The latest report from the Health Services Safety Investigations Body finds that integrated care boards do not have full visibility of some patient safety risks.
The latest report from the Health Services Safety Investigations Body (HSSIB) has found not only that integrated care boards (ICBs) do not have visibility of some patient safety risks, but also that there is variation in how risks are escalated to a regional and national level, and how responses to escalations are fed back.
The investigation from the executive non-departmental public body sponsored by the Department of Health and Social Care considers how safety management is co-ordinated and integrated across the health and care system.
In order to understand the organisational patient safety accountabilities and responsibilities, HSSIB spoke to staff working in multiple ICBs plus a number of national organisations across the health and care system. This included speaking to national healthcare organisations, and regional teams in NHS England about how patient safety risks are escalated to them and how they are managed.
A key message coming from the investigation is there are currently no overarching principles that all health and care providers and ICB’s can use which enable a consistent and collaborative approach to safety management. This has created a difference in understanding between organisations, including accountability for patient safety within organisations.
“It is crucial that lines of responsibility and accountability are defined including at a national level, and those we spoke to welcomed any further work on establishing approaches that would help them to manage recurring or emerging risks more proactively,” said Sian Blanchard, head of patient safety insights at HSSIB.
Working together
The report’s main recommendation is that health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. They can also improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently, patient safety risks are not managed in line with established UK government risk management principles.
HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system.
“Any opportunity to improve safety management should be examined because as we see through our investigations, safety incidents and patient harm happen as patients transition between health and care providers,” said Blanchard.
Finally, HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.
