Implementing National Safety Standards for Invasive Procedures (NatSSIPs 2) at a national level: In conversation with Annie Hunningher and Claire Morgan

Summary

The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. In 2023 the standards were revised (NatSSIPs 2) with the Centre for Perioperative Care (CPOC), with a focus on bolstering of the organisational standards (people, processes and performance) in addition to the sequential steps that teams follow. The standards are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.

Patient Safety Learning spoke to Annie Hunningher and Claire Morgan about the changes to the revised NatSSIPs 2, how NatSSIPs 2 is being implemented and what more needs to be done to promote and engage leadership for action.

Content

What’s changed with NatSSIPs 2?

NatSSIPs 2 were published in January 2023 following consultation with over 30 bodies involved in delivering invasive healthcare. Invasive procedures in NatSSIPs 2 include not only surgery but also anywhere there is an incision or hole made in the patient’s body, and so delivers safety beyond traditional surgical areas and is an evolution of the original WHO surgical checklist. The standards apply not only in hospitals, but include all settings where invasive procedures are carried out, such as community, outpatient care, etc.

NatSSIPs were previously developed under the leadership of NHS England but now responsibility sits with the Centre of Perioperative Care (CPOC) which represents the four nations. CPOC is a cross-organisational, multidisciplinary initiative led by the Royal College of Anaesthetists to facilitate cross-organisational working in perioperative care for patient benefit. It is a partnership between patients and the public, other professional stakeholders, including NHS England and the equivalent bodies responsible for healthcare in the other UK-devolved nations. It also includes medical Royal Colleges and we are pleased to announce CPOC has recently also partnered with the Royal College of Surgeons of Edinburgh (RCSEd).

As well as updating the sequential standards that were in the original NatSSIPs (how a team can keep a patient in the pathway safe), NatSSIPs 2 now also has standards that the organisation needs to deliver to enable teams to deliver safe care. This is a significant change and includes a bigger focus around people, processes and performance – how we train people and have the infrastructure and processes around planning and scheduling in the delivery of safer procedures. It’s about understanding the role of the staff and who is needed.

There were patients involved in the NatSSIPs2 re-write and an important new section about involving patients – so that our patients understands what the checks are, why they are needed and how they can be engaged in speaking up and asking questions; for example, ‘why is there an arrow on my leg when you’re operating on my arm?’ Patient intervention and engagement can help patients be better informed and also could prevent significant avoidable harm. RCSEd particularly welcomes the increased focus on patient involvement, which reflects changes in patient safety both nationally and internationally, noting the theme for last year's WHO World Patient Safety Day on 17 September ‘Engaging patients for patient safety’.

Why was there a need for NatSSIPs 2?

The NatSSIPs 2 review team felt that the original NatSSIPs were quite burdensome to teams. Many organisations responded by developing their own Local Safety Standards for Invasive Procedures (LocSSIPs). Some of these became an endless trail of paperwork and policy changes without recognising how teams work and what makes teams effective. The relentless paper trail of audits meant the original intention had become slightly lost and this needed addressed as well as updating. The concepts around NatSSIPs 2 strengthen involving patients, a Safety II approach (learning from excellence and celebrating success) and a more proportionate (to risk) application of standards.

Invasive teams are highly professional and should be able to make judgments to ensure that they proportionately apply the standards. Teams should understand risk and the risk profile of certain situations. For example, if you’re doing a small case in an outpatient clinic, you’re not going to need to go through all of the eight steps in the original NatSSIPs in detail. But if you’re doing a cardiac transplant surgery you will need to. You can’t apply the same checks to every situation, and professionals should be able to adapt appropriate to the situation and an informed risk assessment.

Both the NatSSIPs documents have the need to standardise, to harmonise and to educate ('SHE’) because that reduces variability and increases reliability. What you find is in different parts of the hospitals and in different specialties, that different checks are going on in a different order, in different styles of language, with different people, and it’s about having a system and process that’s robust, clear and simple that people can use. It’s good safety science – you’re looking at standardising so you try and design out the opportunity for error and variation.

There’s a strong evidence-base for this approach. The WHO checklist came out in 2009 and there is lots of evidence for how it not only improves safety but also the whole team behaviours: communication, situational awareness, leadership and mutual support. The WHO checklist was one of the biggest interventions for safety globally but we’re now in 2024 and we, along with safety, are evolving. That’s why there are additions in the standards, based on our current approach to risk. It’s modernising the WHO checklist.

Although there are systems in place, people find workarounds and we need to recognise ‘work as done’. New things that have come into the revised NatSSIPs – learning from excellence, work as done, civility and the Patient Safety Incident Response Framework (PSIRF). In the past 8 years there has been huge advances in our understanding of safety science in healthcare. The 2015 NatSSIPs version was very much around root cause analysis, blame and ‘never event’ focused. Although never events are still looked at nationally, and are what trusts are required to investigate, there’s now a stronger emphasis on cultural change and a systems approach.

Demonstrating impact

We have wanted for a long time to focus on team working, systems and human factors and NatSSIPs 2 is doing this.

The next step is demonstrating the impact of it and that’s one of the things we are trying to do. We need to demonstrate the impact of moving away from individuals taking personal responsibility to a system responsibility. If you’re only measuring never events, you’re never going to demonstrate impact. Doing a research study and publishing it and demonstrating the benefits would be of global significance.

Implementation plans for NatSSIPs 2

There was a national survey on NatSSIPs 1 asking why it wasn’t implemented and the results showed that there hadn’t been enough spread and there hadn’t been an implementation plan because there wasn’t enough resources to develop or deliver it. Now that NatSSIPs 2 sits with CPOC rather than with NHS England, there should be less of a resource issue. We have been pushing for a NatSSIPs implementation plan and that it needs to be in education curriculums, examinations and inspections.

NatSSIPs 2 is a very detailed document but there is a long and a short version depending on people's needs. Some people want to know what exactly they need to do and why. It’s a specialist area where you need to understand the document and the organisational culture to be able to teach the standards. We’ve been promoting it through multidisciplinary team training (we’ve trained over 100 teams) and visits at various Trusts in the UK.

We use ‘NatSSIPs on a page’ with teams – it’s a good way of gauging where they were and is a strong measurement but it’s a lot of qualitative stuff too.

How should organisations review/assess NatSSIPs 2 and who should be doing it?

This should be done at all levels: self assessment by organisations themselves with peer review, the Care Quality Commission (CQC) and equivalent regulators in nations outside England, and during invited external safety reviews by organisations such as the Royal Colleges. Whoever is reviewing needs to know and understand NatSSIPs and be able to ask requestions related to the standards.

Self

• Similar to PSIRF, it’s about linking it to the quality improvement work and getting people involved, aligning it with the aims of the National Patient Safety Strategy: ‘Insight, Involvement and Improvement’. The actual insight here is really important to know where you are, then involving people and then planning for and doing the improvement. We’re adapting doing things differently at Barts Health. It’s workshops rather than PowerPoints. It’s getting people involved and getting people talking.
• The last course we ran locally was with our thoracic group and we used the NHS Scotland patient safety culture cards, which were brilliant. The whole point is involving staff and being able to facilitate the conversations around them and getting them to prioritise. What we like to see from these reviews is not an inspection, but to really understand how work is done. To talk to people, staff at ground level, and listen. More like an advisory visit that provides support, planting ideas for those at all staff grades for improvement. Its helpful to have improvement staff present who can help facilitate change ideas and support sustainability.

Peer review

• It would be good to have a review mechanism where the organisation doing the review would have their own staff but supplement it with strong expertise from other organisations that are doing it well. Invite someone in who has a knowledge expert who would support them not just in terms of reviewing but actually advising and being a kind of peer knowledge sharing.

Regulatory

• Some CQC inspectors hadn’t even heard of NatSSIPs so it’s hard for Trusts to implement it locally if the CQC aren’t interested in it. If they don’t know about NatSSIPs they won’t be asking the right questions.

Invited review

• The RCSEd along with other Royal Colleges carry out external safety reviews when invited by Trusts. The Terms of Reference for these are set by the inviting Trusts; however, it is a positive move to invite an external body into your Trust to review its safety profiles and work as done. NatSSIPs is certainly something that can be suggested and included in these invited reviews of safety.

Sharing the insight and learning within organisations and more widely

What happens after a safety visit? The expectation is that someone will come and do a safety visit and will pick up ideas for improvement but then what happens? We can tell an organisation what they need to sort out but then it’s over to them to do it. This then links to PSIRF, similar to a horizon scanning or a thematic analysis or review. Going in, finding out risk, suggesting improvements, and then it comes back to the organisation as to what happens next. If nothing happens it’s a complete waste of time. Some of the things identified will be for teams to address, but some things will be a bigger quality improvement project. How do you prioritise the improvements? There has to be an organisational response to sustain things. The best hospitals we’ve been to welcome the visit as they aren’t always looking for assurance. They want to raise their safety and quality.

It's like with any high performing, high reliability team. You don’t have a coach go in, do the training and then never see them again. It’s an ongoing relationship. If CQC goes in and sees good practice, what do they do with that? You sometimes get commendations in the report but other than the organisation inspected, who else will read it? How do you collate that evidence of good practice?

There needs to be a physical mechanism to capture that knowledge. There’s nothing specifically about NatSSIPs in the curriculum for younger beginners, trainees coming through and member students and those starting off in surgery. Getting it into undergraduate and postgraduate curriculum is critical but that all takes time. There’s a massive lag in publication of documents and books.

Getting leaders engaged in NatSSIPs

We need to show those at senior management and Board level how by applying NatSSIPs it can have an impact on other priorities. We need to make these links for them. For example, Trusts need to cut backlogs and waiting lists but leaders are not seeing the links – that an effective team following NatSSIPs 2 will not only be doing this safely but effective teams will also get more done. An infrastructure is required to deliver this and so having clear leadership as per the organisational standards is critical. Safety doesn’t happen by luck.

Civility is a golden thread. Research showing the link between sexual assaults and surgery shows team cultural issues. A team that behaves well will have less staff issues, better communication, situational awareness, be more professional and be more disciplined. The value of promoting this through the civility line is that this is not just addressing the delivery of surgery but it enables organisation to support and treat their staff well, minimise risk, push out poor behaviour, recognise collaboration and team work. The benefits are not only safer care but more effective team working, better collaboration, better culture. It shows leaders understand the pressure our staff are under. RCSEd strongly support members of The Working Party on Sexual Misconduct in Surgery (WPSMS) to raise awareness of sexual misconduct in surgery and to bring about cultural and organisational change ). RCSEds support has translated into their own recent campaign ‘Sexual Misconduct in Surgery – Lets Remove It’.

Next steps

• Increase awareness and understanding of NatSSIPs 2 at regulatory, trust and staff level – Board to ward.
• Ensure infrastructure and governance can deliver safety in invasive areas.
• Understand work as done and not work as imagined.
• Incorporate NatSSIPs 2 into regular team and human factors training.
• Insight, involvement and improvement that’s sustained across the NHS.

Take home message from Annie – “Make it personal”

Ask the question: If you or a member of your family are having surgery would you want these standards followed? They of course say yes. So why is it ok to cut corners and not follow the standards? Make it personal.

About the Author

Annie is the clinical lead author of NatSSIPs 2, a Consultant Anaethetist and Group Safety Lead at Barts Health. Claire sits on the Royal College of Surgeons of Edinburgh (RCSEd) Patient Safety Group and Consultant Restorative Dentist. Annie and Claire both work at Barts NHS Health Trust and are both Patient Safety Specialists.