Patient safety: closing the implementation gap

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I’ve been to many conferences on quality and safety in the NHS, and never cease to be frustrated by suggestions of creating yet another policy or checklist, or by people bemoaning the difficulty of implementing improvement measures with the common complaint ‘Why is it so hard for people just to do the right thing?’

Over the years many of us have tried to implement new measures to improve patient safety, but we are often forced to admit that things haven’t turned out as we had originally intended.

In 2003 when I joined the National Patient Safety Agency (NPSA), a group of us wrote national patient safety guidance for the NHS, which was based on a systematic review of the research, international and national patient safety knowledge and understanding, personal experience, expertise and judgement. But despite being widely disseminated, these strategies have never been successfully implemented at scale. This is disappointing, but it has led us to a realisation that simply telling people to get on with it is not the answer.

What we failed to realise was that relying on passive diffusion of information about safer practices is doomed to failure in a world in which more than two million articles on clinical issues are published every year. Clinicians have to be constantly aware of new approaches and best practice, and in today’s context of a mass of instant information, that is a daunting task.

In the past, the health care sector has assumed that it can implement changes in half the time and with a quarter of the resources used in other industries. But implementing change is a slow and haphazard process, and a complex challenge for many individuals and organisations. This means there is a gap between what we know improves patient safety and what is actually done in practice. We in the Sign up to Safety campaign team have been drawing on support from The King’s Fund to help us develop a theory about why this implementation gap exists, and to explore ways of overcoming it.

Guidelines, in isolation, rarely change people’s individual practice. Through our work with The Fund we have learnt that many factors can hinder effective implementation, including: failure to appreciate the complexity of a problem or the context in which change is required; complicated or unclear guidance; or using an inappropriate method of dissemination such as top-down instruction.

Sometimes the proposed solution to a problem sounds as though it would work in theory, but then without the context having been properly considered it fails to deliver in practice. For example, prescribing alerts for GPs are intended to flag up possible drug interactions, or to warn them if the prescribed dose appears too high. This is a good idea in principle, but then because the alerts appear relatively often they can become irritating for an overstretched GP, and are often simply clicked off straight away.

So how can we ensure that these considerations are taken into account from the outset, and how can we encourage people to embrace changes that will be beneficial for patient safety in the long-term when they may only have five minutes in their day to sit down and look beyond their daily activity? To take up a new way of doing things means to give up the old ways, and if the perception is that the old practice is just fine then there needs to be adequate incentive.

Choosing the right method of implementation is vital. Those leading change need to ensure:

  • an easy method of implementation
  • good-quality guidance
  • clear benefits – with numbers, feelings and experiences demonstrating that the change is better than status quo
  • the message is delivered in person, using the right role model or opinion leader
  • people are recognised and rewarded for their actions, and thanked for their contribution
  • they adopt a coaching style of leadership; if leaders simply try to solve the problems themselves then people will not take ownership of the outcome.

Implementation is more often about making smaller changes that can incrementally make things easier, better, safer and more effective. And it requires ongoing maintenance. Consequently, the problem of implementation needs to be owned by all of us. All of us need to better understand behavioural change theories, including motivation and social learning theory together with lessons from the behavioural insights world – and why some people embrace change while others hold back for a while.

We frequently find in health care that our assumptions about causes and solutions are wrong. Contention and debate can challenge such assumptions and prompt re-thinking the problems we target or how we tackle them.

A workshop at The King’s Fund on 20 October aims to challenge the current thinking around what it takes to make care safer. We hope it will provide new ideas and insights that will make future efforts with the deceptively difficult art and science of patient safety implementation just a little easier. And we promise that you will not hear the words ‘Why is it so hard for people just to do the right thing?’


George Coxon

Various inc care home owner ex senior NHS clinician & commissioner,
Comment date
05 October 2016
In addressing safety in H&SC settings we must engage at all levels in a balanced non accusatory way Sadly a culture that blames and produces guidance after guidance and endless instruction about this will leave many cynical, defensive and paying lip service to the key principles about 'doing no harm' ( title of the very excellent Henry Marsh book about this work as one of the countries leading neurosurgeons )
I was lucky enough to be offered a place on the IHI patient safety programme earlier this year in Exeter. Of the 70 plus senior clinical and managerial attendance I was the only social care protagonist. I wrote lots, asked lots of questions, took away various ideas and implemented several, did several celebrated mind maps and was asked to do a 2 part blog for our local AHSN - all 'value adding and I would argue impactful - to a point. But how quickly we move on, get swamped, feel our focus shifts!! Safety is about embedding care, caution, and curiosity in what we do and how we do it It's got to be integral whilst recognising things do go wrong and we do make mistakes but deserve forgiveness if we've acted in good faith and demonstrated real learning and change when this happens
Suzette's blog must be promoted by the likes of me I suspect. We need to process its recommendations and make sure we do better in all settings including care homes. Yet not detracting from the balance of Safe- guarding as well as Fun-guarding (one of many of our core values in our homes!!). "Being safe in a care home can be a bit boring" - I'm quoting one of our residents who said this recently in a residents meeting. She had lots of emphatic support too. I'll be sharing this blog with my staff and our wider care home fraternity You may get more ideas and thoughts. Thx

Giovanna Forte

Forte Medical
Comment date
04 October 2016
We would have loved to attend the Patient Safety Workshop to find out how best to introduce our ground-breaking innovation to healthcare policy makers and providers. As an SME £450 for a day is out of our league. It would be encouraging if these events welcomed healthcare innovators, who have invested heavily in R&D, design, clinical trials and more, to the ultimate benefit of healthcare decision makers and providers. Our product contributes significantly to front-line patient safety for HCPs and patients alike; our company is not a global entity with huge cash reserves! Any advice?

Ant Harrison

Consultant Nurse,
Comment date
31 August 2016
Good discussion, but my experience is that there's a step before implementation: people need to recognise and acknowledge that some forms of change/improvement needs to take place. This is not a given in most organisations - failure to accept and want change is a significant block to implementation.

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