In all fields of academic study there are ‘seminal’ books, reports and policy documents that have been highly influential and change-making. We all have our own favourites and my top three are An Organisation With a Memory (Department of Health, 2000), the Francis report (2013) and Opening the Door to Change (Care Quality Commission (CQC), 2018). These reports all brought new knowledge and perspectives to patient safety and continue to influence policy direction. There are many other contenders for the category of the most influential patient safety reports—to choose one is an exercise of value judgement and personal preference, and a valuable one in terms of fermenting debate.
Safety strategy update
Another contender for one of my favourite influential patient safety reports is emerging: the NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019). A 2021 update has recently been published, which shows the excellent work going on to implement the policy objectives set out in the original report. This update (NHS England and NHS Improvement, 2021) also refreshes elements of the national patient safety strategy and sets out new objectives.
This detailed report on the implementation of the NHS Patient Safety Strategy reveals ground-breaking initiatives in progress with the potential to create an effective NHS patient safety culture. If all goes to plan with the implementation of the objectives in the report, root and branch patient safety reform will have taken place. The most significant update in the report is the new commitment to address patient safety inequalities in the form of an explicit new objective to the strategy:
‘We recognise that a comprehensive plan to address patient safety inequalities must consider how multiple inequalities combine to affect outcomes for particular patient groups. For example, last year's LeDeR [Learning Disabilities Mortality Review] annual report said that in 2019 people with a learning disability from BAME groups “died disproportionately at younger ages than white British people. Of those who died in childhood (ages 4 to 17 years), 43% were from BAME groups”.’
NHS England and NHS Improvement, 2021: 4
Other changes include a translation of the high-level objectives for the safety culture and safety system strands into more tangible deliverables. Key actions and deliverables in the strategy include:
- Explore the safety culture characteristics of highly safe NHS trusts, and share insights by Q1 2021/22 (p 7)
- Produce a safety culture guide to help organisations implement specific improvement activities by Q1 2021/22 (p 8)
- Continue to establish and test safety culture interventions to support local systems, as part of the key enablers objective (p 8).
In terms of legal claims and clinical negligence litigation, actions include:
‘Publish the first best practice guidance on claims learning for clinicians and managers in collaboration with NHS Resolution by end Q4 2020/21. This will explain to clinicians and managers how to participate in learning from claims and share learning to drive focused improvement.’
NHS England and NHS Improvement, 2021: 18
The activity highlighted above is about the learning of lessons from past adverse events in the NHS and making positive, sustainable changes—looking at what has worked or not, covering all sections of society so that nobody is left behind in terms of quality of care.
Patient safety education and training is an essential prerequisite to the development of an effective patient safety culture and the report sets out an objective to make training in the essentials of patient safety available to all staff by the second quarter of 2021/22.
There is a lot of information contained in the report, which provides an updated patient safety roadmap for the NHS in England and sets out clearly the routes to be followed in implementing the objectives.
Value of patient safety reports
Patient safety is a global as well as a national crisis issue and reports have a wide audience. Patient safety reports are valuable both as educational tools and in standard setting. Healthcare lawyers, as patient safety stakeholders, can also study them as they can indicate standards and clinical guidelines in particular care areas. This will be useful in drawing conclusions about the legal standard of care to be exercised in a case alleging clinical negligence.
Modern ward rounds guidance
The Royal College of Physicians (RCP) and Royal College of Nursing (RCN) have produced best practice guidelines on ward rounds (RCP and RCN, 2021). They first published guidance on ward rounds in 2012 and this update aims to offer a more detailed and thorough reworking of the principles, preparation and processes necessary for a successful ward round. Accompanying documents include ward round case studies, ward round report recommendations and a COVID-19 supplement.
It makes the case that most ward rounds in UK hospitals are less than optimal, and that research and quality improvement is necessary to inform effective practice:
‘There remains considerable variability in the organisation, efficiency, quality, delivery and patient experience of ward rounds.’
It is recognised in the report that current constraints make it challenging to deliver care as described, but all teams will find areas where they can improve practice. Four sections cover the background and context, the process, the environment, and then the areas of quality management, research and innovation.
Section B, ‘the process’, includes discussion on several key areas, including:
- Scheduling ward rounds and considering allied activities
- Before the ward round
- During the ward round
- Documentation and clinical records
- Communicating with patients, relatives and carers
- After the ward round.
Documentation and communication
From a legal perspective, documentation and communication failures are common features found in many clinical negligence claims and complaints. If we improve our record keeping and patient communication skills, we will have less litigation and fewer complaints.
Advice on documentation includes (RCP and RCN, 2021: 23):
- Clear documentation of diagnosis, problems, assessments, goals, progress and plans is essential
- Structured records help to organise documentation to act as prompts to ensure that no important component is missed
- Information recorded at the ward round should make clear the thinking around the clinical decisions and include clinical criteria for discharge.
On communication, advice includes (RCP and RCN, 2021: 25):
- Health professionals should ensure that patients have a clear understanding of the purpose of the ward round when it is likely to take place and what is likely to happen
- At least one health professional, preferably the person leading the round, should be at eye level with the patient
- The patient should be left with a short note explaining the outcome of the ward round, providing the information most important to patients.
This is an excellent report providing best practice guidance on a key area of health care. It makes a valuable contribution to the development of an NHS patient safety culture.
A need to change practice
The NHS over the years has seen many good patient safety reports produced but still the same mistakes are being made, and patients suffer avoidable harm. The regular inspection reports by the CQC are a salutary reminder of what can and does go wrong in terms of care quality and patient safety These reports also provide excellent patient safety education and training tools. A recent inspection report shows the stark nature of the challenges and obstacles that must be overcome.
The CQC has told Medway NHS Foundation Trust that it must make significant and immediate improvements to the emergency department at Medway Maritime Hospital (CQC, 2021a). Inspectors rated the service ‘Inadequate’ for the following reasons:
- Staff did not always keep detailed records of patients' care and treatment when completing records for urgent and emergency care patients
- Care for patients showing signs of deteriorating was not consistently escalated
- The department did not always control infection risk well
- There was poor flow out of the department, with substantial delays before patients were admitted or discharged
- The leadership, governance and culture did not always support the delivery of high-quality person-centred care for patients.
The inspection report provides more detail on the record keeping point:
‘We reviewed six patient records and could not determine what care was being provided to patients in emergency department due to the lack of complete documentation. Patient risk assessments were not always completed or there were minimal care entries. In four of the six patient records we found skin integrity, patient repositioning and/or falls assessments had not been completed. Some patient records were not updated to state the outcome of diagnostic tests.’
I have discussed above the importance of good record keeping and how failures can result in avoidable harm to patients with possible resulting litigation and complaints. The CQC inspection findings here compound my comments and concerns. Practically, if something important is not noted down in a health record it then becomes very hard to defend that health professional and the trust should an allegation of clinical negligence be made. A view could well be taken by a judge that if something is not recorded and written down then it never happened.
Conclusion
Yes, the NHS is very busy in urgent and emergency services and we can add COVID-19 and staff shortages into the mix. There is in a sense a perfect storm brewing. However, if poor record keeping, and communication practices do happen, and we know that they do, then this exposes the patient to avoidable harm. It is a major patient safety issue and potential litigation risk. Record keeping should always be regarded as an expert professional skill and not something that can be put on the back burner
We can see here some of the practical implementation problems and challenges that need to be met in order to create an effective NHS patient safety culture.