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Case Study: The NHS National Patient Safety Agency (NPSA)
National Patient Safety Agency (NPSA)
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 AWard2008 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
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Projects can last between a few weeks to two years. The NPSA would typically run 15 to
20 large projects at one time; large projects would often involve a greater number of
stakeholders outside of the NPSA. No two problems are the same, and the make up of the
team and its solution can have a heavy bias to a design outcome or not, depending on the
nature of the problem and the solution approved.
Work to date has included the cleanyourhands campaign to combat the spread of MRSA
through promoting greater awareness amongst NHS staff of the importance of hand hygiene.
1 Understand the problem
2 Identify potential solutions
3 Risk assess solutions
4 Pilot and learn
7 Closing the loop
This is not about a team of trained designers
working on a wide range of projects but the
solution design process being used by a
diverse range of disciplines working on a
range of problems. The teams at the NPSA
who work on each solution are multi-
disciplinary and design is one of the
recognised professions represented. All
relevant stakeholders are involved, including
nurses, surgeons, manufacturers,
purchasers and universities. There is an
large range of different disciplines within the
Stages in the patient safety solution
Design guidelines have been produced to advise suppliers on how the NHS wishes their
products to be specified. Again the guidelines are set by a multi-disciplinary team of relevant
stakeholders considering the problems caused by the products or equipment and
recommending solutions that are risk assessed and approved by them.
The NPSA has worked with partners such as The Helen Hamlyn Trust of the Royal College
of Art (RCA) to produce guidelines on medical devices, equipment and packaging.
The Medical Futures award-winning resuscitation trolley, in partnership with the RCA, was
the result of a design study exercise addressing a number of problems associated with this
life 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 physical
design prototype. The clinical team played an important part at the start of the process by
understanding the nature of the problem and analysing the work flow and processes of
emergency resuscitation. The design skills came in towards the end of the process.
The majority of patient safety incidents reported by community pharmacy involve selection
errors (selecting the wrong dose or wrong drug during dispensing), which may be related
to pack design. The NPSA, working with a large team of stakeholders, researched the issue
and published guidelines for the design of medication packaging.
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A characteristic of all innovative businesses
and organisations is their need to challenge
the regulations and standards that govern
their industry. The NPSA is a pioneer in a
new approach to work with the
pharmaceutical industry and regulators to
push for improvements in medication
packaging. Until recently the
pharmaceutical pack design was primarily
influenced by regulatory requirements,
rather than ease of use or patient safety.
The guidelines provide more detailed direction
on the design of packaging to improve ease of
use and safety, in addition to that required by
the regulations. In order to implement these
guidelines they promoted the government agenda
of ‘purchasing for safety’, rather than the slow
and expensive regulatory route.
Some of the pharmaceutical companies
welcomed these changes, realising they could
compete on specification as well as price and
embraced the changes, realising that the regulator
is 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 to
design than meeting regulatory requirements.
Although design is not the sole activity of the
NPSA, they employ the design process to a high
level that many professional designers and
manufacturers will never achieve. They will put together the best team of stakeholders to
research a problem thoroughly with evidence-based research; analyse possible solutions
through risk assessment; carefully test and evaluate user interaction; measure the affect
of the solutions and review them.