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Papers by Charles Vincent

Safety challenges of modern healthcare THE WORKSHOP 5 Purpose and structure

BMJ open, Jan 29, 2016

To provide an overview of effective interventions aimed at reducing rates of adverse events in ho... more To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. Systematic review of systematic reviews. PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse d...

Artificial Organs, 2010

In an attempt to reduce the negative sequelae of cardiopulmonary bypass (CPB), a variety of new t... more In an attempt to reduce the negative sequelae of cardiopulmonary bypass (CPB), a variety of new technologies have been created. This study investigates variations in the application of these technologies throughout Great Britain and Ireland (GB & I). All perfusion departments within GB & I were surveyed about equipment and technologies used in CPB. Eighty-five percent of units use a standard arterial line filter in all cases. Forty percent of units occasionally use leukocyte-depleting filters in various sites within the circuit. Sixteen percent always use some element of heparin-bonded circuit, but 62% never use them.Twenty-five percent use solely rotary pumps, 18% use solely centrifugal pumps, and 56% use both. Finally, 20% are now using minimal extracorporeal circulation in certain clinical scenarios. These decisions are most frequently affected by clinician preference and cost. This survey has highlighted significant variation in the utilization of various technologies used in CPB. While some variation between centers is to be expected, as innovative technologies are adopted at varying rates, surveys such as this are useful for alerting clinicians to gaps between evidence-based knowledge and clinical practice.

Textbook of Patient Safety and Clinical Risk Management, 2020

This chapter introduces the topic of error as an essential foundation for an understanding of pat... more This chapter introduces the topic of error as an essential foundation for an understanding of patient safety. We introduce psychological classifications of error and then, using clinical examples, show how we can use these ideas to understand how errors occur and how chains of small errors can combine to cause harm to patients. We outline a practical approach to conducting investigations into healthcare incidents. Finally, we offer some reflections on how doctors experience errors and how best to support yourself or your colleagues when things do not go as well as intended.

Archives of Disease in Childhood, 2021

In a companion paper, we showed how local hospital leaders could assess systems and identify key ... more In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a ‘portfolio’ approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous chal...

World Journal of Surgery, 2020

Background Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after... more Background Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. Methods A cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15. Results 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email ...

International Journal for Quality in Health Care, 2020

This could, for example, include developing instructions and simulations on putting on and taking... more This could, for example, include developing instructions and simulations on putting on and taking off personal protection equipment (PPE) or regarding environment disinfection for cleaners. Advise and support distributed leadership Leadership is essential during a pandemic crisis, at all levels; however, leaders are always at risk of missing feedback, lessons and perceptions from the bedside. Help leaders with system thinking and learning through feedback loops, promoting deference to expertise and distributed leadership. Support and design frequent, concise, open communication about the ongoing situation. Support situational awareness and situation monitoring about the pandemic and its impact (including effects on care of patients with conditions other than the pandemic illness). As a note to leaders, all the above will be made much easier if the head of PS/QI is included in the emergency task force. Promote staff safety, well-being and psychological safety Advise leaders on staff physical and psychological safety needs [2] and on debriefing needs, including those for non-clinical staff. Set up a space for staff to express fears and preoccupations, and relay these, with appropriate confidentiality, to leaders. Promote frequent expressions of gratitude, as carried out, for example, through daily CEO video messages at a hospital in Pisa, Italy [3]. Connect leaders with occupational health services to identify, prevent and mitigate

BMJ, 2020

Healthcare relies on a variety of regulatory activities to manage risks to the public and to driv... more Healthcare relies on a variety of regulatory activities to manage risks to the public and to drive improvement. But the regulation of patient safety in healthcare, and in the NHS in particular, is "bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies." 1 Regulatory activities touch every single aspect of care delivery and place considerable demands on professionals and organisations alike, in the form of inspections, certification, accreditation, revalidation, and compliance reporting. We argue that the safety regulatory system, as seen from the perspective of provider organisations, is much larger and more complex than usually supposed. Individual regulators might achieve valuable impact, but the system as a whole is unnecessarily burdensome, produces multiple unintended consequences, and, most importantly, fragments and dilutes regulatory impact. We discuss the nature of these problems and set out a series of practical proposals for tackling these critical challenges. What is regulation? Regulation can be defined as the "processes that aim to shape, motivate, monitor, and modify the practices and technologies within organisations so as to achieve some desired state of affairs." 2 Regulatory activities take many forms, not all of them formal or backed by coercive or legal force. 3 The work of regulating patient safety reaches from the "ivory towers" of policy making and standard setting to the "adobe huts" of local participation and frontline decision making. 4 Regulation is achieved in multiple ways and by many different organisations. Statutory regulators, such as the Care Quality Commission and the General Medical Council, conduct inspections, monitor standards, and carry out a range of other activities. Many other organisations exert a regulatory effect on NHS organisations in the sense of inspecting, monitoring, influencing performance, and other activities (box 1, box 2). Royal colleges, for example, set standards, review training, and influence organisations and individuals through the encouragement and enforcement of professional norms. They also set standards and have the power to impose sanctions, such as withdrawal of approval of training.

BMJ quality & safety, Jan 17, 2018

In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a pa... more In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for H...

The European journal of general practice, 2015

Quality & Safety in Health Care, 2010

Objectives To identify factors affecting doctors' engagement with the Safer Patients Initiative (... more Objectives To identify factors affecting doctors' engagement with the Safer Patients Initiative (SPI). Design Qualitative interview study. Setting Four organisations participating in phase 1 of the SPI programme, from four different geographical locations in the UK. Participants 34 staff members, comprising senior executive/management leads involved in the SPI programme, the principal SPI programme coordinator and the operational leads in each of the SPI clinical work areas. Main outcome measures Staff perceptions of issues affecting medical engagement with SPI, identified in the interviews. Results Qualitative analysis identified seven factors that were reported to affect medical engagement with the SPI programme: (1) Organisation Track Record in QSI, (2) Resource Availability & Allocation, (3) Perceptions of the purpose of SPI, (4) Evidence of Efficacy of Programme, (5) External Expertise, (6) Local Programme Champions and (7) Managers Involvement. Specific barriers and general enabling strategies were identified and described for each factor, based upon participants' experiences. Conclusions Medical engagement is a complex technical, socio-political and motivational issue that is underpinned by a series of interrelated factors associated with the organisational context, the design of improvement programmes and how they are implemented and promoted. Healthcare organisations planning to embark on safety and quality-improvement programmes may benefit from systematically addressing the core themes identified by this study, in order to promote optimal medical engagement.

Social Science & Medicine, 2009

Large-scale national and multi-institutional patient safety improvement programmes are being deve... more Large-scale national and multi-institutional patient safety improvement programmes are being developed in the health care systems of several countries to address problems in the reliability of care delivered to patients. Drawing upon popular collaborative improvement models, these campaigns are ambitious in their aims to improve patient safety in macro-level systems such as whole health care organisations. This article considers the methodological issues involved in conducting research and evaluation of these programmes. Several specific research challenges are outlined, which result from the complexity of longitudinal, multi-level intervention programmes and the variable, highly sociotechnical care systems, with which they interact. Organisational-level improvement programmes are often underspecified due to local variations in context and organisational readiness for improvement work. The result is variable implementation patterns and local adaptations. Programme effects span levels and other boundaries within a system, vary dynamically or are cumulative over time and are problematic to understand in terms of cause and effect, where concurrent external influences exist and the impact upon study endpoints may be mediated by a range of organisational and social factors. We outline the methodological approach to research in the United Kingdom Safer Patients Initiative, to exemplify how some of the challenges for research in this area can be met through a multi-method, longitudinal research design. Specifically, effective research designs must be sensitive to complex variation, through employing multiple qualitative and quantitative measures, collect data over time to understand change and utilise descriptive techniques to capture specific interactions between programme and context for implementation. When considering the long-term, sustained impact of an improvement programme, researchers must consider how to define and measure the capability for continuous safe and reliable care as a property of the whole care system. This requires a sociotechnical approach, rather than focusing upon one microsystem, disciplinary perspective or single level of the system.

Journal of Evaluation in Clinical Practice, 2009

Rationale and aims In several countries, collaborative improvement programmes involving multiple ... more Rationale and aims In several countries, collaborative improvement programmes involving multiple health care organizations have been developed to address the issue of patient safety and reliability of care at an organization-wide level. In the UK, the Health Foundation's Safer Patients Initiative (SPI) was developed to achieve breakthrough improvement in the quality and safety of care in 24 acute hospital Trusts between 2004 and 2008. Research evidence for the effectiveness of programmes of this type and the mechanisms by which positive outcomes are achieved remains limited. We report a multi-method preliminary study based upon phase 1 of SPI to understand participant's perceptions of the local impact of the programme and to form the basis of future research in this area. Methods Data were collected on the perceived local impact of SPI on a range of clinical, organizational and social dimensions relating to care quality and safety. Data were collected retrospectively from local SPI programme improvement teams using semi-structured interviews and surveys. Qualitative and quantitative analyses were performed, and the results synthesized under common themes and frameworks. Results Specific dimensions of care systems commonly considered to be affected by SPI, included culture, strategic priority, organizational capability and clinical care delivery. Survey data revealed the perceived importance for success of a range of programme components: quality improvement methodology, learning sessions and programme faculty support, along with predefined clinical practice changes. Safety climate and capability dimensions rated as most sensitive to the effects of the SPI programme related to multiprofessional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Conclusions Study findings support the view that programmes such as SPI have considerable impact upon the cultural, inter-professional, strategic and organizational aspects of care delivery, in addition to clinical working practices. The specific implications for understanding the effects of complex organization-level interventions and future research design are discussed.

International Journal for Quality in Health Care, 2012

Objective. To identify strategies to facilitate the sustainability of a quality and safety improv... more Objective. To identify strategies to facilitate the sustainability of a quality and safety improvement collaborative: the Safer Patients Initiative (SPI) and its successes. Design. A qualitative interview study with a repeated sample at two time points. Setting. Twenty organizations participating in the SPI programme in the UK. Participants. Twenty principal SPI programme coordinators took part in interviews towards the end of the supported phase of the programme, 12 of which were interviewed again a year later, along with another three replacement programme coordinators, totalling 35 interviewees across the two time points. Main Outcome Measures. Programme coordinators' perceptions of facilitating strategies to the sustainability of the collaborative and its gains. Results. Qualitative analysis identified three overarching factors for the sustainability of SPI: (i) using programme improvement methodology and measurement of its outcomes; (ii) organizational strategies to ensure sustainability and (iii) alignment of goals with external requirements. Within these were eight themes identified by the coordinators as helping to sustain the efforts of the SPI programme and its successes. Conclusions. This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention.

International Journal for Quality in Health Care, 2011

Objective. The aim of this study was to evaluate the influence of various factors on the perceive... more Objective. The aim of this study was to evaluate the influence of various factors on the perceived impact of a patient safety improvement collaborative in the UK, the Safer Patients Initiative (SPI). Study design. A cross-sectional survey design was used.

Acupuncture in Medicine, 1989

Journal of Evaluation in Clinical Practice, 2010

Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical... more Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery (t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care (t =-2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact.

Journal of Medical Regulation, 2009

We articulate an intellectual history and a definition, description and model of patient safety. ... more We articulate an intellectual history and a definition, description and model of patient safety. We define patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. We also define patient safety as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse events); its nature; its essential focus of action (the microsystem); how patient safety works (e.g., high-reliability design, use of safety sciences, methods for causing change, including cultural change); and who its practitioners are (i.e., all health care workers, patients and advocates). Our simple and overarching model identifies four domains of patient safety (recipients of care, providers, therapeutics and methods) and the element...

Quality and Safety in Health Care, 2010

Patient safety has been high on the agenda for more than a decade. Despite many national initiati... more Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

1.Patient care-standards 2.Medical errors-prevention and control 3.Safety management-methods 4.Ou... more 1.Patient care-standards 2.Medical errors-prevention and control 3.Safety management-methods 4.Outcome and process assessment (Health care) I.Title. Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference t...

Safety challenges of modern healthcare THE WORKSHOP 5 Purpose and structure

BMJ open, Jan 29, 2016

To provide an overview of effective interventions aimed at reducing rates of adverse events in ho... more To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. Systematic review of systematic reviews. PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse d...

Artificial Organs, 2010

In an attempt to reduce the negative sequelae of cardiopulmonary bypass (CPB), a variety of new t... more In an attempt to reduce the negative sequelae of cardiopulmonary bypass (CPB), a variety of new technologies have been created. This study investigates variations in the application of these technologies throughout Great Britain and Ireland (GB & I). All perfusion departments within GB & I were surveyed about equipment and technologies used in CPB. Eighty-five percent of units use a standard arterial line filter in all cases. Forty percent of units occasionally use leukocyte-depleting filters in various sites within the circuit. Sixteen percent always use some element of heparin-bonded circuit, but 62% never use them.Twenty-five percent use solely rotary pumps, 18% use solely centrifugal pumps, and 56% use both. Finally, 20% are now using minimal extracorporeal circulation in certain clinical scenarios. These decisions are most frequently affected by clinician preference and cost. This survey has highlighted significant variation in the utilization of various technologies used in CPB. While some variation between centers is to be expected, as innovative technologies are adopted at varying rates, surveys such as this are useful for alerting clinicians to gaps between evidence-based knowledge and clinical practice.

Textbook of Patient Safety and Clinical Risk Management, 2020

This chapter introduces the topic of error as an essential foundation for an understanding of pat... more This chapter introduces the topic of error as an essential foundation for an understanding of patient safety. We introduce psychological classifications of error and then, using clinical examples, show how we can use these ideas to understand how errors occur and how chains of small errors can combine to cause harm to patients. We outline a practical approach to conducting investigations into healthcare incidents. Finally, we offer some reflections on how doctors experience errors and how best to support yourself or your colleagues when things do not go as well as intended.

Archives of Disease in Childhood, 2021

In a companion paper, we showed how local hospital leaders could assess systems and identify key ... more In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a ‘portfolio’ approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous chal...

World Journal of Surgery, 2020

Background Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after... more Background Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. Methods A cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15. Results 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email ...

International Journal for Quality in Health Care, 2020

This could, for example, include developing instructions and simulations on putting on and taking... more This could, for example, include developing instructions and simulations on putting on and taking off personal protection equipment (PPE) or regarding environment disinfection for cleaners. Advise and support distributed leadership Leadership is essential during a pandemic crisis, at all levels; however, leaders are always at risk of missing feedback, lessons and perceptions from the bedside. Help leaders with system thinking and learning through feedback loops, promoting deference to expertise and distributed leadership. Support and design frequent, concise, open communication about the ongoing situation. Support situational awareness and situation monitoring about the pandemic and its impact (including effects on care of patients with conditions other than the pandemic illness). As a note to leaders, all the above will be made much easier if the head of PS/QI is included in the emergency task force. Promote staff safety, well-being and psychological safety Advise leaders on staff physical and psychological safety needs [2] and on debriefing needs, including those for non-clinical staff. Set up a space for staff to express fears and preoccupations, and relay these, with appropriate confidentiality, to leaders. Promote frequent expressions of gratitude, as carried out, for example, through daily CEO video messages at a hospital in Pisa, Italy [3]. Connect leaders with occupational health services to identify, prevent and mitigate

BMJ, 2020

Healthcare relies on a variety of regulatory activities to manage risks to the public and to driv... more Healthcare relies on a variety of regulatory activities to manage risks to the public and to drive improvement. But the regulation of patient safety in healthcare, and in the NHS in particular, is "bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies." 1 Regulatory activities touch every single aspect of care delivery and place considerable demands on professionals and organisations alike, in the form of inspections, certification, accreditation, revalidation, and compliance reporting. We argue that the safety regulatory system, as seen from the perspective of provider organisations, is much larger and more complex than usually supposed. Individual regulators might achieve valuable impact, but the system as a whole is unnecessarily burdensome, produces multiple unintended consequences, and, most importantly, fragments and dilutes regulatory impact. We discuss the nature of these problems and set out a series of practical proposals for tackling these critical challenges. What is regulation? Regulation can be defined as the "processes that aim to shape, motivate, monitor, and modify the practices and technologies within organisations so as to achieve some desired state of affairs." 2 Regulatory activities take many forms, not all of them formal or backed by coercive or legal force. 3 The work of regulating patient safety reaches from the "ivory towers" of policy making and standard setting to the "adobe huts" of local participation and frontline decision making. 4 Regulation is achieved in multiple ways and by many different organisations. Statutory regulators, such as the Care Quality Commission and the General Medical Council, conduct inspections, monitor standards, and carry out a range of other activities. Many other organisations exert a regulatory effect on NHS organisations in the sense of inspecting, monitoring, influencing performance, and other activities (box 1, box 2). Royal colleges, for example, set standards, review training, and influence organisations and individuals through the encouragement and enforcement of professional norms. They also set standards and have the power to impose sanctions, such as withdrawal of approval of training.

BMJ quality & safety, Jan 17, 2018

In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a pa... more In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for H...

The European journal of general practice, 2015

Quality & Safety in Health Care, 2010

Objectives To identify factors affecting doctors' engagement with the Safer Patients Initiative (... more Objectives To identify factors affecting doctors' engagement with the Safer Patients Initiative (SPI). Design Qualitative interview study. Setting Four organisations participating in phase 1 of the SPI programme, from four different geographical locations in the UK. Participants 34 staff members, comprising senior executive/management leads involved in the SPI programme, the principal SPI programme coordinator and the operational leads in each of the SPI clinical work areas. Main outcome measures Staff perceptions of issues affecting medical engagement with SPI, identified in the interviews. Results Qualitative analysis identified seven factors that were reported to affect medical engagement with the SPI programme: (1) Organisation Track Record in QSI, (2) Resource Availability & Allocation, (3) Perceptions of the purpose of SPI, (4) Evidence of Efficacy of Programme, (5) External Expertise, (6) Local Programme Champions and (7) Managers Involvement. Specific barriers and general enabling strategies were identified and described for each factor, based upon participants' experiences. Conclusions Medical engagement is a complex technical, socio-political and motivational issue that is underpinned by a series of interrelated factors associated with the organisational context, the design of improvement programmes and how they are implemented and promoted. Healthcare organisations planning to embark on safety and quality-improvement programmes may benefit from systematically addressing the core themes identified by this study, in order to promote optimal medical engagement.

Social Science & Medicine, 2009

Large-scale national and multi-institutional patient safety improvement programmes are being deve... more Large-scale national and multi-institutional patient safety improvement programmes are being developed in the health care systems of several countries to address problems in the reliability of care delivered to patients. Drawing upon popular collaborative improvement models, these campaigns are ambitious in their aims to improve patient safety in macro-level systems such as whole health care organisations. This article considers the methodological issues involved in conducting research and evaluation of these programmes. Several specific research challenges are outlined, which result from the complexity of longitudinal, multi-level intervention programmes and the variable, highly sociotechnical care systems, with which they interact. Organisational-level improvement programmes are often underspecified due to local variations in context and organisational readiness for improvement work. The result is variable implementation patterns and local adaptations. Programme effects span levels and other boundaries within a system, vary dynamically or are cumulative over time and are problematic to understand in terms of cause and effect, where concurrent external influences exist and the impact upon study endpoints may be mediated by a range of organisational and social factors. We outline the methodological approach to research in the United Kingdom Safer Patients Initiative, to exemplify how some of the challenges for research in this area can be met through a multi-method, longitudinal research design. Specifically, effective research designs must be sensitive to complex variation, through employing multiple qualitative and quantitative measures, collect data over time to understand change and utilise descriptive techniques to capture specific interactions between programme and context for implementation. When considering the long-term, sustained impact of an improvement programme, researchers must consider how to define and measure the capability for continuous safe and reliable care as a property of the whole care system. This requires a sociotechnical approach, rather than focusing upon one microsystem, disciplinary perspective or single level of the system.

Journal of Evaluation in Clinical Practice, 2009

Rationale and aims In several countries, collaborative improvement programmes involving multiple ... more Rationale and aims In several countries, collaborative improvement programmes involving multiple health care organizations have been developed to address the issue of patient safety and reliability of care at an organization-wide level. In the UK, the Health Foundation's Safer Patients Initiative (SPI) was developed to achieve breakthrough improvement in the quality and safety of care in 24 acute hospital Trusts between 2004 and 2008. Research evidence for the effectiveness of programmes of this type and the mechanisms by which positive outcomes are achieved remains limited. We report a multi-method preliminary study based upon phase 1 of SPI to understand participant's perceptions of the local impact of the programme and to form the basis of future research in this area. Methods Data were collected on the perceived local impact of SPI on a range of clinical, organizational and social dimensions relating to care quality and safety. Data were collected retrospectively from local SPI programme improvement teams using semi-structured interviews and surveys. Qualitative and quantitative analyses were performed, and the results synthesized under common themes and frameworks. Results Specific dimensions of care systems commonly considered to be affected by SPI, included culture, strategic priority, organizational capability and clinical care delivery. Survey data revealed the perceived importance for success of a range of programme components: quality improvement methodology, learning sessions and programme faculty support, along with predefined clinical practice changes. Safety climate and capability dimensions rated as most sensitive to the effects of the SPI programme related to multiprofessional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Conclusions Study findings support the view that programmes such as SPI have considerable impact upon the cultural, inter-professional, strategic and organizational aspects of care delivery, in addition to clinical working practices. The specific implications for understanding the effects of complex organization-level interventions and future research design are discussed.

International Journal for Quality in Health Care, 2012

Objective. To identify strategies to facilitate the sustainability of a quality and safety improv... more Objective. To identify strategies to facilitate the sustainability of a quality and safety improvement collaborative: the Safer Patients Initiative (SPI) and its successes. Design. A qualitative interview study with a repeated sample at two time points. Setting. Twenty organizations participating in the SPI programme in the UK. Participants. Twenty principal SPI programme coordinators took part in interviews towards the end of the supported phase of the programme, 12 of which were interviewed again a year later, along with another three replacement programme coordinators, totalling 35 interviewees across the two time points. Main Outcome Measures. Programme coordinators' perceptions of facilitating strategies to the sustainability of the collaborative and its gains. Results. Qualitative analysis identified three overarching factors for the sustainability of SPI: (i) using programme improvement methodology and measurement of its outcomes; (ii) organizational strategies to ensure sustainability and (iii) alignment of goals with external requirements. Within these were eight themes identified by the coordinators as helping to sustain the efforts of the SPI programme and its successes. Conclusions. This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention.

International Journal for Quality in Health Care, 2011

Objective. The aim of this study was to evaluate the influence of various factors on the perceive... more Objective. The aim of this study was to evaluate the influence of various factors on the perceived impact of a patient safety improvement collaborative in the UK, the Safer Patients Initiative (SPI). Study design. A cross-sectional survey design was used.

Acupuncture in Medicine, 1989

Journal of Evaluation in Clinical Practice, 2010

Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical... more Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery (t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care (t =-2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact.

Journal of Medical Regulation, 2009

We articulate an intellectual history and a definition, description and model of patient safety. ... more We articulate an intellectual history and a definition, description and model of patient safety. We define patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. We also define patient safety as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse events); its nature; its essential focus of action (the microsystem); how patient safety works (e.g., high-reliability design, use of safety sciences, methods for causing change, including cultural change); and who its practitioners are (i.e., all health care workers, patients and advocates). Our simple and overarching model identifies four domains of patient safety (recipients of care, providers, therapeutics and methods) and the element...

Quality and Safety in Health Care, 2010

Patient safety has been high on the agenda for more than a decade. Despite many national initiati... more Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

1.Patient care-standards 2.Medical errors-prevention and control 3.Safety management-methods 4.Ou... more 1.Patient care-standards 2.Medical errors-prevention and control 3.Safety management-methods 4.Outcome and process assessment (Health care) I.Title. Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference t...