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Content Article
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In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, explains how she became involved in Appreciative Inquiry and asks the question: what could Appreciative Governance start to look like in the NHS and what small steps can we all do to achieve that together? -
EventuntilIf you did a quality improvement project related to patient care, have you considered publishing the results? Sharing your project can help others learn from and replicate it, and benefit patients far and wide. It isn’t as hard as you might think! The Patient Safety online Master Class Writing Workshop in Quality Improvement Studies teaches the skills you need to turn your QI project into a manuscript. Session 1: Introduction to Writing a QI Study. Learn the typical elements of a published QI study so you can write one yourself. Thursday, August 29, 4–6 p.m. ET Session 2: Roundtable Manuscript Critique and Discussion. Review your manuscript with other participants tohelp revise it for publication. Thursday, October 10, 4–6 p.m. Further information
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News Article
Maternity services ‘overwhelmed with reporting requirements’, warns DHSC group
Patient Safety Learning posted a news article in News
Government has been warned by its own advisory group that maternity services are being “overwhelmed with reporting requirements” which are hindering safety improvement work, according to documents seen by HSJ. The Department of Health and Social Care (DHSC) set up the “independent working group” on neonatal and maternal care to oversee its response to Donna Ockenden’s spring 2022 inquiry report into Shropshire maternity services; and was then asked to do the same for key recommendations from Bill Kirkup’s report later that year on failings in East Kent. The group is led by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists and made up of representatives of maternity staff. It was asked particularly to look into advising on two Kirkup recommendations: first, on improving standards of professional behaviour and “embedding compassionate care”, including asking royal colleges and others how this can be done. Second, charging the royal colleges and others “with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives, and training from the outset”. However, a recent report from the working group, to the DHSC, released under the Freedom of Information Act, suggests the staff groups are arguing there is little scope to introduce more change. Read full story (paywalled) Source: HSJ, 18 June 2024 -
Content ArticleThis publication describes East London NHS Foundation Trust’s 10 years of experience with learning how to apply quality improvement throughout the organisation and embed a culture of improvement, in partnership with the Institute for Healthcare Improvement (IHI).
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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 ArticleAmbulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised.
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Content ArticleThis book introduces quality improvement for anyone studying or working in healthcare. Written in clear, straightforward language, it explores quality improvement from multiple perspectives and outlines a range models and toolkits you can use in practice. Encouraging you to reflect on your role as an improver, the book equips you with the knowledge and skills you need to work through each stage of the improvement process – from troubleshooting an issue, to working with others to make an improvement, through to its evaluation. Key features: Case studies and activities help you to apply theory and methodology to your everyday role. A comprehensive glossary introduces quality improvement terminology and concepts. A logical four-part structure moves from the basics up, building your knowledge and understanding as you go.
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Content ArticleThe use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioural health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, working against the therapeutic treatment environment aimed to support the healing journey. In this quality improvement project, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting in the US. This was achieved using a strategy of leadership, workplace development and data, and performance was sustained over the following year.
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Content ArticleLarge language models (LLMs) are a form of artificial intelligence that can generate human-like text and functions as a form of an input–output machine. They bring great potential to help the healthcare industry centre care around patients’ needs by improving communication, access and engagement. However, LLMs also present significant challenges associated with privacy and bias that also must be considered. This blog looks at three major patient-care advantages of LLMs, as well as the potential risks associated with using them in healthcare.
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Content ArticleIn this blog, Miqdad Asaria, Assistant Professor at the Department of Health Policy at LSE, argues that AI could lead to a paradigm-shift in healthcare systems likes the NHS. He outlines how AI could help personalise medical treatments, enhance research and development of new drugs and help with the administrative burden currently undermining the productivity and efficiency of healthcare providers.
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Content Article
National Diabetes Foot Care Audit 2018 to 2023 (9 May 2024)
Patient-Safety-Learning posted an article in Diabetes
The National Diabetes Foot Care Audit (NDFA) has published a State of the Nation report for 2018 to 2023. Based on data from England and Wales from 1 Apr 2018 to 31 Mar 2023, it details the findings and recommendations relating to the assessment, outcomes and participation in the NDFA for this period. Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The overall aim of the NDFA is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. This report contains three key findings: The time to first expert assessment (FEA) is key to achieving the positive outcomes of being alive and ulcer free (AAUF) at 12 weeks There is a marked variation between foot care services both in terms of assessment and outcomes There are wide ranging differences between regions, integrated care boards and services in ulcer registration rates, and also the percentage of those registered that are classified as severe. -
Content ArticleThese patient safety professional standards aim to support pharmacists when responding to patient safety incidents. They describe good practice and provide a broad framework for continually improving services, shaping future services and roles and delivering high-quality care across all settings and sectors. They have been developed by the Royal Pharmaceutical Society (RPS), Association of Pharmacy Technicians UK and Pharmacy Forum NI, with the support of an expert steering group and public consultation. Pharmacists, pharmacist prescribers, pharmacy technicians and the wider pharmacy team across the United Kingdom will find these standards useful. They may also be of interest to the public, to people who use pharmacy and healthcare services, other healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
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Content ArticleHealthcare services improvisation relies heavily on collaborating with patients and caregivers by acknowledging their feedback to enhance quality and safety. The 2023 World Patient Safety Day underscores the significance of co-production with patients in safety strategies. In accordance with this, a crucial tool that involves patients and caregivers is the “Patient-reported experience measures (PREMs)” that help in assessing healthcare delivery in terms of quality, safety and performance. These tools for various healthcare processes offer valuable insights into treatment effectiveness and areas needing improvement. PREMs are surveys used to assess patients' care experiences objectively, aiding in pinpointing the areas for improvement. Unlike patient satisfaction measures, which reflect only subjective evaluations, PREMs offer an objective view of care encounters. In view of the importance of a standardised tool for Indian health care organisations, CAHO in collaboration with various stakeholders and patients unveil the White paper on Patient-Reported Experience Measures (PREMs) tool development process. This white paper was released by the honourable governor of West Bengal, Dr C.V Ananda Bose at the recently concluded CAHOCON 2024 at Biswa Bangla, Kolkata.
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Content ArticleComputerised provider order entry (CPOE) prompts can provide patient-specific risk estimates for multidrug-resistant organisms (MDROs). This JAMA Network study aimed to find out whether CPOE prompts could reduce empiric extended-spectrum antibiotic use in patients admitted with pneumonia. The authors found that prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs reduced extended-spectrum antibiotic use by 28.4%, without increasing intensive care unit transfers or length of stay for patients with pneumonia.
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EventuntilSocial innovation labs are innovative spaces that encourage creative thinking and experimentation. A recent evidence review undertaken by the Innovation Unit explores how labs can achieve greater impact. This session, jointly delivered by Q and Innovation, is an opportunity to hear more about the evidence review, hear from leading practitioners in the field and connect with others with an interest in social innovation. Register for the webinar
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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 -
Content ArticleDevolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. This study evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach.
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Content ArticleEnsuring the safe and effective use of medicines is a central function of the pharmacy team. This article in the Pharmaceutical Journal outlines how pharmacists can support the implementation of the Patient Safety Incident Response Framework (PSIRF). It aims to help pharmacists: understand the role of the Patient Safety Incident Response Framework (PSIRF). understand the difference between the PSIRF and the Serious Incident Framework. Know how the PSIRF can be applied to the pharmacy profession. This content is free to access but you will need to sign up for a Pharmaceutical Journal free online account.
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Event
Human Factors – Introduction
Patient Safety Learning posted an event in Community Calendar
This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register -
Event
Human Factors – Introduction
Patient Safety Learning posted an event in Community Calendar
This introductory course from AQUA is aimed at those who are new to Human Factors or those who are interested in refreshing existing knowledge. You will gain the fundamental knowledge and skills for Human Factors in health and care. Taking place online over two half days, this course will blend guided independent study with facilitated discussion and activities. You will be encouraged to apply your learning to your own role and environment, to reduce error, improve processes that underpin patient safety, and support organisational safety culture. Learning objectives: Understand the basic concept of Human Factors Understand the importance of Human Factors for safety and quality improvement Have awareness of what influences human and system performance Understand the basic concepts of systems thinking Who is this for? This programme is ideal for any staff who wish to develop a basic knowledge/awareness of human factors. Programme duration This programme consists of two sessions which will each last for three hours. Delivery methods This programme is delivered virtually through online sessions. Register -
Content ArticleThe World Health Organization (WHO) is in the process of establishing a Roster of consultants in the area of patient safety with the main objective of identifying experts from all over the world in different patient safety areas who may support the implementation of the Global Patient Safety Action Plan (GPSAP) 2021-2030 at global, regional, country and institutional levels. The experts with the successful outcome of their application will be placed on the Roster and subsequently may be selected for consultancy assignments in the specified area of work, primarily across the seven strategic objectives of the GPSAP 2021-2030. More information can be found in the link below. Closing date for applicants: 3 April 2024.
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EventThis conference focuses on quality accreditation, monitoring and assurance. The conference will support you to develop systems and processes for local accreditation for quality. Accreditation can be used as a tool to encouraging ownership of continuous quality improvement, reduce variation and increase staff pride and team working. There will be an extended focus on meeting the CQC Quality Statements in line with the new assessment framework. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/quality-accreditation or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #QualityAccreditation hub members receive a 20% discount. Email info@pslhub.org for discount code.
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News Article
USA: Patient Safety Awareness Week
Patient Safety Learning posted a news article in News
Patient Safety Awareness Week, an annual recognition event in the USA that occurs in March, is intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. IHI works with partners around the world to improve the safety of health care for patients, caregivers, and the health care workforce. Learn more about IHI's work to advance patient and workforce safety. -
Content ArticleCentral venous catheters (CVCs) are widely used in US critical care settings for medication administration, monitoring and reliable venous access. Despite the benefits of CVCs, complications, particularly infections, have become a major focus of US hospital quality improvement efforts due to federal and state initiatives that emphasise patient safety, transparency and accountability. In this commentary in JAMA Network, the authors look at recent research surrounding CVC complications and highlight approaches to help tackle these issues.
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Content ArticleEnthusiasm has grown about using patients’ narratives—stories about care experiences in patients’ own words—to advance organisations’ learning about the care that they deliver and how to improve it, but studies confirming association have not been published. This study assessed whether primary care clinics that frequently share patients’ narratives with their staff have higher patient experience survey scores. It found that sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge. Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organisations need to address how narrative feedback interacts with their staff’s confidence to realize higher experience scores across domains.
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