Blurry hospital ward

Looking beyond the recommendation: building a holistic approach to safety improvement

By Ian Lavery

8 September 2022

As part of our investigation education seminar series for our staff, healthcare improvement expert Professor Mary Dixon-Woods joined us for our August session. In this blog, Ian Lavery rounds-up her thought-provoking presentation.

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Ian Lavery
Ian Lavery, Senior Investigation Science Educator.

Mary Dixon-Woods is Director of THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge. Her presentation to HSIB staff really brought the role of the recommendation in safety improvement to the forefront. 

After a review or investigation, many organisations will make recommendations aimed at safety improvement at a national and/or local level. Mary’s presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system.

At HSIB, most of our national investigation reports contain recommendations aimed at improving patient safety at a national level. However, even as an organisation that sees the value of robust safety recommendations, it is important that we are always asking the critical questions – will the recommendation enable effective improvements and what needs to be done to support the system change that recommendations will inevitably bring?

Moving safety improvement forward

If we identify where the gaps are, then we can move safety improvement systems forward.

We know that there is now a well-established infrastructure of evidence that surrounds the development of clinical treatments. For example, this enabled the mapping of COVID-19 and the vaccine development programme. However, when we start to look at the services that deliver these treatments, there is a lack of infrastructure and evidence-based improvement remains underdeveloped.

The landscape in healthcare is constantly evolving, and especially at a time when the NHS is under extreme pressure, we must be mindful that recommendations are adding further change to an already complex environment.

So, what should be considered when thinking about recommendations that will support the most effective system change? We have put together some key areas below that should be looked at when drafting and developing recommendations and considering how they will be supported and implemented.

Creating recommendations to respond to real world working

Making recommendations following a review or investigation has the target aim of improving how services are delivered. The implementation or actioning of those recommendations is a challenging task. Often those recommendations are not accompanied by any guidelines or suggestions on how to perform that implementation or to translate them into existing processes or working practices.

Involving those most affected

It is important for those who are most affected by patient safety incidents to be involved in the creation and implementation of the process changes.

The newly launched Patient Safety Incident Framework (PSIRF) is a great of example of where there will be such involvement. It will allow the voices of staff and patients to be heard and ensure they are involved in the groundwork from which such changes will develop. This can be the first step in making sure quality-based evidence is collected for improvements in service delivery.

Looking at when things go right

To further support system change when it becomes an inevitable outcome of a recommendation, we should consider looking at incidences of when ‘things go right’. All too often in healthcare when looking to make improvements we do so using the lens of examining ‘what went wrong’ rather than also considering what good looks like.

For our part, at HSIB we are continually looking to improve how safety recommendations from our investigations can be best delivered to support national organisations and NHS trusts to implement them by using system factor approach to investigations.

Further reading

We've blogged about our involvement in producing PSIRF supporting guidance on involving families, patients and NHS staff in patient safety incident investigations.

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