National Advisory Group on the Safety of Patients in England, DH, 6 August 2013
- Professor Don Berwick (founder and former president of the Institute for Healthcare Improvement), was asked to produce a report to highlight the problems affecting patient safety in the NHS following the findings of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals, and to make recommendations to address them.
- 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 wilful or reckless neglect or mistreatment.
- Watch Don Berwick presents the findings from his review into patient safety on the Kings Fund website here.
