 It's Donna Frosser, Chief Clinical Officer with the Patient Safety Movement Foundation. We're here to bring you another COVID-19 update. Today we want to talk about how we can better learn from each other to reduce harm in healthcare. And I'm really excited to be joined today by Helen Hughes, she's the Chief Executive at Patient Safety Learning in the UK. Hi Helen. Hi there. Thanks so much for joining. No, thank you. It's a great privilege to be asked. Thank you. I wonder if you could tell us a little bit about your background. Very quickly, I've got an unconventional background in patient safety in that I don't have a clinical background but I've been passionate and engaged in patient safety for about 20 years. In the UK there's a big report organization with a memory that came out just after the US is to Eris Human and it was light bulb flashing moments for me. I was in a leadership role in healthcare at the time and since then I'm being committed to redesign healthcare for improved safety. So I've worked at a national level at the National Patient Safety Agents here in the UK and I have the privilege of working with Salim Donelson and colleagues at the World Health Organization in setting up the WHO program on patient safety and I've worked in a range of leadership roles in safety and social justice organizations. Wonderful. Well, tell us a little bit about the background of patient safety learning. How did this great resource come about? Yeah, well patient safety learning has been a charity, it's a UK-based charity with kind of global ambitions and reach and we came about, there was a group of experts and advisors, patient experts and our chairman who is the founding chief exec of what is now RLDATICS but we had professors, we had advisors, we had patients, really frustrated that healthcare, health and social care but mainly healthcare was not seeing the improvement we needed to see in patient safety and felt that healthcare systems were looking at a much better understanding about why we needed to change to improve safety and reduce harm, had a better understanding about what we needed to do but there weren't really that many tools to help people deliver the how and we felt that we had an opportunity to be as a charity to speak truth to power, to give messages that we felt were needed for policy makers and politicians to make changes and that we could do something very actively to support frontline clinicians, leaders in patient safety and to translate ideas into action and to address the implementation gap so that was our sort of passion about why we felt we needed to be created and make a difference. So what are your organizational goals for improving patient safety? So what we want to be is an organization that helps improve safety and reduce harm and we don't want to be an organization that just produces policy papers, think tank, there are a lot of organizations that do that and do that very well but we in order to help kind of people understand our thinking and to shape the action that we would take we have actually done a bit of work on our policy thinking and we have produced a report and it's called a blueprint for action and we'll put all the details so that people can have a look at it. What we've done in that report is to reflect on the last 15 to 20 years of thinking on patient safety and from a systems perspective, from an organizational and a health and social care system perspective, we try to answer the question why is harm so persistent? So again from what I was saying earlier we know we know the scale of unsafe care, we know the cost of it, the tragic cost in people's lives, we know the financial cost, the waste of resource from unsafe care and we kind of know what we need to do. There's lots of reports and inquiries, US, UK, European, global but how do we make the change we need to see and we did a really big evidence-based kind of analysis of that 20 years worth of research and we've drawn out kind of seven key messages which I will share briefly with you that we think are system issues that need to be tackled in order to undertake to reduce harm and improve safety. So we know we have a lot of programs, it could be on infection control, it could be on VTE on falls, you know clinically specific area safe surgery but if you look at the kind of issues that come from inquiries and unsafe care we think there's one overarching issue that is core which is that patient safety and avoidable harm, the reduction of avoidable harm has to be the core of every organization and everyone working in the organization. If it's patient safety initiatives are one of many priorities that are being balanced then often the other priorities will take greater precedence whether it's financial priorities or whether you're given volume targets or whatever they are they will often take priority and the presumption is that if you have really good clinicians working collaboratively then the safety just follows and we know it doesn't. We know from other industries outside of health and social care we know you have to design a system for safety and so that's the overarching kind of aim and then what we've identified is six foundations for patient safety and I think people that are watching this will be familiar with many of them but what we've brought together is a real sense of what action needs to be taken to achieve these so why it's called a blueprint for action is that we're proposing you know what those put the barriers to harm to reducing harm are and then what action needs to be taken so they're very tangible and they are around leadership and that's around organizational leadership and system leadership that's about setting goals having leaders behave and commit to patient safety it's about shared learning and finding systematic ways of learning and sharing that learning learning from when things go wrong really importantly learning from when things go right so you know the whole safety one safety two dichotomy but the innovation that we're seeing in the UK and I think globally as people are responding to the COVID-19 pandemic and making changes to improve safety those initiatives some of those I know you've spoken to Rachel Card medic as one that we were actively promoting there's fabulous stuff that's working and how do we get that out across the health and social care system how do we do that within our country how do we do that globally so shared learning is the second of the six third one is we've called it's quite a broad one it's called professionalizing patient safety and by that we mean that everyone is professional in understanding patient safety and systems thinking so all there's a requirement in the UK for all for all health care organizations to ensure that they take all reasonable and practical steps to improve patient safety and one way to do that is to ensure that all staff are trained and systems thinking and can prioritize patient safety so all staff not just clinicians whether it is porters whether it's governors leaders lab technicians all need to have the knowledge the skills and the behaviors for safety so it's kind of designing educational and induction programs for that supported by highly specialists and trained people people understand safety thinking thinking people that use human factors and ergonomic skills for designing safe systems and for us to have standards for patient safety in a way that in the UK we have organizational standards for fire safety and there's a requirement for leaders and governors and boards to attend to those we don't have the same set of standards for patient safety so you've got an inconsistency of approach and an inconsistency of outcome that we address I'm halfway through I'm getting there so the so the so the other three of the six one is around the fourth one is around data and insight how do we know not just where harm happens and how we responded to it and I think over the last 20 years there's been a lot more investment and incident reporting systems and investigations that we still have challenges about the quality of investigations and how we get learning and how that learning is applied for action and improvement but really it's the flip side so we've got the kind of lagging indicators but what are the leading indicators what are the what are the how do we risk assess how do we know whether we've got a resilient organization how can we say what does safe look like and how are we designing our metrics and performance indicators to be safe I think there's much more work that needs to be done on that area the kind of more forward-thinking area the fifth area which is one that's very close to my heart personally because when I worked at WHO I have the absolute honor of being the executive lead for a program that was led by patients and in WHO is the patients for patient safety program which still continues and is is being nourished by your colleagues north of the border so the Canadian Patient Safety Institute are still doing random things with this and that's really about engaging patients in a not inviting them in but co-producing health and social care for for safety and that's at three levels one is at the point of care so you know the information asymmetry the patients and families having the knowledge having the the the authority feeling comfortable about asking questions and supporting big part almost as a part of an extended clinical team in their own care the second stage of three is where if something goes wrong patients insight and wisdom as to what's gone wrong and to share and to give insight to learning and to share that for improvement is really important and we do I don't think as a health and social care systems globally we do enough around inviting patients in to contribute to that and then thirdly patients and families as advocates for for social change for a social movement for safety to say this extent of unsafe care is is not it is is not good enough the risks are too high the costs are too high the OECD has said globally 10 to 15% of all health care systems spent is as a consequence of unsafe care so as well as the tragic reasons why people are harmed and and and die avoidably the cost is ridiculous so as as societies do we really should we be really rethinking how we design our health care systems to make it safer and then the final one which is someone I can't remember his name now said culture eat strategy for breakfast and everything is all about organizational culture how do we how do we create our system and organizational culture for safety so it's just it's open we were actively engaging with our staff and our patients so we're learning we're being challenged we're hearing where there are risks we're not putting barriers to that we're inviting people and we're listening we're thanking them when they're telling us areas that we can improve and when things go wrong we're not blaming individual professionals we've got a much better understanding about system thinking and how we can make how we can design systems for health care workers to be safer when they're providing that care so we've yeah we've we've pushed those kind of six core foundations and then the two areas that we're working on very actively as patient safety learning so sort of suggesting what others can do is is all well and good but actually how are we making that change happen and we're actively designing our patient safety standards so that we could help organizations design their own safety systems and and that's something that we are actively working on now and starting to share with with partners who are testing our thinking and giving us feedback and that's going very well and then the the one that you might want to explore a little bit more about is is our knowledge sharing platform so finding knowledge of examples of where things have gone wrong and how they've been not just they've gone wrong but how people have identified the causes and have taken action to improve it how they've done that in the context of quality improvement initiatives but also how they how they learning from when things go well how do you share that there's a we did a bit of work with Professor Karl McCrae who's very well known here in the in the UK and we asked him to look at how knowledge for safety is shared in other industries and he gave us the example of Skybury from aviation so if you want to know anything about safety in aviation whether you're a aircraft manufacturer whether you're a safety specialist working in a in an airline whether you're air traffic control whether you're designing and specifying and designing equipment for safety everything is always on Skybury and we thought wouldn't it be great if we had a health care skybury so if someone says I've got an issue on maternity care or I'm concerned about safety culture or I want to improve my reporting system how do I find out where the good stuff is and we launched this last October so it's still fairly new we've got a zero marketing budget as we're a small charity we're in 30 countries already we've got thousands of pages of content some of that is peer-reviewed literature some of its inquiries the really great stuff is innovations and initiatives that people have developed around particular problems or issues and we're using our the hub to share that knowledge so it's free at the point of use anyone can just go online and look at it but if you become a member you can participate and we want to create that kind of family that movement where people share their good practice their insights they ask questions and and you know the I suppose the fundamental theme is knowledge has no boundaries and we want to share this knowledge for improved patient safety and avoidance of harm it's kind of UK focused mainly at the moment but it is we've got a lot of people from the Middle East from Africa US in particular about three four weeks ago 30% of our activity in one week came from the US we'd obviously put content on there they kind of resonated so yeah so the safety standards work the campaigning and influencing and the hub the knowledge platform for patient safety is kind of our contribution and what we want to focus on that's fabulous and so the patient safety learning hub is free as you mentioned are all of your resources free or is there a membership cost no no they're all free at the moment what we we are working through that around our safety standards and how we because we need to be a sustainable organization right so we've got we've been helped to set up through the philanthropy but it may well be if we develop we're thinking of different alternatives one of them is around an accreditation an organizational accreditation framework and then there are accreditation frameworks for for quality in different countries and globally but having a highly specialized one focusing on those six foundations on patient safety is not something that's currently there and we think that would be valuable if we did do that that might be something that we would want resources just to enable us to continue the work and it may be that we we develop an accreditation framework around individuals and their their competence around safety and human factors it we're a young organization those are quite early days at the moment but at the moment anything that you go on to our websites so our policy blogs our thinking and on our hub all that content is free free at the point of delivery and we we're actively engaging with with sponsors to sponsor the hub so that we can try and we can reduce the hierarchy because the people that use the hub they are some of them are patient safety managers specialists quality specialists they're also frontline clinicians their patients their policymakers their non-executive directors their researchers it's the whole community so we talk about safety system thinking and we're not thinking just as funders insurers providers we're thinking of professionals policy makers manufacturers every regulators everyone that works to contribute to making a safe system we want to embrace that everyone in partnership for improvements so you know the content is is very wide-ranging because we want it to be a fabulous resource for everyone but sounds like it sounds like it's a great place for people who are passionate about patient safety to get involved. Oh we love them so I mean please everyone in your movement anyone that's watching this please come to to patient safety learning website but come to our hub and and look at what we've got if if you like what we've got please contribute to it I mean the the whole idea is that it's not our knowledge what we are doing is helping share the knowledge and and source it secure it promote it and celebrate it but it you know the knowledge belongs to everyone so if people see see something that they find useful tell us about it why they thought it was good we've had that we had a great blog from colleagues from an exchange visit some of the stuff we put on there isn't on us we always know who puts content on we have very clear standards we have moderators to ensure that but sometimes particularly healthcare professionals find it difficult to put information on there even if it's perfectly reasonable fear factor can be quite a thing on patient safety and sometimes sharing knowledge requires layers of bureaucratic approval so sometimes we will accept people's insights and blogs we know they are we can attest for the quality of their work but we will keep their their identity will be just between them and us because the main thing is that we get the insight and the knowledge for improvement out there so people please please use it and please share with us challenge us to put more on there help us find really good stuff and and unite in sharing knowledge for improvement well it sounds like a really great way for us to collaborate globally on this as I say it's kind of it started it's six months old that's all I were delighted at it at its impact and how many people using it we would love it to go globally and we will only do that with the you know with the support of amazing organizations such as yours in any promotion we get so it's a kind of word-of-mouth thing it's not a as I say no marketing budget so people liking it telling their bodies getting it please join yeah great well Helen thanks so much for joining us today this is a fabulous resource we're going to share it with our network and hopefully we will all be contributing to your hub and learning more from each other oh please do we'd absolutely be delighted if we could do that yeah be great thanks for the opportunity done it's been great talk to you you as well have a great day thank you