How patient safety improvement programmes work
Patient safety improvement programmes (SIPs) are a key part of the NHS Patient Safety Strategy, launched in July 2019, to deliver safety and quality improvements across the NHS in England. They are managed and led by our national patient safety team.
SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes.
- the National Patient Safety Improvement Programme
- the Maternity and Neonatal Safety Improvement Programme
- the Medicines Safety Improvement Programme
SIPs are delivered by local healthcare providers working directly with our national team and through 15 regionally-based Patient Safety Collaboratives (PSCs - see PSC section below). The SIPs support continuous and sustainable improvement through:
- Culture: They promote positive safety culture, encouraging staff to gain insight and share learning from good and poor practice.
- Evidence-based improvement: They support evidence-based, quality improvement (QI) methodology, ensuring change is consistently measured and evaluated.
- Quality improvement (QI) capability: They grow QI capability in trusts and local healthcare systems so they can continue to improve.
- System-level change: They enable regional and local health systems to identify improvement priorities and share learning.
The Patient Safety Measurement Unit supports the safety improvement programmes, including the work of the 15 regionally-based Patient Safety Collaboratives, by enabling change to be consistently measured to help identify what works.
National Patient Safety Improvement Programme
The National Patient Safety Improvement Programme (NatPatSIP) is led by our national patient safety team.
The programme is delivered by 15 regionally-based Patient Safety Collaboratives (PSCs). The PSCs are each commissioned through one of 15 Academic Health Science Networks (AHSNs).
NatPatSIP supports two areas of work:
Preventing deterioration and sepsis:
This helps the avoidance of harm or death caused by failure to recognise or respond to physical deterioration in a patient’s condition, wherever they are being cared for.
- developing a suspicion of sepsis insight dashboard - helping clinicians to recognise and respond to suspected sepsis
- implementing the National Early Warning Score (NEWS2) - helping early identification of acutely ill patients in acute and ambulance trusts
- testing the use of NEWS2 and other “soft” signs of deterioration in community care settings.
Adoption and spread of effective, evidence-based practice:
This helps accelerate the adoption and spread of evidence-based practice across the NHS in England.
There are currently four adoption and spread priorities:
- emergency laparotomy care bundle
- prevention of cerebral palsy in preterm labour (PReCept)
- emergency department safety checklist
- chronic obstructive pulmonary disease discharge care bundle.
The programme also works with national, regional and local partners to develop a “pipeline” of future improvements.
Patient Safety Collaborative commissioning
NatPatSIP is also responsible for commissioning and assuring the work of the Patient Safety Collaboratives.
Maternity and Neonatal Safety Improvement Programme
The Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) is led and co-delivered by our national patient safety team, who work with the 15 regionally-based Patient Safety Collaboratives (PSCs) and with maternity teams from 132 NHS trusts.
MatNeoSIP aims to:
- improve the safety and outcomes of maternity and neonatal care of all women, babies and families in England, reducing unwarranted variations in care and experience of care
- help reduce maternal and neonatal deaths, stillbirths and brain injuries that occur during or soon after birth by 50% by 2025 – a national target set out in Better Births.
The programme focuses on five areas of improvement:
- increasing the proportion of smoking-free pregnancies
- optimising and stabilising very preterm infants
- detecting and managing diabetes in pregnancy
- detecting and managing low blood sugar (neonatal hypoglycaemia) in pregnancy
- early recognition and management of physical deterioration of mothers or babies during labour and immediately after birth (early postpartum).
MatNeoSIP builds on the work of the Maternal and Neonatal Health Safety Collaborative, a three-year programme, launched in February 2017.
Medicines Safety Improvement Programme
The Medicines Safety Improvement Programme (MedSIP) is led nationally and commissioned by our national patient safety team.
It supports an initial set of projects linked to the evidence base on medication errors, and the NHS Long Term Plan; these include a major project delivered by the 15 regionally-based Patient Safety Collaboratives to reduce medicines administration errors in care homes.
MedSIP is also making progress to deliver system enablers, including electronic prescribing systems, and systems to flag patients at risk of harm in primary care (as recommended by the Short Life Working Group).
The programme is developing and rolling out a framework to help care systems self-assess their approach to medicines safety, both as individual organisations and as members of local sustainability and transformation partnerships and integrated care systems.
Patient Safety Collaboratives
Patient safety improvement programmes were launched in July 2019 as part of the NHS Patient Safety Strategy. They build on the work of the 15 regionally-based Patient Safety Collaboratives (PSCs) and the Patient Safety Collaborative programme, established in 2014. The PSCs continue to deliver and support all the patient safety improvement programmes.
PSCs are made up of NHS providers and commissioners in its geographical region. They include hospitals, community, primary care, mental health and ambulance services and clinical commissioning groups.
PSCs are each managed by one of 15 regionally-based Academic Health Science Networks (AHSNs). AHSNs are made up of NHS staff, patients, carers, academics, quality improvement and safety experts.
Our national patient safety team commissions AHSNs to manage the PSCs’ work. The commissioning and assurance process falls within the National Patient Safety Improvement Programme.
The national safety improvement programmes build on the work of the 15 regionally-based Patient Safety Collaboratives. Here are some examples of their success:
Email firstname.lastname@example.org for more information on our patient safety improvement programmes.
For more information on Patient Safety Collaboratives (PSCs) or to get involved in patient safety improvement where you live or work, please contact the Academic Health Science Network (AHSN) that covers your area. PSCs and AHSNs cover the same areas. A link to each AHSN website is listed below.
AHSNs and PSCs cover the geographical areas shown on this map. The PSCs work with their local healthcare providers, staff and patients to identify and develop solutions for local patient safety priorities.
- East Midlands AHSN
- Eastern AHSN
- Health Innovation Manchester (covering Greater Manchester)
- Health Innovation Network (covering South London)
- Imperial College Health Partners (covering North West London)
- Innovation Agency (covering the North West Coast)
- Kent Surrey Sussex AHSN
- North East and North Cumbria AHSN
- Oxford AHSN
- South West AHSN
- UCL Partners (covering North East London)
- Wessex AHSN
- West Midlands AHSN
- West of England AHSN
- Yorkshire and Humber AHSN
Background to our work
The 2013 Francis Report that examined failings in care at Mid Staffordshire NHS Foundation Trust, triggered a need to understand how the whole NHS system could improve further. Professor Don Berwick, a leading expert in global healthcare improvement, was asked to look at whether we could ‘make zero harm a reality’ and what could be done to achieve a continual reduction in harm over time.
The report published by the national advisory group led by Don Berwick, A promise to learn - a commitment to act (2013) made a series of recommendations to improve patient safety. The national Patient Safety Collaborative programme was created to support the call for ‘the NHS to become a system devoted to continual learning and improvement’ in order to make care safer for all'.
In 2018 we commissioned a review of the operational delivery and impact of the Patient Safety Collaborative programme. This report gives its findings and recommendations to strengthen the programme, including greater collective focus on priority workstreams and alignment. The review findings were subsequently incorporated into the NHS Patient Safety Strategy, published in July 2019.