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Showing results for tags 'Process redesign'.
Found 127 results
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Content ArticleIn these presentation slides, Erik Hollnagel, Professor at the University of Southern Denmark, explains what is meant by the terms 'work as done' and 'work as imagined'. The presentation looks at the implications of designing with the two concepts in mind and highlights ways to better align system design with the realities of work as done.
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Content ArticleModern patient safety approaches in healthcare highlight the difference between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined). Research in this area has looked at case study examples, but has lacked insights on how results can be embedded within the studied context. This study used Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with work-as-done. It aimed to show how FRAM can be effectively applied to identify the gap between work prescriptions and practice. It also aimed to show how these findings can be transferred back to and embedded in the daily ward care process of nurses.
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Content ArticleThis blog by Tom Geraghty provides a definition of 'work as 'imagined' and how this differs from 'work as done'. He outlines the roots of the concept of difference between how people think work is done and the reality and also describes the concepts of 'work as prescribed' (how we think the work should be done) and 'work as disclosed' (what we say about the work that has been done). He discusses how we can close the gap between work as done and work as imagined through honest conversations, observations and simulations.
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Content Article
The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. In 2023 the standards were revised (NatSSIPs 2) with the Centre for Perioperative Care (CPOC), with a focus on bolstering of the organisational standards (people, processes and performance) in addition to the sequential steps that teams follow. The standards are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. Patient Safety Learning spoke to Annie Hunningher and Claire Morgan about the changes to the revised NatSSIPs 2, how NatSSIPs 2 is being implemented and what more needs to be done to promote and engage leadership for action. -
Content Article
Cambridge Elements: Design creativity (4 June 2024)
Patient Safety Learning posted an article in Design for safety
Design creativity describes the process by which needs are explored and translated into requirements for change. This chapter examines the role of design creativity within the context of healthcare improvement. It begins by outlining the characteristics of design thinking, and the key status of the Double Diamond Model. It provides practical tools to support design creativity, including ethnographic/observational studies, personas and scenarios, and needs identification and requirements analysis. It also covers brainstorming, Disney, and six thinking hats techniques, the nine windows technique, morphological charts and product architecting, and concept evaluation. The tools, covering all stages of the Double Diamond model, are supported by examples of their use in healthcare improvement. The chapter concludes with a critique of design creativity and the evidence for its application in healthcare improvement. -
Content ArticleIn this article for Health Service Journal, Lord Hunt updates readers on progress in revolutionising NHS procurement by focusing on value-based healthcare, patient outcomes and cost-effectiveness.
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Content ArticleThe National Safety Standards for Invasive Procedures (NatSSIPs) 2 are intended to help share learning and best practice to support multidisciplinary teams and organisations to deliver safer care. This two-page summary document, published by the Centre for Perioperative Care, provides a concise overview of NatSSIPs for anyone who does interventional procedures and the teams who support them.
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Content ArticleThe aim of this study was to investigate the incident reporting process (IR1s), to calculate the costs of reporting incidents in this context and to gain an indication of how economic the process was and whether it could be improved to yield better outcomes.
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Content ArticleEmergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as “Lean,” appear to improve service reliability and efficiency in healthcare. This study found that lean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.
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Content ArticleOne 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.
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Content Article
FRAM in a nutshell (2021)
Patient-Safety-Learning posted an article in Techniques
FRAM (Functional Resonance Analysis Method) is a graphical tool for demonstrating how a process is done through multiple functions and activities. This blog describes how FRAM can be used to analyse any process using four steps: Identifying and describing essential functions to have a successful process Finding out if there is the variability of the functions (if the process can be done in another way) Determining how the variability of a function impact the process Introducing recommendation for managing the undesired outcomes -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Rob talks to us about his passion for using human factors to improve safety in emergency departments, how allowing doctors to choose their own shifts can make staffing safer and how better integrating technology could help doctors diagnose and treat patients more safely and effectively. -
Content ArticleQuality improvement is a methodology used routinely in emergency departments (EDs) to bring about change to improve outcomes such as waiting times, time to treatment and patient safety. However, introducing the changes needed to transform the system in this way is seldom straightforward with the risk of “not seeing the forest for the trees” when attempting to make changes. This article in Annals of Emergency Medicine aims to demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem (“the forest”) and to support quality improvement planning, identifying priorities and patient safety risks.
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Content ArticleThis study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
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Content ArticleThe original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
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Content ArticleThis webinar was organised by the Chartered Institute of Ergonomics & Human Factors (CIEHF) in partnership with the Israel Human Factors and Ergonomics Association (IHFEA). It looks at the impact of human factors in the design and use of a range of medical devices. Experts from Israel, the Netherlands and the UK share their insights about the challenges involved and how they were overcome. In her talk, Avital Zik shares examples from her experience in leading the human factors work of the Medtronic Lung Navigation system. Lung cancer care is currently invasive, ineffective, inefficient, difficult for users and often comes too late. Avital's team is on a mission is to transform the future of lung care.
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Content ArticleIs it realistic to think of separating NHS hospital sites more effectively for “cold” (elective) and “hot” (acute and urgent) care, so that outbreaks or seasonal surges don’t lead to elective care being cancelled or delayed? David Oliver, consultant in geriatrics and acute general medicine, explores this idea in a BMJ article.
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Content ArticleThis paper from Natalie Offord and colleagues describes a service redesign in which has gained learning and experience in two areas. First, a description of measured improvement by the innovation of redesigning the traditional hospital-based assessment of frail older patients’ home support needs (assess to discharge) into their own home and meeting those needs in real time (discharge to assess). In combination with the formation of a collaborative health and social care community team to deliver this new process, there has been a reduction in the length of stay from completion of acute hospital care to getting home (from 5.5 days to 1.2 days for those patients that require support at home). Second, the methodology through which this has been achieved. The authors describe their translation of a Toyota methodology used for the design of complex cars to use for engaging staff and patients in the design of a healthcare process.
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Content ArticleRoyal Cornwall QI conference online book supporting the conference. The online brochure highlights all the quality improvement projects at Royal Cornwall Hospitals.
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Content ArticleOn 31 January 2023, the clinical trial information system (CTIS) will become the single entry point for sponsors and regulators of clinical trials in the European Union (EU). The CTIS includes a public searchable database for healthcare professionals, patients and the public. This webpage contains information on how clinical trials are regulated in the EU, and what changes the CTIS will make to how clinical trials are registered, performed and regulated.
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Content ArticlePhysicians raised a concern to the Quality Department about patients who were diagnosed in the emergency department (ED) with a urinary tract infection (UTI) but who later were clinically reviewed and found to be without disease. These patients were often admitted and treated with potentially unnecessary antibiotics.
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Content Article
What is Appreciative Inquiry?
Patient Safety Learning posted an article in Improving patient safety
Appreciative Inquiry (AI) initiatives are implemented using the '4-D cycle' (Discovery, Dream, Design and Destiny). It's a methodology that allows an organisation to identify its positive core strengths relative to the 'affirmative topic' being addressed and and initiate concrete operational steps to achieve its goals. This article explains more. -
Content ArticleThis video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
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Content ArticleIn this blog, the Healthcare Safety Investigation Branch (HSIB) reflects on the recent publication of the new National Safety Standards for Invasive Procedures (NatSSIPs 2) by the Centre for Perioperative Care. It outlines how these standards can help NHS organisations provide safer care and reduce the number of patient safety incidents, including a comment on this from Deinniol Owens, Associate Director of National Investigations at HSIB.
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Content ArticleIn this video, William Pileggi, a registered nurse anaesthetist, discusses the implementation of the Golden Eagle Project at the VA Pittsburgh Healthcare System to improve outcomes for veterans who may be prone to experiencing post-operative emergent delirium. Through assessments to prescreen for PTSD, staff training and using alternative drug therapies, his hospital has had zero injury events related to emergent delirium since 2018. With minor modifications, the program is replicable at civilian hospitals.
