Case Study: The NHS National Patient Safety Agency NPSA
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dme_ design management europe design management europe National Patient Safety Agency (NPSA) UK The NPSA case-study proves that design management is not restricted to design disciplines but is a creative management process to deliver problem solving activities. The NPSA was established in 2001 to co-ordinate the reporting of patient safety incidents and to learn from them and act in order to improve patient safety in the NHS. Around 60,000 incidents are reported every month covering a wide range of issues from the administration of the wrong medicines to the spread of healthcare associated infections. DME AWard 2008 SELECTION Winner NGO/ NPO category Learning from patient safety reports includes developing solutions that are practical and deliverable. To be effective they need to address the root causes of incidents and reflect the complexities of healthcare delivery and its environment. Dr Helen Glenister, Deputy Chief Executive of the NPSA, has championed the benefits of good design in the NHS and identified a seven step approach to developing safer practice solutions in the NHS. The stages in this problem solving process are identical to those in the design process, which is essentially a problem solving activity. The names of the stages are different but they work on the same principles to a designer interpretation: identifying the problem, generating ideas, assessing solutions, testing them and evaluation. The final deliverable is a reduction of the type of patient safety incident(s) being addressed. Members of the NPSA project team, clockwise; Professor David Cousins, Emma Boakes, Patricia
Transcript of Case Study: The NHS National Patient Safety Agency NPSA
The majority of patient safety incidents reported by community pharmacy involve selectionerrors (selecting the wrong dose or wrong drug during dispensing), which may be relatedto pack design. The NPSA, working with a large team of stakeholders, researched the issueand published guidelines for the design of medication packaging.
dme_des ign
management
europe
design
management
europe
National Patient Safety Agency (NPSA)UK
The NPSA case-study proves that design management is not restricted to design disciplinesbut is a creative management process to deliver problem solving activities.
The NPSA was established in 2001 to co-ordinate the reporting of patient safety incidentsand to learn from them and act in order to improve patient safety in the NHS. Around 60,000incidents are reported every month covering a wide range of issues from the administrationof the wrong medicines to the spread of healthcare associated infections.
page 2 | 3 page 3 | 3
Projects can last between a few weeks to two years. The NPSA would typically run 15 to20 large projects at one time; large projects would often involve a greater number ofstakeholders outside of the NPSA. No two problems are the same, and the make up of theteam and its solution can have a heavy bias to a design outcome or not, depending on thenature of the problem and the solution approved.
Work to date has included the cleanyourhands campaign to combat the spread of MRSAthrough promoting greater awareness amongst NHS staff of the importance of hand hygiene.
DME AWard2008 SELECTION
Winner NGO/ NPO category
Learning from patient safety reportsincludes developing solutions that arepractical and deliverable. To be effectivethey need to address the root causes ofincidents and reflect the complexities ofhealthcare delivery and its environment.Dr Helen Glenister, Deputy ChiefExecutive of the NPSA, has championedthe benefits of good design in the NHSand identified a seven step approach todeveloping safer practice solutions inthe NHS. The stages in this problemsolving process are identical to those inthe design process, which is essentiallya problem solving activity. The namesof the stages are different but they workon the same principles to a designerinterpretation: identifying the problem,generating ideas, assessing solutions,testing them and evaluation. The finaldeliverable is a reduction of the type ofpatient safety incident(s) beingaddressed.Members of the NPSA project team, clockwise;
Professor David Cousins, Emma Boakes, Patricia
Steps Activity1 Understand the problem
2 Identify potential solutions
3 Risk assess solutions
4 Pilot and learn
5 Implementation
6 Evaluation
7 Closing the loop
This is not about a team of trained designersworking on a wide range of projects but thesolution design process being used by adiverse range of disciplines working on arange of problems. The teams at the NPSAwho work on each solution are multi-disciplinary and design is one of therecognised professions represented. Allrelevant stakeholders are involved, includingnurses, surgeons, manufacturers,purchasers and universities. There is anlarge range of different disciplines within the
Stages in the patient safety solutiondevelopment process
Design guidelines have been produced to advise suppliers on how the NHS wishes theirproducts to be specified. Again the guidelines are set by a multi-disciplinary team of relevantstakeholders considering the problems caused by the products or equipment andrecommending solutions that are risk assessed and approved by them.
The NPSA has worked with partners such as The Helen Hamlyn Trust of the Royal Collegeof Art (RCA) to produce guidelines on medical devices, equipment and packaging.
The Medical Futures award-winning resuscitation trolley, in partnership with the RCA, wasthe result of a design study exercise addressing a number of problems associated with thislife saving equipment. A team of two designers from the RCA, a surgeon, an anaesthetist,nurses, a human factors engineer and the NPSA produced a three dimensional physicaldesign prototype. The clinical team played an important part at the start of the process byunderstanding the nature of the problem and analysing the work flow and processes ofemergency resuscitation. The design skills came in towards the end of the process.
Challenging RegulationsA characteristic of all innovative businessesand organisations is their need to challengethe regulations and standards that governtheir industry. The NPSA is a pioneer in anew approach to work with thepharmaceutical industry and regulators topush for improvements in medicationp a c k a g in g . Un t i l r e c e n t l y t h epharmaceutical pack design was primarilyinfluenced by regulatory requirements,rather than ease of use or patient safety.
The guidelines provide more detailed directionon the design of packaging to improve ease ofuse and safety, in addition to that required bythe regulations. In order to implement theseguidelines they promoted the government agendaof ‘purchasing for safety’, rather than the slowand expensive regulatory route.Some of the pharmaceutical companieswelcomed these changes, realising they couldcompete on specification as well as price andembraced the changes, realising that the regulatoris not the customer.
“The gap between what we want and what the regulations want is filled with design solutions.”- Professor David Cousins, NPSA
Manufacturers have realised there is more todesign than meeting regulatory requirements.Although design is not the sole activity of theNPSA, they employ the design process to a highlevel that many professional designers and
manufacturers will never achieve. They will put together the best team of stakeholders toresearch a problem thoroughly with evidence-based research; analyse possible solutionsthrough risk assessment; carefully test and evaluate user interaction; measure the affectof the solutions and review them.
The majority of patient safety incidents reported by community pharmacy involve selectionerrors (selecting the wrong dose or wrong drug during dispensing), which may be relatedto pack design. The NPSA, working with a large team of stakeholders, researched the issueand published guidelines for the design of medication packaging.
design
management
europe
National Patient Safety Agency (NPSA)UK
The NPSA case-study proves that design management is not restricted to design disciplinesbut is a creative management process to deliver problem solving activities.
The NPSA was established in 2001 to co-ordinate the reporting of patient safety incidentsand to learn from them and act in order to improve patient safety in the NHS. Around 60,000incidents are reported every month covering a wide range of issues from the administrationof the wrong medicines to the spread of healthcare associated infections.
dme_des ign
management
europe
dme_design
management
europe page 2 | 3 page 3 | 3
Projects can last between a few weeks to two years. The NPSA would typically run 15 to20 large projects at one time; large projects would often involve a greater number ofstakeholders outside of the NPSA. No two problems are the same, and the make up of theteam and its solution can have a heavy bias to a design outcome or not, depending on thenature of the problem and the solution approved.
Work to date has included the cleanyourhands campaign to combat the spread of MRSAthrough promoting greater awareness amongst NHS staff of the importance of hand hygiene.
DME AWard2008 SELECTION
Winner NGO/ NPO category
Learni ng from patient safety reportsincludes developing solutions that arepractical and deliverable. To be effectivethey need to address the root causes ofincidents and reflect the complexities ofhealthcare delivery and its environment.Dr Helen Glenister, Deputy ChiefExecutive of the NPSA, has championedthe benefits of good design in the NHSand identified a seven step approach todeveloping safer practice solutions inthe NHS. The stages in this problemsolving process are identical to those inthe design process, which is essentiallya problem solving activity. The namesof the stages are different but they workon the same principles to a designerinterpretation: identifying the problem,generating ideas, assessing solutions,testing them and evaluation. The finaldeliverable is a reduction of the type ofpatient safety incident(s) beingaddressed.Members of the NPSA project team, clockwise;
Professor David Cousins, Emma Boakes, Patricia
Steps Activity1 Understand the problem
2 Identify potential solutions
3 Risk assess solutions
4 Pilot and learn
5 Implementation
6 Evaluation
7 Closing the loop
This is not about a team of trained designersworking on a wide range of projects but thesolution design process being used by adiverse range of disciplines working on arange of problems. The teams at the NPSAwho work on each solution are multi-disciplinary and design is one of therecognised professions represented. Allrelevant stakeholders are involved, includingnurses, surgeons, manufacturers,purchasers and universities. There is anlarge range of different disciplines within the
Stages in the patient safety solutiondevelopment process
Design guidelines have been produced to advise suppliers on how the NHS wishes theirproducts to be specified. Again the guidelines are set by a multi-disciplinary team of relevantstakeholders considering the problems caused by the products or equipment andrecommending solutions that are risk assessed and approved by them.
The NPSA has worked with partners such as The Helen Hamlyn Trust of the Royal Collegeof Art (RCA) to produce guidelines on medical devices, equipment and packaging.
The Medical Futures award-winning resuscitation trolley, in partnership with the RCA, wasthe result of a design study exercise addressing a number of problems associated with thislife saving equipment. A team of two designers from the RCA, a surgeon, an anaesthetist,nurses, a human factors engineer and the NPSA produced a three dimensional physicaldesign prototype. The clinical team played an important part at the start of the process byunderstanding the nature of the problem and analysing the work flow and processes ofemergency resuscitation. The design skills came in towards the end of the process.
Challenging RegulationsA characteristic of all innovative businessesand organisations is their need to challengethe regulations and standards that governtheir industry. The NPSA is a pioneer in anew approach to work with thepharmaceutical industry and regulators topush for improvements in medicationp a c k a g in g . Un t i l r e c e n t l y t h epharmaceutical pack design was primarilyinfluenced by regulatory requirements,rather than ease of use or patient safety.
The guidelines provide more detailed directionon the design of packaging to improve ease ofuse and safety, in addition to that required bythe regulations. In order to implement theseguidelines they promoted the government agendaof ‘purchasing for safety’, rather than the slowand expensive regulatory route.Some of the pharmaceutical companieswelcomed these changes, realising they couldcompete on specification as well as price andembraced the changes, realising that the regulatoris not the customer.
“The gap between what we want and what the regulations want is filled with design solutions.”- Professor David Cousins, NPSA
Manufacturers have realised there is more todesign than meeting regulatory requirements.Although design is not the sole activity of theNPSA, they employ the design process to a highlevel that many professional designers and
manufacturers will never achieve. They will put together the best team of stakeholders toresearch a problem thoroughly with evidence-based research; analyse possible solutionsthrough risk assessment; carefully test and evaluate user interaction; measure the affectof the solutions and review them.
The majority of patient safety incidents reported by community pharmacy involve selectionerrors (selecting the wrong dose or wrong drug during dispensing), which may be relatedto pack design. The NPSA, working with a large team of stakeholders, researched the issueand published guidelines for the design of medication packaging.
design
management
europe
National Patient Safety Agency (NPSA)UK
The NPSA case-study proves that design management is not restricted to design disciplinesbut is a creative management process to deliver problem solving activities.
The NPSA was established in 2001 to co-ordinate the reporting of patient safety incidentsand to learn from them and act in order to improve patient safety in the NHS. Around 60,000incidents are reported every month covering a wide range of issues from the administrationof the wrong medicines to the spread of healthcare associated infections.
page 2 | 3
dme_des ign
management
europe
dme_design
management
europe page 3 | 3
Projects can last between a few weeks to two years. The NPSA would typically run 15 to20 large projects at one time; large projects would often involve a greater number ofstakeholders outside of the NPSA. No two problems are the same, and the make up of theteam and its solution can have a heavy bias to a design outcome or not, depending on thenature of the problem and the solution approved.
Work to date has included the cleanyourhands campaign to combat the spread of MRSAthrough promoting greater awareness amongst NHS staff of the importance of hand hygiene.
DME AWard2008 SELECTION
Winner NGO/ NPO category
Learni ng from patient safety reportsincludes developing solutions that arepractical and deliverable. To be effectivethey need to address the root causes ofincidents and reflect the complexities ofhealthcare delivery and its environment.Dr Helen Glenister, Deputy ChiefExecutive of the NPSA, has championedthe benefits of good design in the NHSand identified a seven step approach todeveloping safer practice solutions inthe NHS. The stages in this problemsolving process are identical to those inthe design process, which is essentiallya problem solving activity. The namesof the stages are different but they workon the same principles to a designerinterpretation: identifying the problem,generating ideas, assessing solutions,testing them and evaluation. The finaldeliverable is a reduction of the type ofpatient safety incident(s) beingaddressed.Members of the NPSA project team, clockwise;
Professor David Cousins, Emma Boakes, Patricia
Steps Activity1 Understand the problem
2 Identify potential solutions
3 Risk assess solutions
4 Pilot and learn
5 Implementation
6 Evaluation
7 Closing the loop
This is not about a team of trained designersworking on a wide range of projects but thesolution design process being used by adiverse range of disciplines working on arange of problems. The teams at the NPSAwho work on each solution are multi-disciplinary and design is one of therecogni sed profe ssions represented . Allrelevant stakeholders are involved, includingnurses, surgeons, manufacturers,purchasers and universities. There is anlarge range of different disciplines within the
Stages in the patient safety solutiondevelopment process
Design guidelines have been produced to advise suppliers on how the NHS wishes theirproducts to be specified. Again the guidelines are set by a multi-disciplinary team of relevantstakeholders considering the problems caused by the products or equipment andrecommending solutions that are risk assessed and approved by them.
The NPSA has worked with partners such as The Helen Hamlyn Trust of the Royal Collegeof Art (RCA) to produce guidelines on medical devices, equipment and packaging.
The Medical Futures award-winning resuscitation trolley, in partnership with the RCA, wasthe result of a design study exercise addressing a number of problems associated with thislife saving equipment. A team of two designers from the RCA, a surgeon, an anaesthetist,nurses, a human factors engineer and the NPSA produced a three dimensional physicaldesign prototype. The clinical team played an important part at the start of the process byunderstanding the nature of the problem and analysing the work flow and processes ofemergency resusc itation. The design skills came in towards the end of the process.
Challenging RegulationsA characteristic of all innovative businessesand organisations is their need to challengethe regulations and standards that governtheir industry. The NPSA is a pioneer in anew approach to work with thepharmaceutical industry and regulators topush for improvements in medicationp a c k a g in g . Un t i l r e c e n t l y t h epharmaceutical pack design was primarilyinfluenced by regulatory requirements,rather than ease of use or patient safety.
The guidelines provide more detailed directionon the design of packaging to improve ease ofuse and safety, in addition to that required bythe regulations. In order to implement theseguidelines they promoted the government agendaof ‘purchasing for safety’, rather than the slowand expensive regulatory route.Some of the pharmaceutical companieswelcomed these changes, realising they couldcompete on specification as well as price andembraced the changes, realising that the regulatoris not the customer.
“The gap between what we want and what the regulations want is filled with design solutions.”- Professor David Cousins, NPSA
Manufacturers have realised there is more todesign than meeting regulatory requirements.Although design is not the sole activity of theNPSA, they employ the design process to a highlevel that many professional designers and
manufacturers will never achieve. They will put together the best team of stakeholders toresearch a problem thoroughly with evidence-based research; analyse possible solutionsthrough risk assessment; carefully test and evaluate user interaction; measure the affectof the solutions and review them.
