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Event
TIPS QI National Conference
Patient Safety Learning posted an event in Community Calendar
untilThe TIPSQI Annual Quality Improvement Showcase returns once again in a virtual format. This virtual conference is open to all foundation doctors in the UK. This is a fantastic opportunity to present your QI project as a virtual poster or oral presentation; hear about other projects in the region; and hear our key note speaker Dr Hannah Baird, the founder of TIPS QI, alongside being higher specialty registrar in emergency medicine, Chief Registrar at Royal Bolton Hospital, the Vice-Chair of the Academy of Medical Trainees Doctors Group and the Co-Chair of the Emergency Medicine Trainees Association (RCEM). Junior doctors from around the UK will be presenting their quality improvement projects, highlighting some of the excellent leadership work being carried out amongst foundation doctors. There shall be prizes for the best projects, as well as the opportunity to learn more about the great QI work across the UK. Register -
Event
RCM conference 2024
Patient Safety Learning posted an event in Community Calendar
untilEnergising excellence. Bringing research, education, practice and leadership to life The RCM conference is back for 2024. Professional and educational standards of proficiencies have made clear the importance of midwives working across the professional pillars of the profession: research, education, clinical practice and leadership. Safe and effective care needs an evidence base from research, which is then disseminated and supported through education and strategically implemented into clinical practice and sustained through effective leadership. Furthermore, understanding midwifery professional pillars is relevant for promoting career pathways and ensuring professional recognition alongside our multi-disciplinary colleagues. Register -
Content ArticleThe Health & Social Care Committee is examining the relationship between leadership in the NHS and performance/productivity as well as patient safety. It will consider the findings of and implementation of recent reviews of NHS leadership, such as the Messenger (2022) and Kark (2019) reviews as they relate to patient safety, as well as topics including how effectively leadership supports whistleblowers and learning from patient safety issues. Here is AvMA's response to the Committee's call for evidence.
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News ArticleIn the next few days, once the data has been collected, the Government will come out and say that, thanks to its policies, the situation in A&E is improving. Despite estimates released recently by the Royal College of Emergency Medicine that soaring waits for A&E beds led to more than 250 needless deaths a week in England alone last year, the Government will point to declining numbers of patients who breached the four-hour target this March. The four-hour target means we're meant to see and either discharge or admit patients within four hours of their arriving in A&E. But it's a sham, writes Professor Rob Galloway in the Daily Mail. Because, for the past month, the four-hour data has been manipulated, the result of two policies introduced earlier in the month by the Government. Read full story Source: Daily Mail, 3 April 2024
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Content ArticleNHS England’s response to claims of excess deaths due to long A&E waits leaves a lot to be desired, writes Steve Black for the HSJ. The Royal College of Emergency Medicine (RCEM) claim that more than 250 A&E patients are dying each week because they waited more than 12 hours to be admitted. If long waits in A&E are killing an extra 250-400 people every week, it is the biggest performance problem in the NHS. NHSE should urgently ask their analysts to rework this analysis with current data to test (or refute) the validity of the claim. The first step to solving a huge problem is admitting the scale of the problem, not denying it exists. This analysis features a refinement of the RCEM estimate that includes estimated mortality from waits between four and 12 hours. This increases the estimate to 400 extra deaths per week compared to the RCEM number of 250.
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News Article
New CQC inspections put on hold by ministers
Patient Safety Learning posted a news article in News
The Care Quality Commission’s assessments of integrated care systems (ICSs) have been put on hold at the last minute, as the government declined to sign off on the process. They were due to begin this month, following pilots in Birmingham and Solihull and Dorset ICSs, but the Care Quality Commission (CQC) has put the brakes on assessments elsewhere until it receives government approval. Under the legislation brought in when ICSs were set up in 2022, the CQC can review and assess systems, but ministers must approve its methodology. Interim chief inspector of adult social care and integrated care James Bullion wrote to integrated care board chiefs this week stating that, following discussions with the Department of Health and Social Care, the CQC had agreed to a “short delay… to allow for further refinements to our approach”. He added: “In particular we have been working with NHS England on their strengthened approach to performance evaluation and rating of the ICB elements of the ICS which we will take into account as evidence for our scoring and reporting approach.” Read full story (paywalled) Source: HSJ, 8 April 2024 -
Content ArticleRead the Royal College of Emergency Medicine's general election manifesto. A one page summary is below and the full manifesto can be found at the link at the bottom of the page.
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Content ArticleThe recently published results of the British Social Attitudes survey and the NHS Staff Survey, and recent performance data provide an in-depth backdrop to the health and care landscape in 2024 - a year that's likely to see a general election called. Ruth Robertson is joined by a panel of experts from The King's Fund to discuss the state of health and care. Throughout the conversation, the panel reflects on the prospect of a general election and the impact this might have on health and care services, both in the run up and after. They also discuss the tendency to rely on short-termism in policy-making, and why a long-term strategy might help build a stronger health and care system that will last.
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Content ArticlePrime Minister Rishi Sunak promised speedier care, but specialists believe long waits for hospital beds are costing thousands of lives. The pledge he made in January last year, as one of five priorities on which he said voters should judge him, was that “NHS waiting lists will fall and people will get the care they need more quickly”. New calculations by the Royal College of Emergency Medicine (RCEM) show that, with regard to the broader aim of delivering speedier treatment, his government is falling shockingly short.
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Content Article
LitHealth podcasts
Patient Safety Learning posted an article in Recommended video and audio resources
Lit Health will be lighting a fire underneath the status quo of healthcare through interviews with authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life. -
News Article
Links between primary and secondary care must be ‘streamlined’ says NHSE
Patient Safety Learning posted a news article in News
All trusts should pick a “designated lead” for improving how they work with primary care, according to new NHS planning guidance. The guidance for 2024-25 published by NHS England today states: “Every trust should have a designated lead for the primary–secondary care interface.” It also asks integrated care boards to “regularly review progress” on how secondary care services are working with primary care. NHSE recovery plans include trying to cut the number of patients effectively referred back to GP practices by other services, in order to reduce GP workload. The guidance states: “Streamlining the patient pathway by improving the interface between primary and secondary care is an important part of recovery and efficiency across healthcare systems”. The planning guidance — published on Wednesday night after months of delays — also said systems should continue to develop integrated neighbourhood teams, including by trying to “improve the alignment of relevant community services” to primary care network footprints. Read full story (paywalled) Source: HSJ, 27 March 2024 -
Content ArticleThe NHS England 2024/25 priorities and operational planning guidance reconfirms the ongoing need to recover core services and improve productivity, making progress in delivering the key NHS Long Term Plan ambitions and continuing to transform the NHS for the future.
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Content ArticleThis study examines associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture and job satisfaction. The authors conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. 30% of providers reported burnout and providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout. More pressures related to patient care and lower job satisfaction were also associated with burnout.
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Content ArticleWhen ECRI unveiled its list of the leading threats to patient safety for 2024, some items are likely to be expected, such as physician burnout, delays in care due to drug shortages or falls in the hospital. However, ECRI, a non-profit group focused on patient safety, placed one item atop all others: the challenges in helping new clinicians move from training to caring for patients. In an interview with Chief Healthcare Executive®, Dr. Marcus Schabacker, president and CEO of ECRI, explained that workforce shortages are making it more difficult for newer doctors and nurses to make the transition and grow comfortably. “We think that that is a challenging situation, even the best of times,” Schabacker says. “But in this time, these clinicians who are coming to practice now had a very difficult time during the pandemic, which was only a couple years ago, to get the necessary hands-on training. And so we're concerned about that.”
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Content ArticleFollowing the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008. As part of the review, CQC were asked to look at 3 specific areas: A rapid review of the available evidence related to the care of Valdo Calocane An assessment of patient safety and quality of care provided by NHFT An assessment of progress made at Rampton Hospital since the most recent CQC inspection activity In this report, CQC detail the findings of parts 2 and 3. They will publish a separate report on part 1 in relation to the care of VC in summer 2024.
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Content ArticleImproving maternity care is a key Government and National Institute for Health and Care Research (NIHR) priority. In March 2024, an NIHR Evidence webinar showcased research from their recent Collection, Maternity services: evidence to support improvement. This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A. It highlights seven features of safety in the maternity units, kind and compassionate care around the induction of labour, and the role of hospital boards in improving maternity care.
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Content ArticleTechnology is advancing at a fast pace and holds significant promise for the future of healthcare and the NHS, with the potential to enhance productivity through cost, resource and time efficiencies. Yet there is a gap in practical guidance for healthcare stakeholders on how best to take this agenda forward, and what key roles are required. Systems are now in a place where people can take a large-scale view and make connections across the system to advance the technology agenda. To support them, the NHS Confederation and Google Health have developed this guide.
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EventuntilA four-week introduction to Patient Leadership, led by David Gilbert. Patient Leadership signals a breakthrough in healthcare that moves beyond traditional engagement and uncovers the pioneering and transformative work of patient leaders – those affected by life-changing illness, injury or disability who want to lead change in the healthcare system. Or ‘those who have been through stuff, who know stuff, who want to change stuff’. About this programme This course lays the foundation for understanding patient leadership – it is designed for both patients and non-patients to explore together different facets of this emerging social movement. It is for Patient and Carer Leaders, health professionals, managers, non-clinical staff and those from the independent, voluntary and charitable sector. And open to international attendees. This programme lays the foundations for understanding patient leadership. It leads you through the principles of patient leadership, what it is and where it came from, the qualities of an effective patient leader, support needed and models of embedded patient leadership. For patients, users, carers and staff (clinical, managerial). The framework for May's course The four sessions take place on consecutive Wednesdays, between 4pm and 7pm UK time. Wednesday 1 May - Session 1 - What is Patient Leadership The different tributaries of the ‘patient movement’ The failure of traditional engagement approaches The emergence of ‘patient leaders’ Definitions and clarifications What we bring - Jewels of wisdom and insight from the caves of suffering Wednesday 8 May - Session 2 - The Effective Patient Leader The Different Roles for a Patient Leader What Matters – an anchor for the effective Patient Leader Benefits of Patient Leadership The four main capabilities The different sorts of support needed Wednesday 15 May - Session 3 - Embedding Patient Leadership in Healthcare The Patient Leadership Triangle (the Sussex MSK Model) The Patient Director – a new role in healthcare Culture, systems and processes Progression routes & creating opportunities The current climate for Patient Leadership Wednesday 22 May - Session 4 - Reflections and Next Steps Reflections on the programme Exploring issues in more depth Your next steps Your learning and support requirements Register
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News Article
Concerns over ‘Government’s failure’ to act on patient safety recommendations
Patient Safety Learning posted a news article in News
The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations -
Content Article
The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings. -
Content ArticleThis is the report of a review conducted by the Health and Social Care Select Committee’s Independent Expert Panel, examining progress the UK Government has made against accepted recommendations from public inquiries and reviews on patient safety. It focuses on five recommendations, giving the Government for each a rating in the style used by national bodies such as the Care Quality Commission. The overall rating across all recommendations is ‘requires improvement’.
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Content ArticleFear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
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News ArticleThe Royal College of Paediatrics and Child Health has called on the UK government not to wait until after the upcoming general election to approve an infant immunisation programme against respiratory syncytial virus (RSV), so that babies can be protected next winter. In June 2023 the Joint Committee on Vaccinations and Immunisations (JCVI) recommended developing an RSV immunisation programme for infants and for older adults.1 It issued a fuller statement reiterating the advice in September 2023.2 But the government has yet to make a final decision on rolling out an RSV immunisation programme. A letter signed by more than 2000 paediatricians and healthcare professionals says that the sooner a full RSV vaccination programme is implemented the more effective it will be and that it “could save child health services reaching breaking point.” Read full story (paywalled) Source: BMJ, 20 March 2024
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News Article
William Wragg acts as Parliamentary Ombudsman Office faces life without a boss
Patient Safety Learning posted a news article in News
William Wragg, the Tory chair of the Public Administration and Constitutional Affairs Committee (PACAC), has belatedly intervened in the growing crisis over the failure of the Prime Minister to appoint a new Parliamentary Ombudsman to replace Rob Behrens who quits the Parliamentary and Health Service Ombudsman on 31 March 2024. In a letter published on the committee’s website, Mr Wragg asks Sir Alex Allan, the senior non executive director on the Parliamentary and Heath Services Ombudsman board, what measures will be taken to keep the office going and what is going to happen to people who, via their MP, want to lodge a complaint to the Ombudsman. He also raises whether reports can be published and complaints investigated. The letter discloses that recruitment for a new Ombudsman began last October and a panel chose the winning candidate at the beginning of January. Since then the Cabinet Office and Rishi Sunak, who has to approve the appointment, have not responded. The silence from Whitehall and Downing Street means no motion can be put to Parliament appointing a new Ombudsman, who then appears before the PACAC for a pre appointment hearing. PACAC has only a couple of weeks to set up the hearing. Read full story Source: Westminster Confidential, 12 March 2024 -
Content Article
Just Culture - NHS Mersey Care documentary (2018)
Patient Safety Learning posted an article in Good practice
Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
