HSIB), formed in 2017. HSIB was the first organisation in the world set up as an independent investigator of patient safety incidents. Our new body will continue to build on the expertise and experience developed over the last five years.
Safety and quality at the top of the agenda
Dr Rosie Benneyworth said during her speech that “safety and quality need to be at the top of the agenda” to enable the health service to tackle the huge demands and pressures placed on it.
This was reinforced by Dr Ted Baker, who said “we are setting ourselves a bold ambition to radically change the way safety is managed in our health services, supporting everyone working in them as they strive to keep patients safe from harm.”
HSSIB’s commitment to championing safety management is reflected in our first report, published today. Its focus is on what is known as safety management systems – a proactive and integrated approach used by other ‘safety-critical’ industries to manage risk and safety concerns. The report gives insight into how healthcare could learn from industries that have improved their safety records.
Both speakers emphasised the importance of innovation and partnership working to help reduce the harm caused to patients. Ted Baker called on those attending the event from across the NHS and independent healthcare to work together, saying that HSSIB could not achieve its aims of safety improvement without “the collaboration of everyone in this room and many outside it. Patient safety cannot be delivered by any of us alone. It is a shared goal, a joint enterprise.”
Rosie Benneyworth emphasised that it was crucial that our new organisation looks at any aspect of the healthcare system and that through our work as HSIB we have seen some areas that significantly affect patient safety but do not get the spotlight, such as procurement, supply chains and estates. She pledged: “HSSIB will use its new legislation to ensure that nothing is ‘off limits’ for investigation if there are concerns raised with us about the impact for patients.”
Patient and family involvement
HSIB developed an exemplary model of patient and family involvement for safety incident investigations and this way of working will continue into HSSIB as we see the voice of patients as being vital to improvement.
Ted Baker reflected that many safety problems in healthcare had a reoccurring theme of not listening to patients and families. He said, “they have experienced how healthcare is actually provided, not how we often imagine it is provided. If we are to improve safety, we must understand its reality as experienced by patients.”
Those working across the NHS and the independent healthcare sector have expressed to us that they will value our strong and independent voice within a complex system. Rosie Benneyworth commented that “we need to ensure that our work leads to change for patients. We will be looking at the impact of our recommendations and may return to revisit previous investigations to see what change has happened as a result.”
Tackling the biggest risks
HSSIB will look to tackle the biggest risks to patient safety. This can be seen in some of the areas that we have announced we will be focus on in the coming year, including:
- mental health inpatient services
- fatigue and staff wellbeing
- health inequalities
- transitions of care between different settings
- how safety and innovation can align.
In summarising the importance of HSSIB’s work, Ted Baker said: “A focus on patient safety is important first and foremost because it can reduce harm, and we should never lose sight of that. It can reduce harm to patients. It can also reduce harm to healthcare staff…The problems faced by health services at the moment are complex and do not have simple solutions, but any solutions that will succeed must have safety at their core.”