Several months ago, Don Berwick was asked by the government of the UK and the senior leaders of the NHS to assemble an advisory board to review problems within that organization and make recommendation for the future. The report has been issued and contains the following broad conclusions. While some may appear especially applicable to the national health care delivery system that is under the jurisdiction of the NHS, they are actually equally applicable to health care institutions and delivery systems in the US and much of the rest of the developed world.
From the Executive summary:
The following are some of the problems we have identified:
Patient safety problems exist throughout the NHS as with every other health care system in the world.
NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.
Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.
In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.
When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.
Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.
Fear is toxic to both safety and improvement.
To address these issues the system must:
Recognise with clarity and courage the need for wide systemic change.
Abandon blame as a tool and trust the goodwill and good intentions of the staff.
Reassert the primacy of working with patients and carers to achieve health care goals.
Use quantitative targets with caution. Such goals do have an important role to progress, but should never displace the primary goal of better care.
Recognise that transparency is essential and expect and insist on it.
Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.
Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.
Make sure pride and joy in work, not fear, infuse the NHS.
The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.
We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.
Our ten recommendations are as follows:
1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.
2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.
3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.
5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.
6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.
7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.
8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.
9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.
10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.
From the Executive summary:
The following are some of the problems we have identified:
Patient safety problems exist throughout the NHS as with every other health care system in the world.
NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.
Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.
In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.
When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.
Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.
Fear is toxic to both safety and improvement.
To address these issues the system must:
Recognise with clarity and courage the need for wide systemic change.
Abandon blame as a tool and trust the goodwill and good intentions of the staff.
Reassert the primacy of working with patients and carers to achieve health care goals.
Use quantitative targets with caution. Such goals do have an important role to progress, but should never displace the primary goal of better care.
Recognise that transparency is essential and expect and insist on it.
Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.
Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.
Make sure pride and joy in work, not fear, infuse the NHS.
The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.
We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.
Our ten recommendations are as follows:
1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.
2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.
3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.
5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.
6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.
7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.
8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.
9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.
10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.
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