The National Patient Safety Improvement Programmes

The National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system.


Contents

How patient safety improvement programmes work

National Patient Safety Improvement Programmes (SIPs) are a key part of the NHS Patient Safety Strategy, launched in July 2019 and recently updated in February 2021, to deliver safety and quality improvements across the NHS in England. They are managed and led by our National Patient Safety Team.

SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes.

SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives (PSCs – see PSC section below).

The SIPs support continuous and sustainable improvement through:

  • Culture: they promote positive safety culture, encouraging staff to gain insight and share learning from good and poor practice
  • Evidence-based improvement: they support evidence-based, quality improvement (QI) methodology, ensuring change is consistently measured and evaluated
  • Quality improvement (QI) capability: they grow QI capability in trusts and local healthcare systems so they can continue to improve
  • System-level change: they enable regional and local health systems to identify improvement priorities and share learning.

National Patient Safety Improvement Programme

The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows:

Managing Deterioration Safety Improvement Programme (ManDetSIP)

The aim of the Managing Deterioration Safety Improvement Programme is to reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care.

ManDetSIP focuses on managing deterioration at a system-wide level across both health and social care through Managing Deterioration Networks and Care Homes Patient Safety Networks.

ManDetSIP key ambitions are as follows:

  • To support the spread and adoption of the COVID Oximetry@home remote monitoring model across England by March 2021. The primary focus of responding to physical deterioration in relation to COVID-19 has been support for the national implementation of both the NHS COVID-19 Oximetry@home remote monitoring model and the COVID-19 Virtual Ward model.
  • To support the spread and adoption of the acute Paediatric Early Warning Score (PEWS) and a system-wide paediatric observations tracker for children across all appropriate care settings in England by March 2024.
  • To support an increase in the spread and adoption of deterioration management tools (e.g. NEWS2, RESTORE2, RESTORE2 mini, SBARD etc.), reliable personalised care and support planning (PCSP), and approaches encompassing end of life care principles, to support learning disabilities, mental health and dementia care management in relation to deterioration in at least 80% of all appropriate non-acute settings across health and social care by March 2024.

Maternity and Neonatal Safety Improvement Programme (MatNeoSIP)

The Maternity and Neonatal Safety Improvement Programme has contributed to the national improvement ambition through a range of key activities working with all 134 maternity and neonatal providers in England. The MatNeoSIP team has supported each trust to focus on a range of key improvement projects aligned to the national ambition.

Through a series of national learning sets the team has:

  • trained over 800 healthcare professionals in improvement science
  • developed a mature improvement architecture across the country involving all of the relevant network partners (including the 44 local maternity systems, 15 patient safety collaboratives, the 12 maternity clinical networks and the 10 neonatal networks). This support built the ability and resource across the country for organisations and teams to both undertake and develop improvement projects within their own organisations.

MatNeoSIP aims to:

  • contribute to the national target of increasing the proportion of smoke-free pregnancies to 94% or greater by March 2023
  • to support the spread and adoption of the preterm perinatal optimisation care pathway across England by 95% or greater by March 2025
  • improve the early recognition and management of deterioration of women and babies
  • to support the development of a national pathway approach for the effective management of maternal and neonatal deterioration using the PIER framework across all settings by March 2024
  • to work with key stakeholders to support the development of a national maternal early warning score (MEWS) by March 2021 and spread to all providers by March 2024
  • to support the spread and adoption of the neonatal early warning ‘trigger and track’ score (NEWTT) to all maternity and neonatal services by March 2023.

MatNeoSIP builds on the work of the Maternal and Neonatal Health Safety Collaborative, a three-year programme, launched in February 2017.

Medicines Safety Improvement Programme (MedSIP)

The Medicines Safety Improvement Programme (MedSIP) addresses the most important causes of severe harm associated with medicines, most of which have been known about for years but continue to challenge the health and care systems in England.

The key ambitions for MedSIP are as follows:

  • to reduce medicine administration errors in care homes by 50% by March 2024
  • to reduce harm from opioid medicines by reducing high dose prescribing (>120mg oral Morphine equivalent), for non-cancer pain by 50%, by March 2024
  • to reduce harm by reducing the prescription and supply of oral methotrexate 10mg by 50%, by October 2021.

The MedSIP programme has contributions from across NHS England and NHS Improvement. Key delivery partners are the Patient Safety Collaboratives and the networks of Medication Safety Officers. Working together, the programme supports  a set of projects linked to the evidence base on medication errors, and the NHS Long Term Plan; these include the safety of prescribing of opioid painkillers, anticoagulants (blood thinners) and problematic combinations of medicines. Projects also improve the safety of systems such as electronic prescribing, care after discharge from hospital and the administration of medicines in care homes.

Adoption and Spread Safety Improvement Programme (A&S-SIP)

The aim of the Adoption and Spread Safety Improvement Programme (A&S-SIP)  is to identify and support the adoption and spread of effective and safe evidence-based interventions and practice across England by March 2022.

The A&S-SIP key ambitions are as follows:

  • to support an increase in the proportion of patients in acute hospitals receiving every element for which they are eligible of the BTS COPD discharge care bundle to 80% by March 2022
  • to support an increase in the proportion of eligible sites (i.e. acute hospitals in England that care for patients with tracheostomies) adopting three evidence-based tracheostomy safety interventions (bedhead signs, availability of emergency equipment, daily care bundle) to 90% by March 2021
  • from April 2021, to support an increase in the proportion of patients in acute hospitals receiving every element for which they are eligible of the asthma discharge care bundle to 80% by March 2023
  • from April 2021, to support an increase in the proportion of patients receiving all elements for which they are eligible of the emergency laparotomy care bundle to 90% by October 2022.

The Mental Health Safety Improvement Programme (MH-SIP)

The aim of the Mental Health Safety Improvement Programme (MH-SIP) is to improve the safety and outcomes of mental health care by reducing unwarranted variation and providing a high-quality healthcare experience for all people across the system by March 2024.

MH-SIP is working with the National Collaborating Centre for Mental Health (NCCMH) and Mental Health Patient Safety Networks (which are supported by Patient Safety Collaboratives), and will focus on improving patient safety for those who use inpatient mental health and learning disability services, including staff in health care settings, via the following programme topics:

  • Reduce suicide and self-harm in inpatient mental health services, the healthcare workforce and non-mental health acute settings.
  • Reducing the incidence of restrictive practice in inpatient mental health and learning disability services by 50% by March 2024.
  • Improve the sexual safety of patients and staff on inpatient mental health units and within learning disability services by 50% above baseline by March 2024.

Patient Safety Collaboratives

The national patient safety improvement programmes build on the work of the 15 regionally based Patient Safety Collaboratives (PSCs) and the Patient Safety Collaborative programme, which was established in 2014. The PSCs continue to support delivery of the programmes.

PSCs are made up of the NHS providers and commissioners in a geographical region. They include hospitals, community, primary care, mental health and ambulance services and clinical commissioning groups.

PSCs are each hosted by one of 15 regionally based Academic Health Science Networks (AHSNs). AHSNs are made up of NHS staff, patients, carers, academics, quality improvement and safety experts.

The National Patient Safety Team commissions AHSNs to deliver improvement support through the PSCs and leads on the commissioning and assurance process.

Case studies

The national safety improvement programmes build on the work of the 15 regionally based Patient Safety Collaboratives. Here are some examples of their success:

Get involved

Email patientsafety.enquiries@nhs.net for more information on our patient safety improvement programmes, or visit each programmes’ FutureNHS Collaboration page:

For more information on Patient Safety Collaboratives (PSCs) or to get involved in patient safety improvement where you live or work, please contact the Academic Health Science Network (AHSN) that covers your area. PSCs and AHSNs cover the same areas. A link to each AHSN website is listed below.

Background to our work

The 2013 Francis Report that examined failings in care at Mid Staffordshire NHS Foundation Trust, triggered a need to understand how the whole NHS system could improve further. Professor Don Berwick, a leading expert in global healthcare improvement, was asked to look at whether we could ‘make zero harm a reality’ and what could be done to achieve a continual reduction in harm over time.

The report published by the national advisory group led by Don Berwick, A promise to learn – a commitment to act (2013) made a series of recommendations to improve patient safety. The national Patient Safety Collaborative programme was created to support the call for ‘the NHS to become a system devoted to continual learning and improvement’ in order to make care safer for all’.

  • Patient Safety Collaboratives– In 2018 we commissioned a review of the operational delivery and impact of the Patient Safety Collaborative programme. This report gives its findings and recommendations to strengthen the programme, including greater collective focus on priority workstreams and alignment. The review findings were subsequently incorporated into the NHS Patient Safety Strategy, published in July 2019.