Awareness and safety improvement in hospitals: A SAFE approach

As the fifth round of the SAFE collaborative is launched, Dr Peter Lachman, Lead of the Quality Improvement Faculty at the RCPI, highlights the reasons for the success of the programme’s methodology

The HSE National Deteriorating Patient Improvement Programme (DPIP), supported by the Office of Nursing and Midwifery Services Director (ONMSD), has continued its generous funding of the SAFE (Situation Awareness For Everyone) programme to improve situation awareness in clinical teams across Ireland. The RCPI is now recruiting for up to 13 teams for its 2022-2023 SAFE programme. The key focus is to enable clinical teams to integrate patient safety methodologies into their daily work. 

The World Health Organisation’s Global Patient Safety Action Plan 2021–2030 sets out a vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care, every time, everywhere. The INAES (Irish National Adverse Events Study) reported that the level of harm in the Irish health system is unchanged from the previous report, although with progress in many areas, particularly in the decrease of hospital-acquired infections. The Covid-19 pandemic raised new challenges for clinical teams, with safety of the healthcare worker, delayed diagnosis and communication challenges becoming more apparent. Nonetheless, across the Irish healthcare system there is a strong commitment to improving the quality and safety of care. 

The RCPI is committed to providing tailored education and training to empower those working in healthcare to achieve real and sustained improvements to achieve better outcomes for patients and staff. The SAFE patient safety collaborative is offered by the RCPI to frontline clinical staff in partnership with the HSE and aims to bring multidisciplinary teams together to develop safer systems in their clinical environments. These teams explore patient safety risks and potential harms in their own system so that they can develop and implement patient safety interventions, contextualised for their own environment, using quality improvement (QI) methods in keeping with the HSE’s Framework for Improving Quality. 

The SAFE programme integrates the latest version of the Irish National Early Warning System (INEWS), published by the HSE’s DPIP partnership in 2020, with up-to-date safety theory and methodology, particularly moving from reacting to events towards the proactive anticipation of potential harm or deterioration. Anticipation of potential deterioration is essential and the INEWS is a valuable tool to assist in the assessment. It involves proactive management of risk to enable the earlier recognition of the potential for deterioration using clinical judgement, situation awareness, and an appropriate tiered response model. 

Regular safety huddles facilitate the identification of potential risk and are one of the key interventions that can increase situation awareness. When these huddles are carried out regularly, the clinical team has a shared understanding of potential risk not only to an individual patient, but also to the safety of the environment and the clinical team itself. 

Dr Geraldine Shaw, HSE Nursing and Midwifery Services Director, has stressed the need to create a safe environment for everyone in a clinical setting: “The importance of creating an environment of psychological safety where healthcare professionals feel comfortable seeking help and advice from one another and from senior colleagues cannot be underestimated and is a key feature of the SAFE programme. In the current climate, facing both a global pandemic and a HSE cyberattack, the importance of effective communication and the need for an environment of psychological safety for staff has come to the fore and must be a priority for us all.” 

The SAFE intervention 

Patient safety is a complex process that incorporates many different theories and methodologies. The SAFE programme takes these theories and translates them into actions that clinical teams can adopt in their daily work. 

The SAFE programme has been based on work in Cincinnati Children’s Hospital Medical Centre where theories of high reliability from other industries were translated into an intervention suitable for a clinical team. The focus is on teamwork and the development of psychological safety. SAFE was developed by a team at the Royal College of Paediatrics and Child Health led by 

Dr Peter Lachman and funded by UK charity, the Health Foundation. The programme has been introduced in over 50 hospitals in England. In Ireland, the programme was initially introduced to 20 children’s and neonatal wards across the country and led to demonstrable improvements in how teams worked together. Cork University Hospital (CUH) saw a reduction in transfers to the intensive care unit and this was also ref lected in data from UK hospitals. 

Dr Dorothy Breen, Consultant in Intensive Care and Quality at CUH highlighted that “the success of the safety huddle” has resulted in CUH “leading an application and successfully obtaining funding from RCQPS (Research Collaborative in Quality and Patient Safety) (HRB/HSE/RCPI) for a study known as PROTECT (Proficiency-based simulation training for Safety Huddle Performance). The PROTECT research team consists of national/international leaders in patient safety, communication and healthcare simulation. The study is currently underway.” 

With four rounds of the SAFE programme completed, over 50 teams in Ireland have now benefited from this learning and gone on to implement the safety methods with demonstrable improvements to the culture of safety, as well as an evident decrease in the deterioration of patients. The Covid-19 pandemic has shown the importance of being proactive and prepared, as well as the need to support the physical and mental wellbeing of our healthcare staff. The SAFE programme addresses these challenges by facilitating and enhancing the psychological safety of all who attend, which in turn extends out to the wider community. 

Ms Yvonne Young, Group Assistant Director of Nursing, University of Limerick Hospitals and member of the HSE national sepsis team, says that the SAFE programme makes it easier for healthcare workers to do the right thing. 

The Covid-19 pandemic has shown the importance of being proactive and prepared, as well as the need to support the physical and mental wellbeing of our healthcare staff 

“Two teams in University Hospital Limerick have just completed the SAFE programme with RCPI and a third ‘hospital at night’ team is due to commence. The two teams are comprised of multidisciplinary members working in high-risk areas of the emergency department and the acute surgical assessment unit where often the sickest patients present and department activity is extremely high and fast-paced. The SAFE programme has started the conversation about what we can do to enhance patient safety and make it easy for staff to work safely. 

“It is important we incorporate the science of human factors and make it easy for healthcare workers to do the right thing. It is the start of a new culture of anticipating risk and encouraging all members of a team of all grades to speak up about concerns or risks they see. Everyone’s voice is important. Situation awareness is the foundation for good clinical decision-making and will help more and more of our healthcare workers improve patient outcomes. The time the first two teams commenced married very well with the implementation of the INEWS across UL Hospitals Group, which emphasises the benefits of anticipating risk and situation awareness for patient safety. We know from looking at local case reviews, failures of situation awareness is a vital factor in the genesis of patient harm and we know how it is a core component of an effective deteriorating patient response system. 

“The teams who have completed the SAFE programme are able to tailor their safety huddles and safety pauses to their unique environment and we are looking forward to sharing the learning across the UHL site. SAFE is an exciting programme that gives access to tools, knowledge and skills and that is extremely valuable to all acute healthcare settings for reducing potential harm and increasing patient safety.” 

A crucial element of the programme is that it is person-centred and has both clinical and financial benefits. The subsequent decrease in avoidable harm will be the major return on our investment with less burnout amongst our healthcare workers and a lower cost to patient care. This will have long-term positive implications for the health of the people in Ireland. 

Applications will open in May 2022 for a September 2022 start. To register your team’s interest or for further information, please see the dedicated SAFE webpages or contact the QI Department at qualityimprovement@rcpi.ie