Understanding the factors influencing implementation of a new national patient safety policy in England: Lessons from ‘learning from deaths’

Abstract

Objective: A new patient safety policy, ‘Learning from Deaths’ (LfD), was implemented in 2017 in National Health Service (NHS) organisations in England. This study examined how contextual factors influenced the implementation of LfD policy and the ability of the programme to achieve its goals. Methods: Semi-structured interviews were undertaken with key policymakers involved in the development of the policy, along with interviews with managers and senior clinicians in five NHS organisations responsible for implementing the policy at the local level. We also undertook non-participant observation of relevant meetings and documentary reviews of key organisation procedures and policies pertaining to LfD. Results: The study findings suggest several factors that hinder or support patient safety policy implementation at a local level. These include: (a) an organisation’s capacity and capability to support data collation, analysis and synthesis, (b) the dissemination of the resulting information, (c) the learning culture and hence perceptions of the purpose of LfD within an organisation, and (d) the extent of engagement in cross-organisational approaches to learning. Conclusions: Extra and intra-organisational contextual factors influence all stages of the policy implementation process from preparation and tracking to implementation support and review affecting its chances of success or failure. Successful adoption of a national patient safety policy within health care organisations can be informed by taking into consideration those factors.