Organisational safety culture – the shared beliefs, values, assumptions and patterns of attention and interaction that shape the safety of care delivery – has long been a central concern in efforts to improve patient safety and understand serious failures of care. Recently, supporting and governing safety culture has become a focus for regulators and policymakers.
A large literature has explored the characteristics of safety culture and, a primary focus in healthcare has been the development of tools to measure safety culture (Waterson, 2014). However, this approach to patient safety culture has been criticised as narrow and overly simplistic. Whilst considerable attention has been given to describing and measuring patient safety culture, the fundamental and practical issues of how culture is enacted through the ‘work’ of safety and improvement have received far less attention. There is little evidence for how safety practices are themselves culturally determined; how organisational processes and governance systems shape, enable or constrain culture in different settings; or, how cultural practices and characteristics interact or conflict across the complex organisational and care boundaries that characterise modern healthcare systems. These issues are fundamental to building and governing sustainable cultures of safety and learning.
Previous risk management practices are largely based on learning from past harm and introducing interventions (new procedures, risk assessments, training) or technical fixes (alerts and prompts in electronic health records) to reduce risk. This process of adding new interventions has largely gone unchecked; many (e.g. Ashton, 2018; Wise, 2018) now argue healthcare systems have become overly constrained without clear evidence of benefit. A recent experiment in Nature (Adams et al., 2021) demonstrates a human tendency towards additive rather than subtractive change. Consequently, people tend to think that doing something additional is more effective than doing less. Here, we will deliver research programmes with the common theme of doing less, or de-cluttering.
Many terms describe the process of reducing the burden of excessive procedures, medicines and alerts, e.g. de-implementation, deprescribing, exnovation. Our lay leaders advised that none of these terms captured the different topics or were accessible to the public. Thus, we use the term de-cluttering to capture how this theme will improve safety by: 1. Reducing ineffective safety practices; 2. Reducing problematic polypharmacy; 3. Rationalising clinical decision support systems.
Many people with complex and serious conditions are now cared for at home rather than in hospital or residential care. Caring for oneself at home, or being cared for by others, allows people to maintain independence, quality of life and contact with family and friends. However, the well-intentioned provision and transfer of care to the home also carries significant, but largely unexplored risks.
Healthcare is in effect exporting risk from the hospital to the home. People manage multiple health conditions at home and face significant safety challenges, including managing medication. wound management and navigating health and social services. Patients and carers are increasingly managing clinical tasks that would formerly only have been carried out by professionals. Carers and family members also have to be alert to possible deterioration, judge when to seek help, assess the need for emergency care and coordinate care from multiple, and often highly fragmented services. Risks to safety therefore accrue from numerous sources and over time.
Improving safety in hospital has been challenging, even though hospitals are highly regulated and staffed by people with substantial professional training. Improving safety in the informal environment of the home will require a different approach. We cannot rely on regulation, checklists and imposed solutions. Rather we need to place the patient centre stage as the arbiter of their care. We need to provide support, adapt solutions to different types of home, provide training, and facilitate a rapid response to deterioration. Our focus in this theme will be on understanding both the benefits and risks of home care and on developing interventions to support patients and carers in delivering safe care at home.
Developing effective patient safety intelligence remains a significant challenge for health systems worldwide. Current risk management systems largely signal the absence of safety through monitoring safety events and the resulting avoidable harm caused to patients. Developing systems capable of proactively signalling threats to safety before harm occurs, whilst learning from how work systems and staff continually adapt to maintain safety, will be a key capability of future safety intelligence solutions in health care and other safety critical domains.
In contemporary safety science, system safety is conceptualised not only as the absence of adverse events but crucially the presence of “resilience” within the system. Resilience has been defined as “the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Hollnagel, 2013). This focus has been termed “Safety II”, the notion that we can learn as much (or more) from intelligence on how the system and its staff routinely adapt to maintain safety in the face of dynamic risks (or avert harmful consequences when dangerous variations do occur) than from monitoring past harmful events. Whilst all safety intelligence systems ultimately aim to enhance resilience, understanding exactly how to improve data capture, interpretation and use for this purpose is an important area for research and innovation.
To address this need, recent patient safety measurement and monitoring frameworks have sought to complement a retrospective focus on past harm with real-time monitoring and proactive learning strategies. With promising new developments in incident response and investigation currently being implemented within the NHS in the form of a new Patient Safety Incident Response Framework, there remains considerable opportunity to develop and evaluate complementary forms of safety intelligence, such as “soft” intelligence from staff and patients and insights from integrated “whole system” data. Research is additionally needed to understand how to translate these emerging forms of safety intelligence into frontline improvements in patient safety. Our theme aim is therefore to develop and evaluate novel safety intelligence solutions (spanning data capture, insight and use) to support patient safety improvement across the healthcare system.