Recommendation 41

Reviewing non-compliance with patient safety alerts

Accepted in principle
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency’s functions in June 2012 to the NHS Commissioning Board.

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.

Update

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.