5 February 2024

Patient safety – adopting a learning and improving approach

By Auzewell Chitewe, Associate Director of Quality Improvement 

Over the past year, the Director of Patient Safety, the Risk and Governance Team, the Legal team, nursing and medical leaders, adult mental health services in Bedfordshire & Luton, as well as the Associate Director of Quality Improvement, have been deploying quality improvement (QI) methods to enhance the development and delivery of the organization’s patient safety strategy.

Following sessions with staff, service users, and partner organizations, the strategy was constructed in the form of a Driver Diagram (see image below). Throughout this process, we’ve employed various QI tools, such as process mapping to understand the system, a driver diagram to visualize the theory of change, and a measurement system to track progress. These tools have not only helped identify key areas for improvement but also enabled us to start developing a safety management system. In addition, staff and service users who have attended QI training over the last three months have already benefited from how some aspects of safety science and human factors have been introduced in those training programs. QI coaches are also supporting other corporate-led safety improvement work such as the sharing learning from safety QI project, and the supporting staff after incidents QI project.

Going forward, specific focus areas to advance using the QI approach will centre on the application of the new Patient Safety Incident Reporting Framework (PSIRF) and on how we embed continuous learning and improvement across incidents throughout the Trust. An exciting next step is the initiation of a QI project across Bedfordshire and Luton adult mental health services to improve the incident response process, reduce variation in the quality of incident reports and refine the support offered to staff and families affected by incidents. The intention is to learn deeply in one place, then quickly scale up and spread the lessons to other directorates and as standard practice. This ongoing commitment to quality and safety, informed by continuous improvement, is a testament to the organization’s commitment to improving the experience of staff and service users affected by incidents.


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