Patient safety across regional care pathways: learning from an HSSIB investigation pilot

In 2025, HSSIB undertook a pilot project to test a process for rapid investigation of patient safety issues and to use the learning to help develop HSSIB’s investigation methods. The pilot focused on patient safety issues within a regional system where multiple organisations were involved in providing care across a care pathway.

The report shares learning gained through examination of a regional care pathway – that is, a pathway of assessment and care for patients with a particular health condition – during an HSSIB rapid response investigation pilot.

The investigation aimed to investigate safety concerns shared with HSSIB about the safety and effectiveness of a care pathway that spanned multiple organisations and where specialist services were centralised to a single site. The pathway had been redesigned with engagement from the organisations, the public and staff to reduce inequalities. It was intended to improve patient outcomes and ensure efficient use of resources across the region.

The investigation provided insights into how the governance of care pathways, including oversight and risk management, is achieved, and how cultural and communication challenges between organisations impacted on patients receiving appropriate care. The investigation identified differences between how the redesigned pathway was expected to operate and how it worked in practice. These differences affected staff wellbeing and led to concerns about risks to patient safety, including delays in access to specialist care.

The learning in this report is shared to support organisations and integrated care boards (ICBs) to adopt effective change management processes that are informed by patient safety considerations when designing, implementing and overseeing care pathways.

• A cross-organisation implementation board oversaw the redesign and initial implementation of the care pathway. Support and oversight from the ICB was time limited, ending before the project had been fully implemented, which impacted on the operationalisation of the service.
• A business case for implementation of the pathway was approved but not fully realised. This created expectations for how the pathway would operate that were not met in practice.
• There was no shared view across organisations about what the redesigned pathway could offer patients in reality. This limited the organisations’ ability to understand the risks across the pathway and to mitigate them to as low as reasonably practicable.
• There was no single guidance document shared between organisations, and there were inconsistencies in the documentation used to support decision making about whether patients should be provided with specialist care.
• Organisations held different perceptions of the risks to patient safety created by the redesign of the pathway. This impacted on clinical decision making and led to disagreements between teams.
• Organisational oversight of the pathway after its implementation was limited due to disengagement among staff and the absence of a collaboratively agreed evaluation plan.
• The data collected about the care pathway differed across organisations and was not routinely shared between them. This led to a difference in understanding about how the care pathway was working in practice and where improvements could be made.
• The ICB had limited ability to support ongoing improvement of the care pathway and had limited access to information about the quality and safety of the pathway in practice.
• Differences in the perceived purpose of the pathway led to barriers to collaborative learning and improvement of the pathway. These included examples of incivility among staff, which is known to impact on staff wellbeing and patient outcomes.

HSSIB investigations include safety learning for integrated care boards where this may support the response to a patient safety issue across a geographical area:

• HSSIB suggests that integrated care boards proactively identify the impact of commissioning decisions on pathways prior to implementation and develop mitigations to reduce any potential impacts on patient safety and equitable access to care.
• HSSIB suggests that integrated care boards support organisations to effectively evaluate the implementation of new care pathways.

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts when collaborating with other organisations across a regional care pathway.

Safe implementation of the care pathway

• How do you identify and resource dedicated support to implement new care pathways?
• How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?
• How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?
• How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice?
• How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning?
• How do you identify and mitigate potential harm caused when implementing a new care pathway?

The care pathway in practice

• How do you identify and manage incivility between staff across different organisations?
• How do you facilitate shared learning opportunities for staff across different organisations?
• How do you ensure information and documentation used to support the care pathway are aligned across different organisations?
• How do you enable staff to understand the context in which the care pathway may work in different organisations?
• How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway?
• How do you support interoperability of electronic systems to enable effective information sharing across different organisations?
• How do you enable new technology to be adopted and used across different organisations?
• How do you consider relevant tools and guidance when developing work processes across different organisations?

Oversight of the care pathway

• How do you ensure shared governance forums are appropriately established and resourced, and are effective?
• How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?
• How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards?
• How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
• How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?
• How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?