Safer Clinical Systems Phase 2 Evaluation

Timescale: 2011-2015

Funder: The Health Foundation

Key points

  • Safer Clinical Systems was a Health Foundation programme that sought to develop and test an innovative approach for improving safe and reliable health care based on principles adapted from high-reliability organisations, established risk management techniques from hazardous industries, and quality improvement methods.
  • SAPPHIRE, in collaboration with the University of Birmingham, Imperial College and Johns Hopkins University, was commissioned by the Health Foundation to conduct an independent evaluation of the second phase of the programme, which was implemented in eight NHS organisations.
  • The findings of the evaluation will help to optimise the Safer Clinical Systems approach and suggest practical recommendations for those leading improvement in safety.


The programme’s approach was based on principles adapted from high-reliability organisations which are defined by the proactive nature of their risk management. Eight NHS sites in England and Scotland took part in the second phase which piloted a version of the Safer Clinical Systems approach. This involved small clinical teams in using detailed diagnostic techniques to identify hazards, selecting and undertaking appropriate interventions that would improve reliability, and using the data collected to develop a distinctive form of risk assessment and management tool known as a safety case.

The research study

The evaluators conducted 94 interviews with the project teams, the support team, the Health Foundation, and other stakeholders. They undertook 668 hours of ethnographic observations involving non-participant observation of activities in clinical and non-clinical areas as well as informal discussions. The team also analysed quantitative data on measures of reliability from four of the eight sites.

Rationale behind the evaluation

The aim of the evaluation was to identify the theory (concepts, rationale and assumptions) behind the Safer Clinical Systems approach, to determine how far the approach helped the participating sites to make their systems more reliable, and to explain how the approach might work (the mechanisms of change), while also considering contextual factors.

"This evaluation is essential reading for anyone who believes that learning the lessons of other industries is an easy way for healthcare to improve safety."

(Mary Dixon-Woods)


The evaluation of Phase 2 was conducted over 4 years, from 2011 to 2014, and a report of the findings was published in January 2015. Research Team


Research Team

Prof Mary Dixon-Woods  (Chief Investigator)

Prof Graham Martin

Dr Carolyn Tarrant Dr Sarah Chew

Prof Julion Bion

Dr Chris Goeschel

Dr Peter Pronovost

Dr Liz Brewster

Liz Shaw Liz Sutton

Janet Willars

Dr Diane Ketley Dr Tom Woodcock

Evaluation outputs

Safer Clinical Systems: evaluation findings

Understanding the challenges of improving safety in clinical systems

What to expect when you're evaluating healthcare improvement: a concordat approach to managing collaboration and uncomfortable realities

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