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Found 226 results
  1. Event
    Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Register
  2. Content Article
    The NHS regularly uses temporary staff to fill gaps in its workforce. This investigation explored the challenges of involving temporary clinical staff (bank only staff, agency staff and locum doctors working within trusts) in local trusts’ patient safety investigations. Trust-level investigations are important because they are a way to identify learning to improve healthcare systems, with the aim of reducing the potential for harm to patients. Identifying learning requires staff to be engaged in an investigation; if temporary staff are not involved, learning may be lost, posing a risk to patient safety. HSSIB identified this risk following analysis of serious incident reports provided by acute and mental health NHS trusts. To explore the issue further, the investigation carried out site visits and engaged with NHS trusts, providers of bank staff, agencies that supply staff to NHS trusts, substantive (permanent) NHS staff, bank and agency staff, and a range of national stakeholders.
  3. Content Article
    Fran Ives speaks with Pascale Carayon, a Professor in Industrial and Systems Engineering at the University of Wisconsin Madison. Pascale talks about her vision for the SEIPS (System Engineering Initiative for Patient Safety) framework, which she has been working on for many years. During the conversation, Pascale gives some valuable advice to those who are new to using SEIPS such as focussing on the interactions between the elements of the model, such as the organisation, the task, and the tools. Future possible developments for the framework were considered such as making a connection between patient safety and well-being such as stress and burnout.  
  4. Content Article
    The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward. 
  5. Event
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    This webinar examines why families make complaints and offers a best practice guide on how to involve the patient/family and how staff can be guided by them and their observations. It also looks at how to achieve timely sharing of information and how to ensure good communication with the patient/family. In addition, you will learn how to disseminate the complaint investigation findings in your organisation and how to embed changes. The speakers include two family members (one of whom is also an NHS staff member). They are joined by highly experienced patient safety and complaints staff, who will share their knowledge, experience, and ideas regarding how complaints are dealt with and how this could be improved. This webinar has been developed in line with the national NHS Patient Safety Standards introduced as part of the NHS Patient Safety Incident Response Framework (PSIRF) and the “Engaging and involving patients, families and staff following a patient safety incident” PSIRF supporting guidance. This webinar is for… Patient Safety Leads / Manager / Advisors Complaints staff, PALS staff, Patient and Carer Experience Leads Family Liaison Service Teams PSIRF Implementation Teams Governance Leads / Managers / Directors Clinical Leads in Safety & Quality Presenters: Jo Collins (Deputy Head of Patient and Carer Experience, AWP), Derek Richford, Joanne Simm (NHS Matron), and Jan Fowler (NHS Executive Director retired). Learning outcomes: Delegates will gain a better understanding and develop skills in the following areas: Increasing confidence when dealing with the challenges, opportunities, and benefits of engaging positively with families when they raise a complaint. Reinforcing why positively engaging families achieves better investigation outcomes for everyone. Examining why families make complaints and what you can do to put this right for them. How to involve families in investigations following a complaint, and how to be guided by the patient/family’s observations. How to embed learning from complaints through promoting a learning culture that can lead to effective organisational change. All participants will receive the programme and background information about Making Families Count in advance. Everyone who attends will also receive a resource pack (including a shareable PDF guide and the speakers’ slides) and a certificate of attendance. Register
  6. Event
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    Join Hill Dickinson for the third meeting of their national patient safety network in their series on the Patient Safety Incident Response Framework (PSIRF). They will be joined by guest speakers from Mid Cheshire Hospitals NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and HCA Healthcare to share their experiences and provide valuable insight following the implementation of PSIRF in their organisations. This will include practical feedback on what has worked well, and what in practice has needed tweaking. This will be followed by an opportunity to ask questions to our esteemed panel including NHS England, Hill Dickinson and our guest speakers, giving you valuable insight from acute, mental health and independent provider perspectives. Guest speakers: Dr Caroline Worthington, Lancashire and South Cumbria NHS FT Karen Luscombe, Associate Medical Director for Patient Safety at Mid Cheshire Hospitals NHS Foundation Trust Judi Ingham, Divisional Vice President of Quality at HCA Healthcare Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England Register
  7. Content Article
    One of the major challenges of patient safety incident reporting and learning systems lies in the difficulties of extracting practical information from the vast amount of data collected. Furthermore, many countries have not started collecting incident reports in patient safety at national level which makes it difficult to identify avoidable patient safety incidents and take action on them nationally. Minimal Information Model for Patient Safety (MIM PS) has been developed to provide a simple tool to start collecting data on patient safety incidents to assist in data analysis and extract the minimal, but necessary information to learn from incidents in order to avoid recurrence of same types of incidents in the future. Also, the MIM PS can be used as mapping source from any types of existing reporting systems of patient safety incidents which means no need to develop the new reporting systems based on MIM PS. This MIM user guide aims to explain each MIM category and how to implement MIM. It went through a validation process with EU and EFTA countries in 2014-2015. The MIM PS validation was supported by European Union in which EFTA countries also participated in the pilot testing.
  8. Event
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    The Duty of Candour, introduced in 2014, requires healthcare professionals to be honest with patients when things go wrong. They must also be open with colleagues, employers, and relevant organisations and participate in reviews and investigations when requested. Our training developed with industry experts - Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. The training focuses on empathy and compassion and equips you to navigate the Duty of Candour effectively. The training will cover the following areas: Overview of the Duty of Candour Legislation Requirements and expectations of the Care Quality Commission (CQC) The importance of empathy and compassion in implementing the Duty of Candour Balancing compliance with the human side of the duty Empowering and supporting individuals responsible for the Duty of Candour Understanding the emotional component behind the duty Providing evidence of compliance with the legislation Impact of meaningful interactions on patients, families, and colleagues Avoiding harm when providing an apology Price: £245 + VAT per person Discounted rate for bookings of 3 or more: £220 + VAT per person Event details and booking page Discount Code – Early bird 10% discount code valid until 2 April Hub discount code: DoC-Hub-10 Alternatively, the training can be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  9. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  10. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  11. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  12. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Registration
  13. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  14. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  15. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  16. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  17. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  18. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  19. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  20. Event
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    The Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Book your place
  21. Content Article
    One way to understand the links between unwanted events, conditions and interventions is via causal loop diagrams. These represent how situations perpetuate in 'causal loops'. They are depicted as words and phrases for events and conditions, and arrows with a plus or minus sign to indicate the direction of causal influence. Causal loop diagrams can assist a conversation via the gradual building of each loop. They can otherwise represent data from research and practice.  Steven Shorrock illustrate the progressive build of a causal loop diagram concerning reactions to unwanted events, including fixes that fail, based on practice and research. This might be useful to professionals seeking to understand why unwanted events continue to occur despite, or because of, interventions. The diagram is not ‘complete’ and would be drawn differently for different purposes, contexts and situations.
  22. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  23. Content Article
    NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan.
  24. Event
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    This popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
  25. Content Article
    The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen. Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.
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