The NHS is forever learning and continuously aims to improve the safety and quality of patient experiences. At Sussex Community Foundation NHS Trust (SCFT) there is a team of professionals, the patient safety team (PST), at the heart of these experiences.
The PST follows a strategy aiming to continuously improve patient safety, building on the foundations of a safer culture and safer systems. The team has dedicated patient safety leads (PSLs) from nursing and allied health professional backgrounds, who review the quality and safety aspects of patients care.
Errors do occur. However, SCFT PSLs acknowledge their job in supporting staff, patients and families to make the NHS safer for everyone. It is all too easy to blame individuals following an incident. PSLs are leading essential change and promoting a just culture where those involved feel supported.
The role of a patient safety lead
A day in the life of a PSL varies but usually starts with triaging patient safety incidents that staff report through the local risk management system. This clinical triage helps in promptly identifying harm or risks to patients as a result of healthcare delivery. The PSL needs an enquiring mind and will often contact staff requesting further information to help us assess if the issue needs escalation for a more in-depth investigation and analysis to maximise learning.
PSLs lead on Serious Incident investigations and need the investigative and people skills to ensure they are supportive of all individuals they engage with during these investigations. They require heightened listening skills, empathy and compassion. Equally, PSLs need to reflect with colleagues and support one another, whilst undertaking complex or distressing investigations. When reporting their investigations, they must use language that is fair and objective. By sharing the investigation findings with other PSLs within the team, unconscious bias can be checked and other perspectives can be obtained.
Part of the PSL role is to encourage the teams and services involved to utilise the learning from the investigations to make recommendations to improve working systems and processes. The role empowers teams to lead change and deliver on those actions. For instance, a recent action at SCFT promoted hidden disability awareness and the widely recognised ‘sunflower scheme’ – created to make hidden disabilities visible – within our inpatient units. The action has resulted in a pilot of the project and will allow patients to ‘opt’ in to wearing a sunflower bracelet, which identifies that the patient may require additional assistance.
These quality improvement initiatives are aimed at improving patient safety, experience and outcomes. PSLs work closely with other teams within the quality and safety department, including medical devices and the patient advice and liaison service (PALS). Working collaboratively can help with measuring the effectiveness of improvement initiatives in practice.
Seeking expert advice and liaising with the right professionals is a crucial part of the PSL role. For instance, an investigation which involves reviewing a specialist lymphedema service, will require the input those professionals who have the most knowledge and insight into that particular field.
The role aims to promote resilience. We treat humans not as hazards but resilient individuals who should be involved in the process of learning to improve systems and processes. This way we avoid focussing on individuals to find blame whilst still promoting professional accountability. To further support this SCFT has developed a reflection tool which helps staff learn from incidents to support their professional development and for nurses, their revalidation.
Not easy saying sorry
The methodology in patient safety is evolving and underpinning this is the NHS Patient Safety Strategy. SCFT has recently engaged with a team for a wider quality and safety learning exercise, rather than looking at incidents in isolation. This provided assurance of the quality and safety measures for that team whilst also identifying the areas that the team want to improve upon.
All healthcare professionals abide by a professional code, which also encompasses a duty for being open and honest with patients when things do not go to plan or unexpected outcomes occur. This is also enshrined in legal regulations and monitored by the Care Quality Commission to ensure that professionals and organisations manage incidents with openness, transparency and compassion.
The PSLs support staff across the Trust with ensuring that this duty is followed and embedded. Sometimes, it is not easy saying sorry and admitting to making mistakes – but the right support and culture makes this easier and it is always the right thing to do.
Informing patients when an incident has occurred from the onset, can provide patients with assurance that incidents will be reviewed and learning will be supported. Incident reporting is part of a just culture; where transparency and willingness to learn is essential.
SCFT encourages colleagues to have professional curiosity and learn more about the work undertaken and promoted by the PSLs. Through welcoming students, returning back to the floor, using digital platforms and wide spread communication, the PST at SCFT is building stronger foundations to promote an inclusive safety culture for staff and patients.
Resilience is key to empowerment and learning, when we stretch a rubber band; we aim not for the rubber band to snap but to be able to bounce back.