The framework for measuring and monitoring safety

The framework consists of five ‘dimensions’ and associated questions that organisations, units or individuals can use to help understand the safety of their services. Used over time, this will help to give a rounded, accurate and ‘real time’ view of safety and will support efforts to identify those areas which present the greatest opportunity for safety improvement.

Figure 1: A framework for measuring and monitoring safety

Why does the NHS need a new approach?

A huge volume of data is currently collected on medical error and harm to patients. There have also been many tragic cases of health care failure, as well as a growing number of major reports on the need to make health care safer. However, despite this focus, the answer to the question ‘How safe is our care?’ remains elusive. This is illustrated in a number of ways:

  • Progress has been made to reduce the incidence of specific health care associated harms, such as MRSA and Clostridium difficile, but this does not tell us how safe people are today, just the degree to which they were affected by specific causes of harm in the past.
  • Increasingly sophisticated measures of mortality have been developed, but differences in methodology make comparisons over time very difficult.
  • There have been a number of successful, high profile national programmes to improve safety, such as Matching Michigan which aimed to reduce central line infections, but the different ways in which people collect data can make comparisons across units ‘almost meaningless’.

These issues demonstrate that individual organisations need to think carefully about how they can better understand the safety of their services, while balancing the requirements of regulators and external bodies.

One of the recommendations made by Don Berwick in his 2013 review into patient safety was that all NHS organisations should:

‘…routinely collect, analyse and respond to local measures that serve as early warning signals of quality and safety problems such as the voice of the patients and the staff, staffing levels, the reliability of critical processes and other quality metrics. These can be ‘smoke detectors’ as much as mortality rates are, and they can signal problems earlier than mortality rates do.’

The framework asks a series of open questions that can help to drive responsibility for measuring and monitoring safety to the front line, ensuring that measures are relevant to the local context, as well as the requirements of external bodies. The costs for NHS organisations to respond to nationally mandated data collection is high – around £300-£500 million a year – so it is vital that resources are used as effectively as possible.

How can the framework help?

As shown in Figure 1, the framework suggests five questions that can be asked by individuals, units, teams, departments and organisations across all health care settings – including primary, community, mental health and acute care. The questions are:

  • Past harm – Has patient care been safe in the past?
  • Reliability – Are our clinical systems and processes reliable?
  • Sensitivity to operations – Is care safe today?
  • Anticipation and preparedness – Will care be safe in the future?
  • Integration and learning – Are we responding and improving?

By using the framework and considering these questions, organisations and individuals will be able to understand and discuss more clearly what it means to be safe. The framework shifts the emphasis away from focusing solely on past cases of harm, and more on real-time performance and measures that relate to future risks and the resilience of organisations.


A promise to learn – a commitment to act.

** Challenging Bureaucracy. NHS Confederation, 2013.

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