"The book describes how a process oriented management system, already well established in other safety critical industries, can be used in the healthcare industry to ensure patient safety. The principles of the management system are rooted in Safety 2 and the book gives practical. detailed instructions on how to create such a system, with processes that map out 'work as done'. The book also explains how healthcare differs from other industries and describes how to implement a safety management system within a healthcare organisation. Leadership, culture and learning also have central roles to play in patient-safe care and the author explains how the management system must work with these three elements.
Aside from this, I particularly like the practical nature of the book and the way you give detailed instructions so it can serve as a manual for creating and implementing a management system, based on learning from other industries and the principles of Safety 2. I've seen other people advocate for the use of a safety management system in healthcare, but you have taken it much further than that. I've certainly not seen anyone giving such detail on the practical steps to take to create one."
Chairman at Patient Safety Learning. Chief Executive at Perfect Ward
ISQua is holding a World Patient Safety Day event which will look at how healthcare safety is important for patient safety too.
1. Dr Zainab Yunusa-Kaltungo, Consultant Plastic Surgeon, Former Patient Safety Lead, Federal Teaching Hospital Gombe, Gombe, Nigeria
2. Dr Gbonjubola Abiri, Consultant Psychiatrist and Medical Director Tranquil and Quest Behavioural Health
3. Chika Odioemene, RN, CEO & Founder Utopian Healthcare
11:00 AM – 11:10 AM Welcome address/introduction
11:10 AM – 12:10 PM Panel discussion: mental health of health workers, concept of 2nd victim and workplace bullying: how do these affect patient safety? (Chika, Gbonjubola and Zainab)
12:10 PM – 12:25 PM Wrap up: Opportunities surrounding quality and safety improvement and how to get started (Zainab)
12:25 PM – 12:30 PM Closing remarks
Having flu and COVID-19 together significantly increases your risk of death, say government scientists who are urging all those at risk of getting or transmitting flu to get the vaccine in the coming weeks and months.
The evidence for the double whammy is currently limited and comes mostly from a study with small numbers – 58 people – carried out in the UK during the early phase of the pandemic.
“As I understand it, it’s 43% of those with co-infection died compared with 26.9% of those who tested positive for Covid only,” said England’s deputy chief medical officer, Prof Jonathan Van-Tam. These were people who had been hospitalised and had been tested for both viruses, he said, and so were very ill – but the rate of death from Covid alone in the study between January and April was similar to the known rate of Covid hospital mortality generally of around 25% or 26%.
"I think it is the relative difference in size of those rates that’s rather more important than the absolute rate,” he said. The study may have been small and they would be doing further studies this season, but the findings tallied with other work that has been done, he said.
“If you get both, you are in some serious trouble, and the people who are most likely to get both of these infections may be the very people who can least afford to in terms of their own immune system, or their risk for serious outcomes. So please protect yourself against flu, this year,” says said Prof Yvonne Doyle, medical director of Public Health England
The government has bought 30,000,000 doses of flu vaccine, which is more than ever before. They will arrive in batches, so the elderly – over 65 – and those with medical conditions will be called for immunisation first. Relatives of those who are on the shielding list will also be called up. The letters will begin to go out this week.
Because of the threat of Covid and the risk that people with flu could be infected if admitted to hospital, all those aged 50-64 will be offered flu vaccination, but not straight away. They should wait to be called by their GP.
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Source: The Guardian, 22 September 2020
Emergency departments across England are reporting ‘dangerous’ overcrowding similar to levels seen pre-covid, and struggling to maintain social distancing, A&E leaders have warned.
The Royal College of Emergency Medicine said it was concerned about covid spreading among the most vulnerable patients, as overall transmission rates continue to rise sharply across the UK.
It was always anticipated that A&E activity would return to pre-covid levels this winter, following a significant drop-off in A&E activity during the spring and early summer, and that service transformation would be needed to help maintain social distancing. But the emergence of widespread overcrowding so far ahead of winter is of serious concern to system leaders.
A&E staff were already being forced to make difficult trade-offs over which patients to isolate, the college’s vice president told HSJ. He also urged NHS leaders not to place unrealistic expectations on the impact a new model involving walk-in patients booking slots by phone could make on addressing overcrowding in emergency departments.
RCEM vice president Adrian Boyle said the NHS was “largely back to the pre-covid levels of crowding” but it was “much more dangerous now because of covid”.
He said: “We are hearing that most emergency departments can’t maintain social distancing safely and staff are having to make fairly difficult trade-offs about which people need to be isolated. No one can be safely social distanced in a corridor.”
Read full story (paywalled)
Source: HSJ, 21 September 2020
Hundreds of people believe the helpline failed their relatives. Now they are demanding their voices be heard.
Families whose relatives died from COVID-19 in the early period of the pandemic are calling for an inquiry into the NHS 111 service, arguing that many critically ill people were given inadequate advice and told to stay at home.
The COVID-19 Bereaved Families for Justice group says approximately a fifth of its 1,800 members – more than 350 people – believe the 111 service failed to recognise how seriously ill their relatives were and direct them to appropriate care.
“We believe that in some cases it is likely these issues directly contributed to loved ones dying, due to causing a delay in receiving treatment, or a total lack of treatment leading to them passing away at home,” said the group’s co-founder Jo Goodman, whose father, Stuart Goodman, died on 2 April aged 72.
Many families have said they had trouble even getting through to the 111 phone line, the designated first step, alongside 111 online, for people concerned they may have COVID-19.
The service recorded a huge rise in calls to almost 3m in March, and official NHS figures show that 38.7% were abandoned after callers waited longer than 30 seconds for a response. Some families who did get through have said the call handlers worked through fixed scripts and asked for yes or no answers, which led to their relatives being told they were not in need of medical care.
“Despite having very severe symptoms including skin discolouration, fainting, total lack of energy, inability to eat and breathlessness, as well as other family members explaining the level of distress they were in, this was not considered sufficient to be admitted to hospital or have an ambulance sent out,” Goodman said.
Some families also say their relatives’ health risk factors, such as having diabetes, were not taken into account, and that not all the 111 questions were appropriate for black, Asian and minority ethnic people, including a question to check for breathlessness that asked if their lips had turned blue.
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Source: The Guardian, 21 September 2020
In July, the PHSO submitted a report to the Public Administration and Constitutional Affairs Select Committee exploring the state of local complaints handling across the NHS and UK Government Departments. Drawing on evidence from a wide range of individuals and organisations, Making Complaints Count identified three core weaknesses in the existing complaints system:
There is no single vision for how staff are expected to handle and resolve complaints.
Staff do not get consistent access to complaints handling training.
Public bodies too often see complaints negatively, not as a learning tool that can be used to improve service.
The PHSO stated in this report its intention to consult on a new Complaint Standards Framework for the NHS, aiming to “help create a stronger culture in which complaints are genuinely learned from”.
Patient Safety Learning believes that having an effective complaints process in healthcare is vital to improving patient safety, and in this blog we will set out our response to the consultation on this new Framework.
Complaints: an untapped patient safety resource
Too often complaints processes in healthcare are viewed in a negative light and patients and their families are not recognised as being a “primary source of learning for safety”. Having an effective complaints system provides an important opportunity to learn from incidents of unsafe care. Patients experiences can be used to help identify patient safety problems, ascertain the causes of these issues and put in place remedial measures to prevent them from recurring.
The absence of an effective system has often been cited in patient safety scandals as contributing towards the persistence of unsafe care. Robert Francis identified this in the Public Inquiry into the Mid Staffordshire NHS Foundation Trust, noting that complaints “were not given a high enough priority in identifying issues and learning lessons”. More recently, the Independent Medicines and Medical Devices Safety Review stated that the current complaints system is “both too complex and too diffuse” to promptly identify safety issues arising from a medication or device.
It has also been long acknowledged that the complaints system in the NHS requires significant improvements, in terms of both the processes and finding an effective way of learning from complaints to bring about improvements. In the wake of the Mid Staffordshire Inquiry, a review of NHS hospital complaints, co-chaired by Ann Clwyd MP and Tricia Hart, made a number of recommendations for change in complaints handling and procedures. More recently, a report from Healthwatch England which focused on how hospitals report on and communicate their work on complaints highlighted concerns about inconsistency in reporting and a focus on counting complaints rather than learning from them.
The consultation process for the PHSO’s Complaint Standards Framework was composed of a survey with several questions and a section in which to add any additional comments. Below is the response provided by Patient Safety Learning in the additional comments section.
Patient Safety Learning welcomes the PHSO’s Complaint Standards Framework and its recognition of the need to reform the NHS complaints system. From a perspective of making improvements for patient safety, we welcome:
The statement that organisations should “have clear processes in place to show how they capture learning from complaints, report on it, and use it to improve services”.
Its acknowledgement of the importance of sharing learning and complaints widely with other organisations in healthcare.
The identification of the need for clear complaints governance structures, ensuring the feedback is regularly reviewed by staff at a senior level.
Its recognition that an effective complaints system is intrinsically linked with promoting a Just Culture in healthcare, one that is less focused on blame and encourages transparency and accountability when mistakes occur.
We note that this Framework is focused on providing “a shared vision for NHS complaints handling” rather than looking in more detail at how this would be put into practice. While we welcome many of the aspirations set out in this, its implementation will ultimately determine its effectiveness in reforming the NHS complaints system.
Too often, there exists a gap between learning and implementation in healthcare. We may know what improves patient safety, but in practice such measures can often remain siloed in specific organisations, resulting in patients continuing to experience harm from problems that have already been addressed. If this Framework is to create a more effective complaints process, one which contributes to improving patient safety, we feel that there are several issues that will need to be addressed prior to its implementation:
It will need to be clear how organisations report on their progress in implementing the Framework.
There will need to be guidance on how organisations report on their implementation of the Framework and a level of transparency and consistency to allow for monitoring and comparison.
It needs to be made clear who is responsible for ensuring that organisations will design this approach to complaints into their governance structures.
There is also the question of how this change will be monitored. In the consultation survey, the PHSO pose a question related to this, asking whether they “should be given legislative powers to set and enforce national complaint standards for the organisations it investigates”.
At Patient Safety Learning, we think that it is vital that this process is monitored. However, we question whether the PHSO, specifically, can do this, in terms of whether it has both the legislative remit and the resources for this undertaking. In practice, we suggest that this role would sit better within the remit of the Care Quality Commission and its existing inspections regime. We feel this issue needs further consideration.
As mentioned previously, we believe a key question that needs to be addressed before implementing the Framework is how it will be reported on by organisations, and whether reporting will be consistent to allow for monitoring and comparison.
A recent report from Healthwatch earlier this year looking at hospital complaints highlighted the difficulties around this. It noted significant variations amongst different hospitals regarding how they reported on complaints (in terms of the data provided publicly) and, in some cases, whether they did actually report on these complaints. It stated “because the regulations don’t require trusts to publish their annual complaint reports, we can’t know for sure how many of them are fully compliant with the regulations”.
Achieving the goals of the Framework may encounter similar challenges, not providing clear indications of how its suggestions should be implemented. For example, the Framework states that organisations should “report on the feedback they have received and how they have used that feedback to improve their services”. We believe that this needs to be accompanied by clear guidance, for instance, stating that feedback should be publicly reported on a quarterly basis.
Sharing good practice
We welcome the strong emphasis that the Framework places on the need to learn from complaints, and to share this learning widely. We believe that complaints too often remain an untapped resource for making patient safety improvements; a negative view of these processes present a barrier to effectively utilising the insights they can provide.
In our report, A Blueprint For Action, we note that “healthcare is systematically poor at learning from harm”. This has also been recognised in the CQC’s report, Opening the door to change, stating that “there is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well”.
How we achieve this ambition of sharing learning from patient complaints widely between NHS organisations requires further consideration. Organisations need the means to be able to share learning from complaints widely and effectively with other organisations in the NHS, without this getting lost in “the avalanche of other information that bombards organisations daily”. Patient Safety Learning welcomes the opportunity to collaborate with PHSO on this issue and to promote and share good practice on the hub.
PHSO, Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020.
Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019.
Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013.
The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020; Patient Safety Learning, Findings of the Cumberlege Review: patient complaints, 30 July 2020.
Rt Hon. Ann Clwyd MP and Professor Tricia Hart, A Review of the NHS Complaints System: Putting Patients Back in the Picture, October 2013.
Healthwatch, Shifting the mindset: A closer look at hospital complains, January 2020; You can find further reading on complaints in healthcare on the hub.
PHSO, Have your say in shaping the future of NHS complaints handling, Last Accessed 18 September 2020.
PHSO, Complaint Standards Framework: Summary of core expectations for NHS organisations and staff, July 2020.
CQC, Opening the door to change: NHS safety culture and the need for transformation, 2018.
Ehi Iden, Chief Executive Officer of the Occupational Health and Safety Managers, shares with the hub his blog 'Safety of the patients and correlation with the safety of the healthcare workers' (see attachment below). He also share the interview he did for TVC News Nigeria on World Patient Safety Day.
Images from the day
The taskforce carefully considered an extensive range of issues in relation to the social care sector as a whole, brought together as key themes. These included the provision of personal protective equipment, COVID-19 testing arrangements, the winter flu vaccination programme, infection prevention and control, and issues of funding. The taskforce examined a number of issues relating to the workforce and family carers (unpaid), including how best to restrict the movement of people between care and health settings. Among other themes, the taskforce reviewed the role of clinical support within the sector, the availability and application of insights from data, and implications of inspection and regulation.
This report sets out the action that will need be taken to reduce the risk of transmission of COVID-19 in the sector, both for those who rely on care and support, and the social care workforce. This report sets out how we can enable people to live as safely as possible while maintaining contacts and activity that enhance the health and wellbeing of service users and family carers.
Throughout this report, a number of recommendations are made based on learning from the first phase of the pandemic. They range from 'quick wins' to consideration of topics that will require a degree of more substantial change and/or additional resource. In addition, there are a number of supporting recommendations in the annexed reports of the subject-specific advisory groups, which should be considered in tandem with the main report recommendations.
The results paint a bleak picture of the massive toll on all patients of the coronavirus pandemic and the emergency measures taken in response to it. Despite the large scale celebration of the NHS over the spring and early summer, the emergency measures came at a huge cost to patients. In particular, access to services became very difficult, and many patients were left feeling unsupported, anxious and lonely. The relationship between patients and the NHS has been significantly disrupted.
It was by no means all bad: some patients reported good ongoing care, and were impressed by the way their local communities came together to support them.
This report uses what patients said to look to the future, both near and long-term. It contains recommendations for the next phase of the emergency response, and also a call for the health and care system to be built back better after the pandemic: the current emergency footing cannot be the basis for the ongoing relationship between patients and the NHS.
As the NHS recovers from the first wave of the COVID-19 crisis, many organisations and health systems are not seeking to return to their pre-Covid ways of working. Instead, they are using the ‘reset and recovery’ phase as an opportunity to transform and enhance patient care whilst locking-in efficiencies and operational improvements. This transformation is seen as essential by many as the NHS prepares for ‘Winter Pressures’, builds resilience for any future Covid waves and, importantly, manages the backlog of elective procedures.
The pace and extent of disruptive transformation driven by the Covid crisis would have been unimaginable at the turn of the year. Since the pandemic erupted, organisations and networks across the NHS have implemented, almost overnight, many transformation initiatives that have been in planning stages for months or years. It has also necessitated a radical redesign of many ways of working. These changes have led to a fundamental rethink of both the speed and level of change that is possible. Despite all of these pressures it is recognised that the speed and level of change must be implemented in a managed and phased way.
This webinar will highlight:
The challenges the NHS faces.
How solutions to those challenges have been designed – by listening to what the NHS needs.
How the NHS has successfully implemented the solutions (hearing success stories from the NHS itself).
The importance of embedding transformation and new ways of working for the future.
This webinar is applicable to a wide range of NHS personnel, including Clinicians, Operational Staff and Patient Groups.
Hanan L'Estrange-Snowdon, Picker's Insight Manager, is hosting a discussion about the care experiences of people living with cancer. Hanan is joined by Chris Graham, Picker's CEO; Ruth Hendy, Lead Cancer Nurse at UHBW and Sue Kernaghan, Cancer Patient Representative.
The conversation will cover:
The Cancer Patient Experience Survey (CPES).
How University Hospitals Bristol and Weston are working to improve patient care.
How to effectively engage patient groups.
This webinar will give you a deeper understanding of the CPES survey, enabling you to use the results more effectively. There will be insights into best practice to take back to your organisation and an understanding of how to engage with your patients.