A SAFE approach to awareness and safety in hospitals

As the fourth round of the Situation Awareness for Everyone (SAFE) collaborative is launched, Lead of the Quality Improvement Faculty, RCPI, and former CEO of the International Society for Quality in Healthcare, Dr Peter Lachman, discusses the methodology of the programme and how it complements the Irish National Early Warning System

The HSE National Deteriorating Patient Improvement Programme (DPIP), supported by the Office of Nursing and Midwifery Services Director (ONMSD), has generously funded the most recently graduated cohort of 13 adult and maternity frontline teams who undertook the Situation Awareness for Everyone (SAFE) programme. The RCPI is delighted to announce a further funding partnership with DPIP and ONMSD to cover the 2021-22 SAFE course fee for up to 13 teams with recruitment underway.

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 recent Irish National Adverse Events (INAES) study reported that the level of harm in the Irish health system is unchanged from the previous report, despite some progress in many areas, particularly in the decrease in hospital-acquired infections.

Across the Irish healthcare system, there is evidence of a strong commitment to improving the quality of care, seen in the many and various improvement initiatives being undertaken by frontline teams and at group, organisation and system level. Improving quality and safety is the responsibility of all who work in healthcare, and healthcare providers need to know how to deliver safe care based on the science of patient safety. The RCPI is committed to providing tailored education and training to empower those working in healthcare to achieve real and sustained improvements and better outcomes for patients and staff.

The SAFE quality improvement (QI) collaborative offered by RCPI to frontline clinical staff is one such training programme. SAFE brings multidisciplinary teams together with expert faculty, patient representatives and peers to explore patient safety risks and potential harms in a clinical system; and develop and implement bespoke patient safety interventions using QI methods to enhance safe and person-centred car, which are core values of the HSE framework for improving quality.

An updated version of the Irish National Early Warning System (INEWS) was published by the DPIP in 2020. The updated guidelines see a move towards an anticipatory approach to the management of clinically deteriorating patients. An anticipatory approach to care acknowledges the vulnerability of patients with ‘no’ or ‘low’ INEWS scores.

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. To facilitate the sharing of information, the use of safety huddles and other communication tools to enhance patient safety is strongly advocated.

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 has to be a priority for us all.

Dr Geraldine Shaw, Nursing and Midwifery Services Director, Office of the Nursing and Midwifery Services Director

The SAFE Intervention

Patient safety is a complex process and needs to incorporate many different theories and methodologies. The SAFE programme empowers teams to proactively manage safety in their clinical teams and settings. The SAFE programme has a strong theoretical basis and aims to address the challenges of working in a complex adaptive system. It is strongly based on work in Cincinnati Children’s Hospital Medical Centre, US, and the latest theories in patient safety. Learning is borrowed from other high reliability industries with a focus on investment in teamwork and the development of proactive safe systems with a strong foundation in psychological safety.

SAFE was developed by a team at the Royal College of Paediatrics and Child Health, led by this author and funded by the Health Foundation. The programme was introduced in over 50 hospitals, with paediatric teams. In Ireland, the programme was tested and introduced on 20 children’s and neonatal wards across the country with demonstrable improvements in how teams worked together. In Cork University Hospital, there were decreased transfers to the ICU which also reflected the data from hospitals in the UK.

The success of the safety huddle in Cork University Hospital has resulted in CUH leading an application and successfully obtaining funding from 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 patent safety, communication and healthcare simulation. The study is currently underway.

Dr Dorothy Breen, Consultant in Intensive Care and Clinical Lead for Quality, Cork University Hospital

The SAFE programme aims to develop safer clinical systems which will have an impact on safety, person-centred care and ultimately on the cost of healthcare itself. The Covid-19 pandemic demonstrated the lack of preparedness in clinical systems. It also demonstrated the need to pay attention to healthcare worker physical and mental wellbeing. The SAFE programme addresses these deficiencies by attending to both the psychological and physical safety of staff and the people for whom they care.

Four people from obstetrics and midwifery at the Rotunda Hospital were delighted to get involved with the SAFE programme. Optimising patient safety is a key priority for everyone in healthcare, especially in obstetrics and midwifery where the consequences of unsafe systems can be devastating for patients and staff alike.

Working in a hospital built in the 1750s, where capacity and infrastructure frequently fall short of ideal, can be frustrating. It is easy to become preoccupied by failure. The SAFE programme provided us with a firm foundation in the science of patient safety acknowledging how it can be difficult to feel safe in complex systems, but focusing on safety being the ability to sustain required operations under expected and unexpected conditions (with ‘unexpected events’ being very common in the work we do.). The programme emphasised the role of anticipation in preventing harm.

Armed with this knowledge, we introduced a multidisciplinary, interdepartmental safety huddle. The aim was to improve safety by facilitating communication within and between hospital teams. This has proven to be popular and effective even more so when we had to adapt to unexpected challenges including building works, Covid surges and the recent HSE cyber hack. This initiative has enhanced our understanding of situational awareness, emphasising the importance of enabling all staff to recognise elements of their environment that may affect patient care, and supporting them to respond or escalate appropriately in order to mitigate risk.

Dr Maeve Eogan, Consultant in Obstetrics and Gynaecology, Rotunda Hospital

Another participant on the SAFE Programme was Dr Julie Lucey, Consultant Paediatrician with a special interest in Infectious Diseases, University Hospital Waterford

What’s the point of Situation Awareness for Everyone? In the case of a busy paediatric department, the whole idea is to reduce risk and reduce harm to patients. On the opening day, the course director alluded to Hudson’s safety culture ladder of five levels; pathological, reactive, calculative, proactive, and generative. Like most other teams in the room that day, we placed our organisation in the ‘reactive’ category, where safety becomes a priority after an accident. What would we have to do to move into a culture where we could say ‘Safety is how we do business here’.

We were given our task of introducing a daily huddle on our ward to highlight safety concerns on that given day.
We perceive the huddle as a positive move towards delivery of quality care to our young patients. Two years on, it is embedded in our day-to-day ward activity. Nursing staff believe that their concerns are being heard in a timely manner. It has promoted better communication and goodwill among staff in general. We are also more cognisant of our patients’ and parents’ opinions through regular surveying of our inpatients and their families.

Investment

A crucial element of the programme is that it has clinical, person-centred and financial benefits. There will be a return on investment that will have long-term positive implications for the health of people in Ireland.
The outcomes that teams have seen include reduction of avoidable error and harm to the acutely unwell, improvement of communication between all involved in an individual’s care, and improvement in the working culture for healthcare staff providing care.

For further information, please see the dedicated SAFE webpage (www.rcpi.ie/news/releases/situation-awareness-for-everyone-safe-collaborative/) or contact the RCPI QI Department at qualityimprovement@rcpi.ie