The Safer Clinical Systems Programme
A million people use healthcare services each day and the vast majority are treated without incident. However studies suggest that one in 10 patients admitted to hospital will experience some form of harm during their stay. In nearly every case, the problem is caused by unreliable healthcare systems and processes. That is why the Safer Clinical Systems programme (sponsored by the Health Foundation) tested and demonstrated improvements to healthcare systems to make care safer. Safer Clinical Systems was a five-year programme which took a fresh and proactive approach to safety improvement. Rather than waiting until a problem occurred, the programme helped healthcare teams proactively identify potential safety breaches, enabling them to build better, safer healthcare systems. Phase I of the programme began in 2008, with four project teams identifying problems with current clinical systems and working to develop and test improvement interventions. Phase II of the programme began in January 2011 and the team, led by Warwick Medical School, supported eight healthcare organisations to implement and test the defined approach developed in Phase I. This work focused on improving systems in two key areas: handover of clinical information, and prescribing. Phase II formally finished at the end of January 2014, but further work may be undertaken to embed and sustain the improvements made within the clinical teams.
The Safer Clinical Systems Approach
The safer clinical systems approach is based on systems thinking. Systems thinking is an approach to understanding how things work together - how things influence each other within a process, an organisation or any structure with a common purpose, and how to appreciate the complexity of the wider system. It is now well recognised within healthcare that, when things go wrong for a patient, the fault rarely lies with individual practitioners, but rather with the system in which they work. By taking a systems approach, we can begin to identify the elements of a care process which may be adversely affecting safety. This means focusing on the systems that support care as well as on the care delivery itself as provided by clinicians.
The work undertaken in Phase II consisted of the following four key steps which, at a high level, form the basis of the Safer Clinical Systems approach:
- Defining the pathway that is the focus of the Safer Clinical Systems project and its context
- Diagnosing the system to demonstrate the reliability and risks of the existing system
- Options selection, appraisal and planning of interventions
- System improvement cycles
The research team was:
Prof Matthew Cooke (Principal Investigator)
Dr Rosemary Jarvis