Use of information about compliance by regulator from: Patient safety alerts

Accepted in principle.
The Care Quality Commission already monitors compliance with patient safety alerts, such as those issued by the Medicines and Healthcare products Regulatory Agency, and is able to investigate further where it identifies the need to do so in order to hold providers to account for failures to act on them. The Care Quality Commission is currently exploring how it can give greater prominence to safety alerts in its revised surveillance and inspection model. However care is needed to be clear that providers retain accountability for implementing patient safety alerts. It is not the Care Quality Commission’s role to oversee providers’ individual decisions or actions. Providers must be able to explain and account for how they act on safety alerts; the Care Quality Commission’s role will be to assess their capability and performance in terms of whether it results in good quality care.
NHS England is developing proposals for a new system of safety alerts, and, to strengthen the ability to monitor alerts and compliance with them, the Care Quality Commission is closely involved in that work. The role of regulation is integrated into an overall approach that allows for both safety improvement and accountability.

Led by NHS England, there is now a redesigned system for National Patient Safety Alerts. Each alert includes reference to the fact that failure to take the actions required may lead to CQC taking regulatory action. CQC uses indicators on declared compliance with alerts in their assessments. See the response to recommendation 35 for information on how regulators work together, and the current regulatory landscape.

Patient safety alerting

NHS England currently issues alerts as ‘National Patient Safety Alerts’ and is accredited by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards, which include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions to reduce the risk of death or disability.

NaPSAC requires healthcare providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, and must include executive oversight.

Each NatPSA includes reference to the fact that failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action. CQC uses indicators on declared compliance with alerts in their assessments.

The Learn from Patient Safety Events (LFPSE) service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. This replaced the National Reporting and Learning System.

The Care Quality Commission is giving greater prominence to safety alerts in its revised surveillance model. The Care Quality Commission’s NHS acute Intelligent Monitoring system includes a composite indicator around completion of safety alerts which contributes to providers’ risk scores.

The Care Quality Commission is continuing to develop its approach to the use of data and intelligence, including the role of safety alerts, across all the sectors it regulates, both to inform risk identification and to support and test inspection findings, as an integral part of its new regulatory approach

Providers are expected to retain accountability for implementing patient safety alerts while demonstrating safety improvement and learning in order to give safety alerts more prominence in the inspection model.

The Government accepted this recommendation in principle.

In the January 2014 Hard Truths report, the Government said that the Care Quality Commission was giving greater prominence to safety alerts in its revised surveillance model, with the Intelligent Monitoring system including a composite indicator around completion of safety alerts which contributed to providers’ risk scores.

However, the Government said that care was needed to be clear that providers retained accountability for implementing patient safety alerts, with it not being the Care Quality Commission’s role to oversee their individual decisions or actions.