Patient safety and human factors: policy and strategy

This section signposts policies and strategies which are particularly relevant to the patient safety agendas in each of the four UK countries.

For policy on healthcare associated infection see the RCN resource dedicated to this at Infection prevention and control. You may also want to look at:

Policy and strategy are arranged by country and listed alphabetically. Some of the resources are in PDF format - see how to access PDF files.

England

Health and Social Care Act 2012
The Act gives effect to the policies that were set out in the White Paper Equity and Excellence, bringing about an extensive reorganisation of the NHS. Changes made include the abolition of the National Patient Safety Agency (NPSA) and the formation of the NHS Commissioning Board Special Health Authority (NHS CBA). As from June 2012 NHS CBA has taken on the functions of the NPSA with Imperial College Healthcare NHS Trust (ICHT) responsible for the operational delivery of the National Reporting and Learning Syste (NRLS).

Care Quality Commission (2010) Essential standards of quality and safety
This guide aims to help providers of health and adult care comply with the regulatory standards that demonstrate compliance with the Health and Social Care Act 2008. Against each standard, guidance is provided in the form of detailed outcomes and prompts. The standards relate to 'safeguarding and safety' and provide guidance about compliance for: safeguarding people who use services from abuse; cleanliness and infection control; management of medicines; safety and suitability of premises; safety, availability and suitability of equipment. There are also standards relating to quality and management processes and suitability of staffing, see: Essential standards of quality and safety.

Department of Health (2012) The 'never events' list 2012/13: Policy framework for use in the NHS
'Never events' are defined as "serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers". This paper sets out the expanded list for use in the NHS in 2011 to 2012 and provides further guidance for how the 'never events' policy should be implemented.

Department of Health Quality, Innovation, Productivity and Prevention (QIPP): Safe care workstream
The Safe Care workstream established Safety Express as a pilot programme focussing on reducing harm from: hospital and community acquired pressure ulcers; blood clots (DVT and pulmonary embolism); urinary tract infections in patients with catheters and falls in care settings. This workstream has now developed into the website Harm Free Care which provides a range of tools and guidance, including the NHS Safety Thermometer, to assist frontline health care staff to achieve harm free care - see Harm Free Care.

Department of Health (2010) Equity and excellence: Liberating the NHS
The NHS White Paper sets out the Government's long term vision for the future of the NHS and aims to "help ensure that patient safety is placed above all else at the heart of the NHS".

Department of Health (2010) NHS Outcomes Framework 2011/12
There are five domains in the Outcomes framework - Domain five is "Treating and caring for people in a safe environment and protecting them from avoidable harm". The outcomes and corresponding indicators that will be used to hold the NHS Commissioning Board to account for the outcomes it delivers through commissioning health services from 2012/13.

Department of Health (2010) Clinical governance and adult safeguarding: an integrated process
The 2009 review of the 'No secrets' guidance on policies and procedures to protect vulnerable adults from abuse highlighted the absence of adult safeguarding systems within the NHS to ensure that healthcare incidents that raise safeguarding concerns are considered in the wider safeguarding arena. This document aims to encourage organisations to develop local robust arrangements to ensure that adult safeguarding becomes fully integrated into NHS systems and includes guidance and a flowchart to help in achieving this.

Department of Health (2008) High quality care for all
'High Quality Care for All' was the final report of the NHS Next Stage Review. In it, Lord Darzi defines three dimensions of quality of care: patient experience, patient safety and clinical effectiveness.

Department of Health (2007) The White Paper Trust, assurance and safety: The regulation of health professionals
This White Paper sets out a programme of reform to the United Kingdom's system for the regulation of health professionals. It is complemented by 'Safeguarding patients' -  the Government's response to the recommendations of the Fifth Report of the Shipman Inquiry and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries.

Department of Health (2006) Guidelines for the NHS: In support of the Memorandum of Understanding - Investigating patient safety incidents involving unexpected death or serious untoward harm
These guidelines provide practical advice to NHS organisations about what to do when faced with a patient safety incident or incidents that may require investigation by the police and/or Health and Safety Executive.

Older policy documents

The following documents are older policy documents which have shaped the patient safety landscape and provide background to the more recent policy.

Department of Health (2006) Safety first: A report for patients, clinicians and healthcare managers
This report was commissioned by Sir Liam Donaldson, Chief Medical Officer, to reconsider the organisation arrangements currently in place to ensure that patient safety is at the heart of the healthcare agenda.

Department of Health (2004) Design for patient safety
Building on the NHS patient safety agenda, this report applies the fresh, design approach and experience of other safety-critical industries to the NHS. It delivers the clear message that the NHS can and must think in terms of broad design and systems.

Department of Health (2001) Building a safer NHS for patients - implementing an organisation with a memory
Following the publication of the report 'An organisation with a memory' and the commitment to implement it in the NHS Plan, this document sets out the Government's plans for promoting patient safety placing patient safety in the context of the Government's NHS quality programme and highlights key linkages to other Government initiatives.

Department of Health (2000) An organisation with a memory
This document set out to understand what was known about the scale and nature of serious failures in the NHS, examine how the NHS might learn from those failures, and recommend methods to minimize future failures.

Northern Ireland

Department of Health, Social Services and Public Safety (2011) Quality 2020 - A 10-Year Quality Strategy for Health and Social Care in Northern Ireland (PDF 668.2KB)
A 10 year Quality Strategy for Health and Social Care has been developed for Northern Ireland. It is intended that the strategy will protect and improve quality and aim to achieve excellence, in terms of safety, effectiveness and patient/client experience in the period up to 2020. Safety is described as "avoiding and preventing harm to patients and clients from the care, treatment and support that is intended to help them".

Department of Health, Social Services and Public Health (2010) Changing the culture 2010. Strategic regional action plan for the prevention and control of healthcare-associated infections in Northern Ireland (PDF 306.70KB)
This strategic action plan brings together the main regional actions that DHSSPS and Health and Social Care (HSC) organisations will be taking to reduce the incidence of healthcare-associated infections (HCAIs). It builds on the first Changing the culture report published in 2006 and continues its core principles. In 2010 to 2011 the focus will continue to be on accountability and assurance and embedding infection prevention and control in everyone's responsibilities and this will include promotion of a zero tolerance culture. The document sets out the core aim to eliminate the occurrence of preventable healthcare-associated infections and to strengthen and maintain public confidence and the objectives and the actions required to achieve these.

Department of Health Social Services and Public Safety (2006) The quality standards for health and social care
'Safe and effective care' is one of the five overarching themes which are the basis for the reviews of health and social services undertaken by the Regulation and Quality Improvement Authority (RQIA)  The theme is subdivided into three areas: ensuring safe practice and the appropriate management of risk; preventing, detecting, communicating and learning from adverse incidents and near misses and promoting effective care.

Department of Health, Social Services and Public Safety (2006) Safety first: a framework for sustainable improvement in the HPSS
The action plan and the steps underpinning sustainable improvement are brought together in five key themes: implementing evidence-based practice and learning from adverse events; agreeing common systems for collecting, analysing and managing adverse events; sharing the learning; building public confidence; promoting education, training and support for health and social care staff.

Department of Health, Social Services and Public Safety (2006) Improving patient safety - building public confidence
This response to the Shipman Inquiry contains an action plan designed to take forward a number of proposals to improve quality of care and patient safety. The action plan focuses on death certification, systems and processes relating to controlled drugs and accountability, professional and organisational performance.

Scotland

Healthcare Improvement Scotland (2011) Healthcare Quality Standard: Assuring person centered, safe and effective care: clinical governance and risk management
The draft standard from Healthcare Improvement Scotland is the new core clinical governance and risk management standard for Scotland and will be used to test the arrangements that health care organisations have in place to deliver against the Healthcare Quality Strategy quality ambitions.

Scottish Government (2010) The healthcare quality strategy for NHS Scotland
The quality strategy identifies three health care quality ambitions: to support the delivery of person-centred, safe and effective care to the people of Scotland. Progress will be measured against 12 national quality outcome measures. The strategy includes priority areas of action and improvement interventions for patient safety, building on the work of the Scottish Patient Safety Programme.

NHS Quality Improvement Scotland (2007) Shifting the focus: leading on quality improvement and patient safety in community and primary healthcare services
This document reflects strategic direction set out for Scotland in 'Delivering for Health' and the drive to move care from hospital settings into the community. One of the aims of this strategy document is to "improve patient safety in community and primary healthcare by using available data to address variations in practice, learning from past experiences and supporting the implementation of clinical governance and risk management".

Older policy documents

The following are older policy documents which have influenced the patient safety landscape and provide background to the more recent policy.

Scottish Government (2007) Better health, better care action plan
This strategy sets out a programme for Scotland which has three main components - health improvement, tackling health inequality and improving the quality of health care. In the section on patient safety the plan establishes the role of the Scottish Patient Safety Alliance and describes priorities within acute care and activities to tackle healthcare associated infection.

NHS Quality Improvement Scotland (2005) Clinical governance and risk management: achieving safe, effective, patient-focused care and services
These are the national standards which have been developed "to support all NHS Boards to put into place the necessary systems and processes to ensure that safe, effective, patient-focused care and services are being delivered across Scotland". A peer review programme assesses the performance of all NHS Boards against these standards.

Wales

1000 Lives Plus (2012) Achieving high reliability in NHS Wales
This is the latest white paper from 1000 Lives Plus. It draws on technical theory and practical work from the NHS and other industries to explore how 'high reliability' could make NHS Wales a better and safer place to both work and be a patient in. The white paper includes a driver diagram that identifies the five key areas NHS Wales organisations need to consider when seeking to achieve high reliability: effective engagement; looking beyond the simple and obvious; learning from failure; valuing expertise and promoting situational leadership and organisational reflection.

Health in Wales: Healthcare associated infections
This page describes the strategic approach to reducing healthcare associated infections (HCAIs) in Wales and includes a strategy document for hospitals and a community strategy.

NHS Wales: Governance e-Manual
The  manual is designed to assist NHS organisations in Wales develop robust governance and assurance arrangements that meet the standards of good governance set for all public services in Wales. explains the context of patient safety in Wales. Information which explains the context of patient safety in Wales about is in the Putting the citizen first heading.

NHS Wales (2011) Doing well, doing better: standards for health services in Wales
The standards for health services in Wales set out the Welsh Government's common framework of standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. Standard 7 is about safe and clinically effective care.

Welsh Assembly Government (2006) The Healthcare Quality Improvement Plan (QuIP)
The QuIP sets out the strategy and actions necessary to achieve the Designed for Life objective that by "2015 Wales will have minimised avoidable death, pain, delays helplessness and waste".

Welsh Assembly Government (2005) Designed For Life: Creating world class Health and Social Care for Wales in the 21st century
Designed for Life is the Welsh Assembly Government's 10 year vision for creating world class health and social care in Wales in the 21st century. It focuses on three basic principles: lifelong health, world class care and fast, safe and effective services.

Welsh Assembly Government (2004) Fundamentals of care
This Welsh Assembly Government initiative aims to improve the quality of aspects of health and social care for adults. 'Ensuring safety' is one of the twelve aspects of care which draw together guidance on the quality of care service users may expect from health and social care providers in Wales.