In October 2023, we published Safety management systems: an introduction for healthcare. This report provided an overview of how safety management systems (SMSs) operate in other industries, where SMSs are a regulatory requirement.
An SMS is a proactive approach to managing safety which sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.
An SMS explainer video was produced to introduce the principles described in the report. We are now exploring the extent that these principles are used or could be used to inform safety management across the healthcare system.
Everyone working in healthcare has some measure of responsibility for patient safety. When an organisation is accountable for patient safety, they should ensure that systems and processes are in place to effectively manage safety. This includes healthcare providers and integrated care systems (ICSs).
ICSs bring together providers and commissioners of NHS services across a geographical area to plan care in order to meet the needs of people. An ICS aims to join up hospital and community-based services, physical and mental health, and health and social care to improve long-term outcomes and minimise inequalities. Many patient safety risks go beyond organisational boundaries and may not be managed effectively without a clear safety management process. Gaps in responsibility and accountability can have serious consequences for patient safety.
This investigation considers how safety management is coordinated and integrated across the healthcare system. We have ensured that the patient voice is represented and that challenges to safety management are understood by hearing from patients that may have been harmed and those working within the system.
We have reported on pathways of care for the health needs of patients that require multiple contacts across different healthcare settings and providers. Contacts with the healthcare system were mapped with a detailed account of organisational patient safety accountabilities. We explored recurring risks when patients receive care from multiple services, and considered vulnerable patients.
We collected a diverse range of views to identify opportunities for the improvement of safety management. As part of the evidence collection, we interviewed NHS staff, patients, and carers. We spoke to patient groups to determine methods of engaging with patients that encounter multiple organisations to address their healthcare needs.