HelenH

Hi Tom, thank you, it’s been a great collaboration and we built on a well received presentation at the Health Plus Care show earlier this year. Not sure I’ve seen your roadmap and framework for change. Something we can add to the hub? Do let me know helen@patientsafetylearning.org 

On 07/02/2023 at 12:08, Exonian said:

The worst, and unforgivable thing about this situation is that it was entirely predictable. Those of us working as NHS nurses knew that when governments of both parties started to slash bed numbers from the late 1970’s onwards, despite the known demographic of an ageing population, as well as a population that is increasing in numbers year on year, then this was a recipe for disaster. Added to this is the fact that staff have been put under unbearable pressure ever since then to fulfil government targets that are unattainable, and are not able to give the care that they were trained to give, leading to burnout. My colleagues and I often said that we had given our lives to the NHS, but it would not be there for us when we needed it, although we have all been surprised by the speed at which this has happened . Staff shortages will continue until the NHS learns to treat its staff well, as it is an extremely poor employer. From the point of view of working at the sharp end in a dangerously understaffed NHS, I am so glad that I am retired.

Thanks for sharing and so sad to hear your reflections. Encouraging retirees back to the workforce might be quite a challenge! 

Yes, interesting recommendation. As you say, guidance isn’t legally binding. It’s something we highlight a lot at Patient Safety Learning, the inconsistency of response to guidance and failure to implement good practice. Something we highlighted in a blog last year https://www.patientsafetylearning.org/blog/mind-the-implementation-gap-the-persistence-of-avoidable-harm-in-the-nhs

You’re welcome! Lovely to get your feedback 

Thanks @lzipperer Festive greetings to you and thanks always for your support. Interesting developments in the US on patient safety, here’s to strengthened Federal leadership and action in 2023 🎄

Hi @richard vA. I've been speaking with Henrietta a few times and she presented at out 'Safety for All' conference last week. That was filmed so we'll be sharing that as soon as we've done the video editing.

There is an e-form for patient reporting but it's difficult to find and is woeful. It's part of the NRLS replacement, the LFPSE programme but there's no timeline for its development that I'm aware of. 

I understand that her office will have 4 staff only and she's actively recruiting.

It's a requirement of the Commisisoner's role to have a stakeholder advisory group and I would expect that patients and patient groups would have a strong voice in this. I know she's been meeting with many in her first few months and is looking for people to contact her office with their views. Here contact details are: commissioner@patientsafetycommissioner.org.uk.

Hope that's helpful

Helen

Hi @Colette Laws-Chapman What a  good question! Lets add any answers and content to the hub

Searching the hub, I found this. Helpful? 

Too right @Steve Turner And staff managing complaints seem to be ostracised within the Trust 

‘Complaints staff attributed this lack of timely action to an avoidant and defensive attitude towards complaints on the frontline, contributing to their sense of being othered within the institution’

Thank you for your comment. It’s a dreadful and upsetting set of circumstances. My husband was recently in hospital and the experience of calls being unattended was routine.
 

This was clearly devastating for the patient, her family and all involved.  It reinforces the need for a safety systems approach and sufficient resources to ensure that risks are assessed and managed. There are 50k nursing vacancies in the NHS, this comes with significant safety consequences. I strongly agree with your point of the need to prioritise for acuity and dependency, clearly a huge challenge for the service at the moment. 

David makes a valid point, CEOs must be able to listen to those that raise concerns, staff and patients. And that how issues are raised will be affect this, I’m sure. But we have so much evidence that there is a failure to acknowledge and respond to concerns. We need a culture that celebrates and takes action when people highlight where improvements are needed. Think it’s Appropriate to add one of my favourite Einstein quotes: insanity, doing the same thing over and over again and expecting different results 

Excellent blog, thanks Becky. A colleague of mine has brought this project to my attention:https://www.visualdx.com/projectimpact/  It’s a Global project with a strong US focus. Many members of the ILDS are contributing to this project https://ilds.org/our-members/

Our Mission

Project IMPACT is a global effort brought to you by VisualDx to reduce disparities in medicine and highlight the tools we use to bridge gaps of knowledge and improve care.

Hi Derek,

It's a pushing water uphill task, at times, as you and we well know. 

Sharing is not the problem, it's getting people to listen and act that's the challenge. By adding content to the hub, we try hard to bring innovation to people's attention. 

Any more we can do @Clive Flashman ?

Helen

Hi Derek,

You describe a frustrating and lonely path for innovation. @Clive Flashman any suggestions of where Derek could promote this approach?

Helen

Hi @Derek Malyon 

Thank you got this, really interesting. Do you know of any work being taken forward in this area? 

This approach would not only provide a feedback loop that would highlight activity omissions but would place the consenting patient at the heart of decision making. 

Hi Sally

Hope you're well. Thanks again for another great blog. 

Very useful! My husband and I do go on very long walks - rather muddy now we're into autumn.

Praise to criticism ratio of 5 to 1. Gulp, not sure whether I achieve that. Especially with my young adult kids!,

Helen

Thanks for posting Steve. Truly shocking. I’ll read the full report and try and answer your questions! 

Hi Lorri

Thank you so much for your latest (and now, last) blog. I've learned a lot and they always have given us an interesting perspective.  Who'd have thought we'd have been reflecting on the impact of Covid 19 on the physician/patient relationship and safety issues? That was a 'stand out' article for me from this month.

Best wishes from us all at Patient Safety Learning and thanks again for your fascinating insights.

@lzipperer

'If you are aware that there are delays for a particular service and your patient is likely to be affected by this, you should make this clear to them and manage their expectations from the outset.' Really important. 

@Jon Holt Spot on ‘This is because investigations often stop at the point of identifying what went wrong and how rather than focusing on the working conditions, environment, team dynamics, culture and other human factors / systems factors which need to be explored to identify why things went wrong and generate meaningful solutions. ‘

How can we make the changes needed @Katrina and @Jerome P?

@Claire Cox suggested on Twitter this weekend a network of PS Managers. That would help amplify the voices for change and to share good practice and ideas.  

Very well made points. I think the new SI framework is indeed intended to address the 'hamster wheel' approach. It would be good to hear from the pilot sites how they've approached the challenges you outline and the approach to taking appropriate action - evaluating and sharing the impact of quality improvements. Would be great to get these on the hub.

Will be of interest to you, I'm sure  @Jon Holt

Thanks @Shamim Odera RN And good point about the principles for clinical trial settings being used more widely. I’m not sure we have these on the hub. Where’s the best source for these, do you think?
 

This seems comprehensive. But what are the mechanisms for ensuring that these standards are known, adopted, adhered to? And how are patients informed and engaged?

@Steph O'Donohue @Claire Cox How can we find answers to those questions?

Thanks Sue for your comment and sorry to hear that you’ve had direct personal experience of these issues. 
 

I think the saddest part of your response for me was ‘There can be no dissenting, no admission of problems or bad practice and this usually results in the removal of both the person raising concerns and the manager who acknowledged it.’ We are destined to repeat errors and harm patients unless we challenge the status quo. 

Alarming also what you say about the role and approach of professional bodies. Would you like to share more? You’d be very welcome to contact me direct on this. Maybe that’s something we can explore and highlight on the hub? 
 

Thanks again for your insight and comment helen@patientsafetylearning.org

A truly wonderful initiative ❤️

One of the most powerful responses I’ve heard to the pandemic. Wonderful insight and advice. Thank you, Sally. I’m going to share widely. Helen