D2: Improving services following adverse events

Wednesday 17 May | 11:00-12:15

Format: Presentation
Stream: Safety
Content filters: n/a

Chair: Katrine Kirk, Patient Safety Champion, Patients for Patient Safety, WHO

PART ONE – The rates of hospital complaints are associated with their performance ratings – a cross-sectional and longitudinal study

The level of complaints received by NHS hospitals is inversely correlated with their respective CQC performance ratings. The NHS hospitals with the worse CQC ratings had received significantly higher rates of complaints than those with better ratings. In a three-year analysis from 2019 to 2022, those who had improved their CQC ratings demonstrated a greater reduction of complaints as compared to those who had deteriorated. Overperforming organisations had reduced their new complaints significantly by a third. The results of this study had noteworthy implications for managers of healthcare organisations. This project proposed four key recommendations for NHS hospitals to improve their performance ratings and reduce their complaints.

Co-authors: Dr Yincent Tse, Dr Mark Anderson, Dr Anita Devlin, Professor Robert McFarland

After this session, participants will be able to:

  • Understand the current landscape of complaints in UK hospitals

  • Appreciate the relationships between hospital performance ratings and patient complaints

  • Learn strategies on how to address patient complaints at hospital organisation level

Albert Lim, Newcastle upon Tyne NHS Foundation Trust, England

PART TWO – Improving more by investigating less: rethinking patient safety incident response

Little evidence suggests investigating patient safety incidents has returned widespread sustainable improvement in patient safety, or benefits to those affected. NHS England’s Patient Safety Incident Response Framework fundamentally changes how healthcare providers respond to patient safety incidents for the purpose of learning and improvement. PSIRF is not a framework that describes when and what to investigate; instead it:

  • Advocates a co-ordinated data-driven approach to patient safety incident response that prioritises compassionate engagement with patients, families and staff

  • Embeds patient safety incident response within a wider system of improvement, prompting a significant cultural shift towards systematic patient safety management

After this session, participants will be able to:

  • Describe a new, innovative approach to responding to patient safety incidents to maximise learning and improvement

  • Understand how providers in the NHS are redesigning their systems and processes to prepare to transition to PSIRF

  • Know where to access resources to support improvements in engaging with those affected by patient safety incidents and incident response oversight as well as further tools, templates, and guides to inform safety management

Tracey Herlihey, NHS England, England

PART THREE – Learning from patient and relative reported adverse events

Adverse events reported by patients and relatives are often of high quality and therefore a potentially solid basis for learning. In Denmark, it has been possible since 2011 for patients and relatives to report to the national database (DPSD). At Rigshospitalet, 229 reported incidents from patients and relatives have been reviewed. This review will give delegates a good insight into how patients experience the treatment they receive from the hospital. Aggregated results from the reported incidents will be reviewed.

After this session, participants will be able to:

  • Understand the patients’ and relatives’ perspective and focus on patient safety in their contact with the hospital service

  • Include the problems patients and relatives experience in connection with communication

  • To improve their response to patients’ and relatives’ information about the course of the disease and description of symptoms

Mark Krasnik, Rigshospitalet, Denmark