Patient safety in complex systems: developing and applying 'Safety II' in multidisciplinary care for younger people with eating disorders

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[...]Our field of study is youth mental health, specifically eating disorders amongst young people. It is estimated more than 1.6m people in the UK are affected by an eating disorder (www.jcpmh.info), although this is recognised as a conservative estimate since the problem is often hidden and there exists unmet need (some estimates put the number at 4m). The problem is not exclusive to, but much more prevalent among, teenage girls. There have been high profile inquiries into deaths of patients from eating disorders, such as that of Emma Carpenter, a 17 year-old in Nottingham, detailed in national press (Daily Mirror, 26 June 2015). Her death was ascribed to patient safety failure with poor co-ordination of care resultant from dissipated responsibility amongst organisations and professionals. The proposed PhD research is likely to have significant positive impact upon service delivery through working closely with service providers (specifically CWPT - see below), and then diffusing local evidence and practice through the NIHR £10m funded CLAHRC WM (clahrc-wm.nihr.ac.uk) and CLAHRC EM (clahrc-em.nihr.ac.uk), the former for which Currie is Deputy Director and Implementation Research Lead, the latter for which Martin is Deputy Implementation Research Lead. A notable characteristic of younger patients with eating disorders is the complexity of their care, and the duration of treatment over which various groups of professionals intervene. In circumstances such as this, patient safety can be conceptualised as a 'dynamic non-event', whereby in most cases of complex, long-term treatment and care, safe practices generate a constant and hence apparently uninteresting non-event outcome (Reason, 1997). Yet provision of such care is challenging because it requires effective coordination at interfaces across multiple organizations, in particular at transition points in order to mitigate risk and enable positive outcomes (Vincent & Amalberti, 2016). Indeed, poor transition between professionals and organisations is a common patient safety failure globally (Waring et al., 2015; Burgess & Currie, 2013). Further, care is likely delivered in a discontinuous way over time. A patient with a long-term condition may have intense periods of intervention, but these are punctuated by longer time periods where they manage their condition without recourse to clinical or other interventions. There have thus been calls for a more wide-ranging conceptualisation of harm and, correspondingly, safety: as a matter not just of avoidance of harmful events, but also relating to issues such as lost opportunities for better care and improved outcomes due to poor coordination, whether inside a hospital, or transition with primary care, or over a long period of time in the community (Vincent & Amalberti, 2016).In reconceptualising harm and safety in this way, the organisation and management of health care at the system level becomes foregrounded, but to date there has been limited research on organisational factors that enable safety across organisation and sector boundaries. This PhD seeks to address this lacuna, building on the insight that patient safety resides at all levels of healthcare systems and using a case study of the care of younger people with eating disorders to examine how safety is enacted, reproduced and coproduced at the interface between different professional and non-professional actors, including healthcare professionals, managers, administrators, patients and informal carers. It addresses issues such as accountability, the co-ordination of leadership across professional and managerial groups, and organisational culture (and particularly the encouragement of a 'just culture' or 'safety culture' which combines appropriate personal responsibility with recognition for the interdependencies upon which safety relies, and the need to prioritise learning over blame).[...]