This week's HSJ survey on patient safety exposes a substantial perception gap between chief executives and senior managers.

The survey, published to coincide with the HSJ and Nursing Times Patient Safety Congress, reveals that, while few chief executives think they are obsessed with targets at the expense of safety, many managers think otherwise.

Similarly, managers are far more worried than their boss about whether they have the resources to tackle a major infection outbreak.

The two simplest explanations for this discrepancy are either chief executives are more hamstrung by targets than they would like to admit, or they really do feel less constrained by central control but have yet to drive this significant cultural change down through their organisations.

The excessively prescriptive operating framework issued by the Department of Health is, sadly, a fixture for the next 10 months.

The challenge for chief executives and managers is to keep focused on the big picture, with safety at its core, and not see their role as delivering every dot and comma in this year's instruction manual - bold brush strokes rather than painting by numbers.

If most chief executives really do not believe they are ruled by targets, and staff now have room for initiative and innovation in the way they shape and deliver services, those at the top need to demonstrate this by devolving power as far down their organisations as possible.

It is, perversely, sometimes easier for a member of staff to assume targets dictate every aspect of their working day. It allows them to cede responsibility for their actions. It is this attitude which erodes patient safety, as staff fail to understand that, ultimately, it is their decision whether they work in a safe way.

The front line is where patient safety, patient empowerment and the other aspects of care that really matter take place. The role of managers in patient safety is to show leadership; HSJ's survey scores management poorly in its contribution.

Without leadership, empowerment and responsibility, poor patient safety will continue to blight careers and cost lives.

For more on the survey, see HSJ survey: chiefs and managers at odds on patient safety and Patient safety survey: those in peril

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