Listening, Leading and Learning – reflecting on IHPN & CQC’s joint Patient Safety Conference

Anyone who knows me, knows that patient safety is my true passion and hosting IHPN’s joint annual conference with the CQC on this topic is a true highlight of the year.  

The theme for this year’s event – the fifth of its kind – is around the “Culture of Care: Listening, Leading, Learning”. And over 120 members had the pleasure of hearing from a wide range of speakers from across the patient safety landscape, from clinicians and regulators to researchers and patients.  

We kicked off the day with the Director of Secondary and Specialist Care at the CQC, Nicola Wise, who talked through the CQC’s progress in implementing their new Single Assessment Framework. The framework like the old framework is based on the five key questions and ratings system, and will be supported by improved technology meaning that physical site visits by the CQC will now be used for specific purposes such as observing care, understanding how staff interact and what the environment is like to name just a few rather than being the default.  

This is not without controversy, and we’ve heard from members some of their challenges around this – particularly through the provider portal and the removal of the relationship manager role – but there was a welcome steer from Nicola that sorting these issues is a priority and that they will continue to work with the sector through IHPN to ensure independent providers are confident of the new approach. 

Later on in the day, the CQC’s Chief Executive, Ian Trenholm, gave his reflections on the CQC’s wider strategy and some of the complexities of regulating health and care services in such a challenging operational environment. How do you assess a facility that is providing excellent care, but due to rising waiting lists, the ability of patients to actually access it is poor? And balancing the role of a regulator as a judge vs a coach – acknowledging their role in spreading best practice and scaling up innovation but equally understanding they are “not in the management consultant business” and can’t directly implement change. Likewise, how to assess tackling health inequalities when you “can’t inspect an outcome”. 

While understanding the regulatory environment that we operate in is obviously important, healthcare of course begins and ends with the patient. We were therefore so pleased to be joined by Paula Goss who is a campaigner for people who have been injured by surgical mesh and founder of Rectopexy mesh victims support. You could hear a pin drop in the room as Paula spoke of her experiences of being injured by surgical mesh and not just the physical impacts, but the psychological and financial ones as well. Communication with patients is so important – both in terms of ensuring there’s informed consent, with patients well equipped to ask the right questions, as well as the need to not just listen to patients but really hear them and ensure their concerns are acted upon.  

Paula’s remarks really set the tone for the rest of the day and following her session, members had the opportunity to hear from the Patient Safety Commissioner Dr Henrietta Hughes who talked through her key priorities in the coming year, including around implementing Martha’s Law across the health system, and the importance of working with other patient safety bodies to ensure there’s a joined up approach in what can seem like a very crowed safety landscape… 

Indeed a new player in the patient safety world is the Health Service Safety Investigations Body (HSSIB) whose role is to investigate incidents where there are implications for the safety  of patients, and whose remit has expanded to investigate all  healthcare  services in England, including the private sector.  Interim CEO Rosie Benneyworth talked through the key investigations they are currently undertaking including “Workforce and patient safety – temporary staff, the digital environment, primary and community care coordination” and “Safety Management Systems”, with the aim to understand how a wide range of sectors tackle these issues and share insights and information across the whole healthcare system.  

In the afternoon sessions we took a look at the vital role of healthcare staff themselves in fostering a culture of safety and learning. National Freedom to Speak up Guardian Jayne Chidgey Clark looked at the importance of having open cultures so staff can feel they can speak up not just about safety issues, but equally about issues of improvement. A fascinating discussion with members also took place about how it feels for leaders to be on the receiving end of “speaking up” and the importance of “listening with fascination” and not taking the defensive stance.  

Spire’s Erica Bowen built on this theme, and outlined how they had fostered a “ward to board” approach to speaking up with the need for all parts of the organisation to be “clinically curious” and not “comfort seek” when it comes to safety matters. The importance of the “top of the office” embracing the speaking up agenda was also highlighted and the need to be explicit about what action has been taken in response to staff concerns.  

We then ended the day with some brilliant academic insights from the brains of the industry. Prof Jane O’Hara from The Healthcare Improvement Studies (THIS) Institute at Cambridge University showcased her research on “What can patients and families tell us about safety, and why should we care?” All too often there are cases of patients and families not being sufficiently involved in investigations despite, in fact, being the only people there “across the journey”. Not only are you therefore missing the opportunity to fact check and gain new insights, but also the opportunity for those involved to “heal” and understand what went wrong. Jane has worked on some fantastic resources on how to meaningfully engage with patients and families which I’d recommend all those in the sector to look at. 

Another brain from the sector was HSSIB’s Senior Safety Investigator Saskia Fursland who presented the case on “Learning from errors and mistakes​ – Retained swabs following invasive procedures”. While this took place in the NHS, there were key takeaways for all parts of the health system, including the often overreliance in serious incident reports in making predominantly “people-focused” recommendations (e.g surgical checklists) with a limited application of a systems-based approach to investigation which look at the more complex and interrelated system factors at play in avoiding future incidents.  

We finished the day with our sponsor Bevan Brittan who, while looking specifically at how healthcare providers  can use incidents and inquests as an opportunity for proactive learning and improvement, really summed up the day nicely around how to develop the right “culture of care”. This included being as open and inclusive as possible in any investigation and really getting people’s buy-in to the process (often involving something as simple as a “thank you”); asking open questions “with curiosity” and always seeing incidents as learning opportunities where patient care can be improved, rather than failures.  

Phew! This really was just the tip of the iceberg of what member delegates took away from the day, and I’m so grateful for all the speakers who have reaffirmed my passion for patient safety and just how important it is to develop cultures where listening, leading and learning are king. If you take away just one thing from the day its “listen with fascination”, “don’t comfort seek” and “ask questions with curiosity” and remember that we’re all patients, they are you, me, our families and friends. Keeping this in mind and you can’t go too wrong.