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In the first part of this blog I talked about being invited to attend a three-day World Health Organization (WHO) meeting on behalf of Patient Safety Learning to contribute to the development of its Global Patient Safety Action Plan for 2020-2030. Part 1 looked at the truly global scale of the patient safety challenge that we face, and I reflected on some of the presentations, discussions and topical areas that were considered on the first day of the event.
In part 2 I’ll focus on the discussions that took place on the second and third days and highlight the key issues that came up, reflecting on how this work should be taken forward.
The second two days were spent in workshops, feeding back on the 12 themes for implementing the Global Patient Safety Action Plan:
This feedback will help inform Global Action Plan recommendations which will subsequently be submitted to the World Health Assembly (the decision-making body of WHO which is attended by delegations from all member states) later this year. When published by the WHO we will share this on the hub.
The final plenary discussions were informed by a presentation from Jeremy Hunt MP (who joined the meeting for two days) and the WHO Director-General, Dr Tedros Adhanom, who took time to join the meeting despite the pressures on his time in responding to Covid-19. In due course, WHO will report on the meeting, the conclusions and recommendations. In the meantime, below I have shared some of my reflections and what I think were some of the more significant issues discussed in the plenary session.
Sir Liam Donaldson (WHO Envoy for Patient Safety) emphasised that when mobilising public pressure to deliver change, we need to ensure that we are learning from past campaigns that have succeeded. The example he drew on was the campaign around antimicrobial resistance in the in UK. What proved not to be effective was putting out information about the burden of disease, the economic impact and using catastrophic warnings. What did make an impact, however, was making the campaign personal, changing mindsets so that people understood how it would affect them. For example - my child won’t have access to antibiotics that work in future unless we change how we use antibiotics now.
In discussing how to learn from these lessons and organise professional campaigns for change there was a lot of focus around patient safety becoming a global social movement. But how do you start and support a social movement? A key consideration when discussing this was the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change.
Patients understand unsafe care and this needs to be talked about openly. It’s important to capture compelling stories from patients and staff to hear what needs to be changed and crucially to share how changes then happen. Representatives from the Canadian Patient Safety Institute spoke about their Conquer Silence campaign, set up to record stories of healthcare harm and share advice or insight to help others avoid harm. Patient Safety Learning is also sharing stories on the hub from the front-line, from patients and staff, to evidence ‘work as done’ rather than ‘work as imagined’ and as a call for action and change.
There is a huge economic cost of unsafe care; it’s estimated that nearly 15% of all health expenditure is attributed to patient safety failures annually, running into a trillions of dollars each year. Yet despite healthcare wasting huge resources on unsafe care, and the resulting litigation form this, steps to improve patient safety continue to be viewed as an expense rather than an investment. It was recognised that there needs to be a renewed effort to engage strongly with governments, healthcare systems and policy makers on this issue.
There were also conversations about the need to professionalise patient safety, one of the six foundations of safer care we highlight in our report A Blueprint for Action, as well as conversations about addressing the existing capacity and expertise gap. This applies not only to staff in patient safety specific roles, but to all staff across healthcare, particularly those in leadership positions. It’s important that patient safety is recognised as a core purpose of healthcare and its leaders deliver on patient safety standards. All staff needs to be skilled and trained in patient safety and human factors. The WHO curriculum on patient safety is being updated and, as part of the discussion, suggestions were developed for the current revision.
How can we take forward a global approach to tackling patient safety while recognising the significant difference of the challenge between high income and low and middle income countries? Transferring learning that works in the former may be much more difficult in the latter. Some of the issues highlighted included the significant problem of having a large number of unregulated providers of care in low and middle income countries, and challenges such as a lack of consistent running water in hospitals and undertaking surgery with periodic power failure.
There was a strong consensus on the importance of sharing learning; on what causes harm (and how we address it on a global scale) and sharing micro innovations to health system-wide improvements. We discussed examples of leadership and programmes that have transformed services, such as the Venous Thromboembolism programmes in the UK led by patients, parliamentarians and physicians. Emphasis was placed on the importance of peer-to-peer evaluation and communities of practice.
I started the three-day meeting with a series of questions:
While I’m not sure that I had answers to all my questions, I was assured that the commitment to harm reduction is absolute and global, with patient safety leaders now looking at shaping solutions on how we can achieve this. There is no magic bullet for patient safety. Participants evidenced that we have learned much from the last 20 years, but we must do more and differently if we are to succeed. I was encouraged that there now appears to be a greater awareness, understanding and commitment to:
I look forward to the Action Plan being developed by WHO for the World Health Assembly. It will include actions, recommendations, structure, process and outcomes (goals) for:
However, for me, several questions remain unanswered.
Patient Safety Learning will be contributing to this agenda by supporting the WHO Action Plan and collaborating with Dr Abdulelah Alhawsawi (Director General at the Saudi Patient Safety Center) and colleagues to engage and promote the G20 discussions at ministerial level. As well as this policy-influencing role to ensure that patient safety is a core purpose, our energies will be focused on our six foundations for patient safety, in particular developing standards for patient safety and sharing knowledge through the hub.
Our priorities are strongly aligned to that of WHO and global leaders on patient safety, moving from knowledge to the ‘how to’ of action for harm reduction. Going forward it is important we all do our part to make the case for tackling unsafe care and ensuring that healthcare leaders, politicians and patients all come together to ensure patient safety is embedded as a core purpose of health and social care.