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This is a poem written and read by Elaine Freeman, Patient Safety Partner (PSP) at Lincolnshire Community and Hospitals NHS Group. Elaine and her PSP colleagues shared their poems with the Group Chief Governance Officer, her deputy, and the new Chair of the Group, inviting reflection on the importance of patient-centred care. The PSPs chose poetry as a powerful and personal way to express their experiences, insights, hopes, and concerns, and to highlight the human story behind the numbers. Two other poems they shared are included at the end.  The video has been created by Patient Safety Learning.  The human Behind the Digit I am the person behind the number, The face behind the case, The story in the spreadsheet, A name you can’t erase. I’m more than just a metric, A target or a trend, I’m a mother, father, sister, A neighbour and a friend. When you look at columns, And data on the screen, Remember there’s a heartbeat, And a life that’s lived between. So, as you make your choices, And the digits start to climb, Don’t lose the human spirit, In the pressure of the time. Other poems by the Patient Safety Partners Can you hear me? By Ruth Krampf Can you hear me? You told us that my partner needed to come in for some tests. You told us that my partner’s future was grim. My partner was frightened. Can You Hear Me? We came to you. I told you my concerns about my partner. I told you about my partner’s condition. Can You HEAR Me? You put my partner on Nil by Mouth. Nobody told me. Doctor take your eyes away from your tablet and look at us. Listen to us! CAN You HEAR Me? My partner is not a metric, they are confused. My partner is not a tick box, they are anxious. My partner wants to come home. CAN YOU HEAR Me? My partner is not just another statistic to put a tick against. My partner is a spouse, parent, sibling and friend. My partner is loved. CAN YOU HEAR ME? The Human Behind the Digit (2) By Elaine Freeman The screen is filled with rows of green, A grid of targets, met and signed. But in the spaces in between, What of the souls we’ve left behind? A metric is a frozen thing, A snapshot of a process done, But safety is the life we bring To every daughter, father, son. A 'tick' is not a healing hand; A 'box' is not a life restored. We need a Board to understand The truths that live beyond the board. For outcomes are not found in ink, Or graphs that track a steady line, But in the time we stop to think: “Is this a person, or a sign?” So let the data find its place, But let the patient lead the way. Put back the name, the story, the face, Into the words we choose to say. True success is not a score, Or how we’ve played the system’s part; It’s when we open up the door And lead with data—and with heart.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

The Healthcare Governance Academy, PSIRF training trusted by more than 4,000 healthcare professionals. Delivered by a patient safety consultant that developed PSIRF tools. This training will support the development of expert understanding and oversight 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: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email [email protected] for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

Any staff with responsibility for implementing the duty of candour and/or PSIRF and those responsible for quality; safety; clinical governance; safety investigations; complaints; CQC compliance; or patient experience/ involvement would benefit from attending this one-day training. The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive 20% discount. Email [email protected] for discount code.

A different approach to Structured Judgement Reviews (SJRs); using them as a triage tool and avoiding the use of poor and very poor to better align with PSIRF. This course looks at moving SJRs away from questions of avoidability of harm and instead looks at how they can be used to determine what type of learning response should follow a patient’s death. The explicit judgements of poor and very poor that are in traditional SJR models are no longer helpful and delegates will be provided with updated and positive alternatives that focus on organisational learning. WHO SHOULD ATTEND Healthcare professionals tasked with deciding on an appropriate learning response following the death of a patient. Healthcare professionals who undertake Structured Judgement Reviews who wish to align these with PSIRF principles. KEY LEARNING OBJECTIVES Where SJRs fit in the overall clinical governance structure of their organisation, why they are being conducted and what questions they are designed to answer How to organise case notes for effective review; use of timelines What other sources of evidence to consider Making explicit judgements around quality of care; evidence base and standards used When and how to escalate potential issues with professional conduct Register hub members receive 20% discount. Email [email protected] for discount code.

The Healthcare Governance Academy, PSIRF training trusted by more than 4,000 healthcare professionals. Delivered by a patient safety consultant that developed PSIRF tools. 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. Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Register hub members receive 20% discount. Email [email protected] for discount code.

The Healthcare Governance Academy, PSIRF training trusted by more than 4,000 healthcare professionals. Delivered by a patient safety consultant that developed PSIRF tools. 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. Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Register hub members receive 20% discount. Email [email protected] for discount code.

RCA continues to be used around the world by healthcare teams to better understand and learn from their patient safety incidents. While it is no longer an approved learning response under the NHS Patient Safety Incident Response Framework (PSIRF), many care and non NHS organisations continue to use RCA as a structured and effective approach for understanding incidents and improving safety. This one-day intensive and interactive masterclass will provide insights into how RCA is being used effectively by healthcare and non-healthcare organisations across the world to enhance safety. RCA relies on the creation of a skilled team of investigators, working together to look beyond surface-level symptoms. By following a clear seven-step process and by embracing a range of established RCA techniques, healthcare teams can collaborate to make their patients safe. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register