This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
In this short article we reflect on how the management of patient safety risks may be considered from different perspectives. Understanding the value of these different perspectives may provide new opportunities for improvement if they are represented across the health and care system.
Over the last year the structure of health and care has changed. The introduction of integrated care systems aims to move towards new ways of working. The goal being to deliver ‘joined up health and care services’ to improve the lives of people living within a specified geographical area. This article outlines some of the opportunities to improve risk management practices that may now be achievable as a consequence of this structure.
The need for proactive risk management
Risk management may be used to identify threats to patient safety by developing controls to mitigate harm. Proactive assessments enable a health care provider to present calculations and qualitative evaluations of the level of risk and associated costs to manage the risk. However, at the provider level it is often difficult to assess risks to patient safety in a meaningful way. This is because some of the most significant threats to patient safety occur as patients interact across multiple providers.
Integrated care systems could be designed so that overarching risks to patient safety are identified and managed. Many types of patient safety risk only become apparent when considering a patient’s journey through the health and care system. Thus, does it not become evident that the responsibility for these overarching risks, often not owned at a provider level, be managed at the appropriate local system level?
The representation of different perspectives
The concept of risk management may be considered from different perspectives. Firstly, in terms of the ability that clinical staff have to manage clinical risks at the point of care; secondly, how health care providers identify and manage risks associated with their organisational care settings; and thirdly, how the system manages recurring overarching risks that harm people living within a specified geographical area. Although there are clinical governance systems and patient safety roles in NHS organisations, they do not provide the necessary capability needed for risk management at a local system level.
Clinical governance perspective
In 1948 the NHS was established with no particular agenda for safety. “It was assumed appropriate quality would result from the provision of an infrastructure and the training and education of staff”.1 In 1983 the Griffiths Report described a lack of clarity in assuring quality at local level.2 The report found that there was no clear definition of management functions within the NHS. Griffiths made a number of recommendations, which led to the introduction of general management in the NHS at regional and district levels of the system. However general management became fundamentally driven by meeting financial targets, safety was “subsumed under the heading of organisational performance”.3
Following the Health Care Act 19994 there is a statutory ‘duty of quality’ for healthcare providers, and this led to the establishment of associated frameworks for clinical governance. The ability of clinical staff to manage clinical risks at the point of care may be assessed using clinical governance frameworks. Clinical governance was proposed as a means by which accountable quality would be achieved by providers. Clinical governance becoming ``the main vehicle for continuously improving the quality of patient care''.5
Organisational and local system perspective
Risk management at an organisational and local system level goes beyond the remit of the clinical governance frameworks that are used by health care providers. This is because of the need to identify and manage risks that arise as patients move between providers, and the risks associated with accessing timely and appropriate care. Risks arise at different levels of the system where there is variability in patient needs and variability in care delivery capabilities and capacities. There is also an urgent need to manage high-level healthcare system pressures at organisational and local system levels.
HSIB’s investigations have identified that patient safety policies, the implementation of interventions, and associated regulation are highly fragmented. Safety activities often overlap and conflict, multiple guidelines exist for similar situations, and guidelines generated from provider level Serious Incident reports, in an attempt to manage safety risks, often do not account for local system level factors. The local system risk picture must be understood and managed when planning and evaluating health and care services.
Societal concerns inform the perception of the associated cost appropriate to manage a risk, for example if there is a decision not to implement a control to manage a risk this may cause a loss of trust by the public. Representation of the patient perspective and associated care needs is critical if risk management activities are to be successful at local system levels.
There is an opportunity to integrate risk management activities by considering clinical governance, organisational and local system pressures, and societal needs. The structure of integrated care systems seems to provide the opportunity to achieve this. However, HSIB have observed through our investigations across several integrated care systems, that there is a lack of capability to perform safety management activities including risk management. Many types of patient safety risk only become apparent when considering a patient’s journey through the health and care system, and there should be capacity to manage these at the appropriate level.
- S Nicholls, R Cullen, S O’Neill and A Halligan (2000). Clinical governance: its origins and its foundations. British Journal of Clinical Governance, Volume 5 Issue 3, page 172–178.
- Roy Griffiths (1983). Independent public inquiry. NHS Management Inquiry: Griffiths Report on NHS.
- Sheila Leatherman and Kim Sutherland (1998). Evolving quality in the new NHS: Policy, process and pragmatic considerations. Research report. Nuffield Trust.
- Health Act 1999.
- Gabriel Scally and Liam J Donaldson (1998). Clinical governance and the drive for quality improvement in the new NHS in England. The BMJ, Volume 31 Number 7150, page 61–65.