Stephen Ramsden on punitive processes

The current regulatory frameworks certainly have an image problem. Many people in the service see regulation as externally imposed, concentrating only on minimum standards and scrutinising processes rather than outcomes, which leads to a bureaucratic paper chase. This is compounded by the sense that there are a number of competing regulators, with a multitude of inspections, and the whole process seems punitive.

This is not to argue that there is no place for regulation. It is right for everyone in a national health service to meet minimum standards. National standards, set centrally and applied through the regulators, have undoubtedly driven up performance.

At a recent Institute for Healthcare Improvement conference, I was inspired by the approach of some of the best US hospitals to transforming patient safety. They seem to be light years ahead of us.

Transformational goals

At Ascension Health they are aiming for "no preventable injuries or deaths in five years". Since 2003 non-profit providers has avoided 2,395 deaths and is close to achieving its goal by this summer. Can any NHS hospital even measure the lives it has saved or the harm it has avoided, let alone set such an ambitious transformational goal?

Ascension's approach combines determination to meet the external regulatory goals with absolute focus on developing a safety culture, with all staff motivated to participate in an ambitious improvement programme.

The recent focus by all political parties on fining trusts for healthcare-acquired infections mirrors what is happening in the US. The Centers for Medicare and Medicaid Services have listed eight healthcare-acquired conditions, including foreign objects left in surgical patients, pressure sores and certain infections, which means that no payment will be made for treatment in these circumstances.

While this policy seems punitive, perhaps there is merit in discussing regulatory standards that focus on outcomes rather than processes. Healthcare organisations themselves can then determine how they achieve such outcomes, and be judged on their results. The safety agenda in the US has come into even sharper focus since these measures were mooted.

The right blend of regulation and organisational change takes a sophisticated approach, nationally and locally. The balance is delicate. Performance management systems need to recognise and reward innovation and improvement as well as achievement of national targets. Regulation should protect and ensure minimum standards, but NHS leaders need to create a culture that encourages the use of improvement science to keep driving up quality and safety.