Investigating serious incidents, using root cause analysis (RCA), has been a cornerstone of improving patient safety in the National Health Service (NHS) for more than two decades. However, there has been a growing awareness that RCA is ineffective in complex adaptive systems like healthcare, as it promotes looking for 'cause-and-effect' relationships, a posteriori. Current thinking is that serious incidents are the result of emergent properties and interactions that are difficult to explain. In mental healthcare, because service delivery involves human intense interactions, incidents cannot reliably be explained in this way, because of the intractability of human behaviour. A new national framework for the NHS in England aims to promote a systemic rather than causation philosophy to explain the occurrence of serious incidents. It also aims to promote a proportionate response to incidents, so that resources allocated to learning are balanced with those needed to deliver improvement, to make an appreciable contribution to reducing the human and financial impacts of harm. Successful implementation will require a cultural change, through use of system-based investigations of incidents as a learning and improvement response, to review the multiple interactions in the socio-technical system healthcare operates within. To understand the problems with delivering NHS serious incident frameworks, this thesis explores what works well and what could be done better to maximise the effectiveness of the serious incident investigation process, in the context of mental health Trusts in England. A multi-phase, sequential mixed methods research design was used. The first study used thematic analysis to identify learning from the past implementation of national patient safety policies, to better understand the evidence about what supports their implementation. The second study used a questionnaire survey to explore the current state of serious incident investigatory capability, to identify gaps and so inform recommendations for implementing changes to policy frameworks for incident management. The third and fourth studies used semi-structured interviews with patient safety professionals to explore, in the context of serious incident management, what the current national patient safety strategy for the NHS in England describes as the two foundations of safer care, namely safer systems and patient safety culture change. These professional perspectives have reported how incident management systems can be improved and how a patient safety culture can be supported to improve the effectiveness of serious incident frameworks and so maximise safety. Findings are presented concerning the complex, systemic factors influencing patient safety efforts, particularly the response to serious incidents, that have informed recommendations for how to maximise the effectiveness of their investigation. A key recommendation is that investigators should be provided with the capability to conduct investigations, supported by a resilient infrastructure. This thesis also contributes new knowledge relevant to the NHS safety system. It asserts that a shift in the way patient safety resources are deployed across this system would contribute to more effective frameworks to respond to serious incidents and so make progress towards the national ambition of providing safer care.
- patient safety
- mental health
- healthcare
- culture
- systems
- serious incidents
- practice
- qualitative research
- policy
- strategy
- improvement
- training
- education
A mixed methods study exploring serious incident frameworks in mental health Trusts in England
Wood, D. (Author). 16 May 2024
Student thesis: Phd