Improving the Safety of Community Services 
Patient Safety in Community Services Programme

Expert Reference Panel Meeting

Tuesday 9th June 2009

Hilton Birmingham Metropole


The Improvement Foundation has been commissioned by the Health Foundation to run an improvement programme to improve the safety of community services in initially one SHA area.


Dr Lyon GP outlined the first stage of the project, which is to bring experts and professionals together to form an Expert Reference Panel to identify key issues and strategies.  The panel will take the learning from a range of case studies and innovative practice from across the country together with the Improvement Foundation's tried and tested improvement methodology to identify key principles for change.  The key outcomes will then inform the support offered to participating organisations.


The methods employed bring together the systematic transfer of knowledge, the creation of an environment that facilitates the uptake of ideas and an infrastructure for spread, resulting in large system change.


There are three fundamental questions to apply in the development of the reference panel.  They are:


-         What are we trying to trying to accomplish?

-        How will we know that a change has led to improvement?

-        What changes can we make that will result in an improvement?


Annette Bartley, Programme Director, Institute for Healthcare Improvement & Health Foundation gave an overview of progress with the Safer Patients Initiative.


Around 16 million people are admitted to hospital each year in the UK. The majority are treated safely and successfully. However, a disturbingly high number will find that something goes wrong with their treatment or care, resulting in unnecessary harm, pain and suffering, sometimes leading to death. Estimates suggest that one in ten patients in hospital experiences an incident which puts their safety at risk, and that about half of these could have been prevented. The Health Foundation's Safer Patients Initiative was set up to address this problem and find ways of making hospitals safer for patients. The Safer Patients Initiative (SPI) has been run in two phases - the first starting in 2004 and including four hospitals, the second starting in 2006 and including 20 hospitals


The first four sites are following a programme designed by IHI for the Safer Patients Initiative, which works on three levels:


-         addressing five clinical areas, each containing multiple interventions that have an established and accepted evidence base in the UK (such as better management of patients in intensive care, infection control, preventative antibiotics for surgery and medicines safety)

-        teaching methods for quality and safety improvement

-        establishing a specific role for the chief executives and senior executive team.


The second tranche of 20 hospitals are developing their expertise to drive forward system-wide improvements so that unintended harm, errors or mistakes are less likely to happen. The initiative will test out ways of making care safer in three areas of the hospital - on the wards, before, during and after operations and in critical care. In each of these settings staff will look at ways to improve infection control, the management of drugs and communication between staff teams and patients.  Chris Sides, Associate Medical Director, Bradford Royal Infirmary, presented examples of how they had implemented safety briefings and reduced the use of cannula and had demonstrated a significant reduction in adverse events as a result of the interventions used.


Breakout sessions followed the presentations where patient safety issues, and expertise in

Community Services, Community Hospitals and General Practice were aired and shared. Some practical ideas and good practice were discussed and the next steps will be to draw from the day agreed criteria that will be of the most benefit to drive the culture of safety in the community healthcare setting.  

If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at