Patient Safety Learning visits the IHI's national forum

A blog by Helen Hughes, Chief Executive

  • 16th December 2019
Jonathan and Helen

Patient Safety Learning Chair, Jonathan Hazan, and Chief Executive, Helen Hughes

Last week the Institute for Healthcare Improvement (IHI) held its National Forum on Quality Improvement in Health Care. This is the biggest annual quality improvement and patient safety event globally. It brings people together to hear the latest developments in quality improvement and patient safety to gain insights on topical issues and challenges, and network with some of the thousands of delegates.

I attended this year’s event for Patient Safety Learning, along with our Chair, Jonathan Hazan, as we were invited to attend the CEO Forum. This involved several presentations and discussions that were particularly of interest for patient safety.

Psychological harm and foundations of patient safety

The keynote speeches to open the conference introduced the idea of a broader definition of patient safety to include psychological harm for patients. This is an important recognition of the impact of unsafe care can have on patients and families. Patient Safety Learning is planning work in this area, with support from Linda Kenward, next year. Linda contributed to our conference and is developing our understanding of second harm.

Recently on the hub we’ve featured some specific articles on the impact that a patient safety incident has on the healthcare professional involved. An example of this is a new initiative to support staff launched at Chase Farm Hospital (part of the Royal Free London NHS Foundation Trust).

IHI also introduced the work that is being developed by their National Alliance Steering Committee for Patient Safety. The committee has identified four foundations for patient safety:

  1. Culture, Leadership and Governance
  2. Learning Systems
  3. Patient and Family Engagement
  4. Workforce Safety

These foundations are very similar to the six foundations for patient safety that we’ve outlined in our report, A Blueprint for Action, and Patient Safety Learning has been invited by IHI to engage directly with this work. Watch this space!

Learning from the UK

It’s always interesting how often we make contacts from the UK at international events! It was great to meet up with Dr John Boulton (Director of NHS Quality Improvement and Patient Safety/Director of Improvement Cymru at Public Health Wales) and we had an opportunity to discuss Wales’ ambition to deliver safer and more effective care. We discussed collaborating with him, his team and leaders in Wales, and how the knowledge and insight from A Blueprint For Action and the hub can contribute to this.

There were also two presentations from London-based NHS chief executives, Caroline Clarke (Group Chief Executive, Royal Free London NHS Foundation Trust) and Dr Navina Evans (Chief Executive, East London NHS Foundation Trust). They gave fascinating and inspiring presentations, drawing on one of the key themes of the forum, tackling waste by doing the right thing; engaging with staff and patients to improve quality and safety, and saving money.

Caroline Clarke explained how Royal Free London is integrating quality and cost savings in its reduction in clinical variation project. She emphasised that reporting cost drivers is critical to changing behaviour. Having relevant reports that track performance against budget, waste, sustainability, etc. is very innovative. Caroline and I have agreed to follow up and share for wider learning.

Dr Navina Evans described the importance of blowing myths of ‘cost efficiency programmes’ or, as Janet (her staff mentor) described them, ‘cuts’. She explained that their Trust is creating a 'breaking the rules' campaign for improving quality and reducing waste. She shared that reducing the length of patient safety incident investigations has saved staff costs of £500k.

That generated some fascinating table discussions, including:

  • How organisational leaders need to align with a common purpose
  • The complexity of quality and safety initiatives, and the necessity of aligning them all for effective and safer care
  • Leadership for patient safety; that the whole health and social care system need to align and work collaboratively with clear goals for safer care

Other discussion points

Partnering with Austria-based Salzburg Global Seminar and working with healthcare leaders from across the world, IHI launched at the conference eight global principles for the measurement of patient safety. The principles are intended to act as a call to action.

As we highlight in A Blueprint For Action, we need to develop practical models for measuring, reporting and assessing patient safety performance. This should not be limited to just measuring the incidence response to harm but include how we measure and manage healthcare to be safe.

Another topic considered was equity in healthcare provision and public health challenges in the US healthcare system. A particularly alarming statistic is that the maternity mortality of black women is four times that of white women in the US. To use Dr Joia Crear-Perry’s powerful quote, ‘Race is not a risk factor. Racism is.’

It was also notable for me that there was a real absence of patient engagement across the event. There were a lot of presenters who spoke sincerely and energetically about the importance of patient engagement but where was the patient voice? This was not very visible at the CEO Forum.

Tarana Burke

The final session of the CEO Forum was a keynote speech from Tarana Burke, the founder of the #MeToo movement. As well as being Chief Executive of Patient Safety Learning, I chair Solace, a charity that providers support and services to women and children survivors of domestic violence and sexual abuse.

Tarana told a highly personal story of how she became an advocate for change, and she called on all health professionals to "address this public health emergency". "Sexual violence has no basis in race, gender or sexuality," she said, "but the response to it does."


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