Assistant Professor, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK.
Associate Professor, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK.
J Health Serv Res Policy. 2021 Oct;26(4):263-271. doi: 10.1177/13558196211010850. Epub 2021 Apr 25.
In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development.
A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon's Multiple Streams Approach was used to frame the policymaking process.
The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a 'policy window.' Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as 'policy entrepreneurs,' recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them.
The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.
近年来，英国出现了大量的患者安全政策，这些政策是由医疗保健方面广为人知的失败引发的。学习死亡（LfD）政策是针对南方健康国民保健制度（NHS）基金会信托的失败而实施的。本研究旨在制定一个叙述，以使人们能够理解其演变的关键驱动因素及其对未来国家患者安全政策制定的影响。
采用定性研究方法，对参与 LfD 系统设计、实施和保证的组织的政策制定者进行了文件分析和半结构化访谈（n=12）。采用金登的多流方法来构建决策过程。
南方健康独立审查的发表以及随后护理质量委员会强调 NHS 从死亡中学习的方法分散，打开了“政策窗口”。在受患者安全失败影响的家庭和当时的国务卿的影响下，作为“政策企业家”，最近开发的死亡率审查方法与提高透明度和治理的机制相结合。这迅速创建了一个框架，旨在确保 NHS 组织确定补救安全问题，并能够负责解决这些问题。
LfD 的发展与 NHS 中的其他患者安全政策具有几个共同特征。它是由危机引发的，需要迅速的政治反应，并试图解决与安全相关的一系列问题。与其他安全政策一样，LfD 存在与其主要目的相关的内在紧张关系，这可能会阻碍其影响。在没有对这些政策进行正式评估的情况下，对决策过程的更深入了解有可能确定实现目标的潜在障碍。
