The Healthcare Commission and Patient Safety

AvMA NPSA Patients for patients safety partnership event

Richard Elson

18th March 2008

Summary

•The regulator’s current role

•The regulator’s future role

•Our safety programme

THE REGULATOR’S CURRENT ROLE• Assessment of NHS• Trusts tell us how they think they are doing• We ask patients and the public what they think• We cross-check against information from other sources • We award a rating to each trust: excellent, good, fair or weak

• Investigations We investigate where we find a serious risk, for example

• Treatment of patients with learning difficulties in Cornwall and Sutton and Merton NHS trusts

• Infections in Stoke Mandeville hospital, Bucks• Maternal deaths in Northwick Park, North West London

THE REGULATOR’S CURRENT ROLEReviews and studies

• Services for people with learning difficulties• End of Life Care arrangements• Psychological Therapies• Medicines Management• How well hospitals are involving patients and the public in their service

delivery

Second stage complaints

• Each year we handle 8,000 complaints that have not been settled locally• This will not be a role of the future regulator

THE REGULATOR’S FUTURE ROLE• New health and social care regulator – Care Quality Commission

– from April 09

• March 08– consultation on new regulatory requirements– to include systems to ensure safety

• October 08– consultation on new hygiene code of practice and shadow

leadership

– New system is expected to be based on registration requirements

“To regulate effectively we need to understand the

views of patients and the public”

What is safety?

‘The prevention of harm to patients, that arises as part of the healthcare process’

This should be seen as an integral part of healthcare – not a bolt on.

…about one in ten patients admitted to hospitals in developed countries, a third of whom will suffer severe morbidity or die. Around 50% of these events could be avoided, if lessons from previous incidents were learned.

How many patients are harmed??

When is an organisation operating safely?

- when its staff, carrying out routine tasks, do things in ways that are known to be safest, every time and for every patient

- when its staff, if operating in uncertain or complex situations, are able to anticipate risks and work as a team to prevent them arising

- when it learns the lessons from when things go wrong, and has a culture that supports staff to report incidents and act on the learning

- when all staff, from ward to board, are committed to safety, and the board and managers prioritise and lead change

What we know about key safety issues•Accidents to patients (falls most common) 263,915*•Treatment / procedure errors 66,428*•Medication errors 63,555*•C. Difficile infections** c.55,000•MRSA bacteraemias** c.6,000

•Direct comparison of numbers is difficult as the risk factors leading to patient outcome are different•There is no doubt that infections are a serious concern for patients

(* incidents reported to NPSA national and reporting and learning systems July 2006 – June 2007)

(** patients aged > 65 years and / or reported in same time period)

How are we going to assess safety?

An increased focus on whether the organisation is

managing the key known risks well:

1. Does an organisation have a strong corporate approach to safety?

2. Does it manage the key (nationally-recognised) risks to safety well? 

How did we agree which key risks to focus on?

• Internal engagement - including national clinical advisors and topic leads

• External engagement - Consultation with risk managers, and major national stakeholders including NPSA, MHRA, NHSLA, DH.

• Patient engagement – are we covering the right topics? Opportunity to discuss ideas and concerns that could be developed further.

What key risks are we focusing on?

• Falls• Use of certain medical devices• Implementation of certain safety alerts• Infection control (compliance with the hygiene

code and meeting MRSA and C.diff national targets)

• Management of medicines after discharge from acute or mental health care

How are we going to do this?

Changes to the annual healthcheck

• Falls• Use of certain medical devices• Implementation of certain safety alerts

National Review of medicines management after discharge

How are we going to do this?

NHS Acute sector inspection programme•All acute trusts to be inspected in 2008/9.

Core Standards Assessment and Targets •Existing targets – MRSA – reduction by 50% by 2008.•Agree local targets for C. difficile in 2007/8 and new national target of 30% reduction by 2012.

Outside the NHS acute sector•Prioritise for patient safety and regulation through risk assessment based on available information.

Healthcare Associated Infections

What else are we doing?

• Work on using serious incident data to target interventions

• Work to learn what is currently reported to boards about safety, and how this could improve

• Developing better indicators to identify good and poor performers

• Developing our website, so it brings together all the information we have on safety in one place so that it’s easy to access and clear for different audiences

Your input is important to us…

•Are we addressing the right things?

•Have we missed anything?

•Are there priorities to consider for the future?