HelenH

@Goingviral Thank you so much for your post. That's a sorry tale indeed, all rather confusing and clearly evidences that one of the reasons that the clinics are difficult  to find, is that they're just not there!

We will take up your suggestion and I will write to Sir Simon Stevens today. Do you have a contact in his office that we can follow up with?

@Stephanie O'Donohue Let's look at the other helpful contacts suggested and follow up. Talk tomorrow?

@ElspethJ Many thanks. The framework looks really good and we'll add to the hub.

There's no mention of an implementation plan with timeline, resources, patient communication and engagement etc. 

They conclude in their framework :

11. Key First Steps

This Framework has been developed to enable organisations to support their planning for recovery and rehabilitation services following the Covid-19 pandemic. We know that there is excellent practice already in place and it is essential to share and build on this across the whole system.

A National Advisory Board for Rehabilitation, which will also address the public health aspect of early intervention for prevention will be formed to provide expert advice to the Scottish Government and support leadership in NHS Boards and Integration Authorities.

The Scottish Government has appointed a Professional Advisor for Allied Health Professions who will take a leadership and advisory role and will oversee the deployment of the plan across Scotland, feeding back to Ministers and policy colleagues on its implementation.

It is anticipated that this work will closely align to existing rehabilitation pathways and strategies and a Once for Scotland Approach will be developed and provide a practical, accessible strategy to deliver quality rehabilitation to everyone who needs it.

@Patient Safety Learning Let's add the Scottish framework to the hub and ask on social media (twitter and LinkedIn) what the timescale is for implementation 

@Aileen I agree with you, it doesn't seem that GPs are getting the information or support they need. By starting this thread we thought that we'd be highlighting where the clinics were. Seems to be more that we're hearing that there aren't clinics being set up and a general confusion as to who is responsible and what action is being taken. We most definitely will use this insight to write to DHSC, NHSE etc

@Luke Brown 'Bandage not band aid.' Absolutely

Love Claire's 3 things!

For me,

1. Physical safety - staff should not be harmed by working in health and social care; whether PPE to prevent Covid 19/HAI, lifting and handling support so staff don't get injured , prevention of burnout through overwork/unsafe staffing levels; sufficient rest time so staff are properly eating and drinking on long shifts etc

2. Safety goals and teamwork - breaking down the professional silos and working in ways that have safety as a common core goal. Everyone can and should contribute to safety with staff supported with skills, training, knowledge and ways of working that promote safety 

3. Psychological safety. A just and learning culture must be psychologically safe for staff  to speak up for safety, to challenge unsafe care, to call out and address the blame culture and to work in an environment that supports their growth and self esteem. Leaders and organisations providing the space and support for staff to raise difficult issues and demonstrate that the listening leads to action and change (then sharing for wider implementation)

'If reporters don’t get any feedback and can’t see any changes made as a result of reporting, they’re going to stop reporting.' The heart of a learning system is acting on staff and patients' insights on what can be improved and what has gone wrong. If reporting doesn't demonstrably lead to lead to improvement, then what's the point? Reporting just becomes part of accountability not learning. 

How much time and money do we spend on reporting? What's the value if we don't act on this knowledge?

@Steve Turner I think you raise important issues. We know well the very visible whistleblowing cases. But the ones that reinforce the power imbalance are more seditious - the quiet underhand reminders that if you speak up you’ll be performance managed; the suggestions that people want team players, not trouble makers; the threat of not getting a deserved reference; that someone will make sure there’s a quiet word spoken; that the organisation is more important than the customers; the banter about ‘not being like us’ etc. So difficult to prove. People shouldn’t have to be brave and take huge personal risks to do the right thing. How do we lift the lid? 

Increasingly HR professionals are advising not to give references other than ‘worked here, role title, dates’ and only anodyne feedback from job applications. This protects the organisation from challenge but makes it very difficult to know whether a failed application is because there are better candidates out there or there is something more sinister going on. The whistleblowers that I have spoken with and read their books clearly feel that there are blacklists. Understandably, not many people would want to raise publicly, or attributably. We’d be happy to publish comments anonymously. It’s important to explore and expose these issues, as you do @Steve Turner 

Let’s use this community hub to identify examples where staff are experiencing challenge from frustrated and angry patients and families. We need to highlight this issue so that health and social care leaders, policy makers and politicians understand theses issues and respond to patient concerns and ensure that staff are protected.

Hi Steve, I suppose it’s impossible to know how such blacklisting works. Might there be patient safety focused HR people that could provide such insights (unattributably if needed)? Have you any contacts? Helen 

Carrie, this is a ghastly experience. And truly shocking to use Covid 19 as an excuse. We will be refocusing our work with Hysteroscopy Action. Have you been in touch with them? They’re amazing and so supportive. 

Thank you for sharing your experience. 

@Claire Cox @Steph O'Donohue 

@Mary-Jo Patterson and @Jon Holt 

Hi both, would love it if you can use the hub and this community to engage, support, champion and challenge for patient safety. Please let us know how we can help.

Helen

Hi Nik,

Thanks for your post. How gruesome, I'm so sorry. We know that many women similarly report this intense pain and just have no idea what they're going to experience when they agree to the procedure.

We've been working with the amazing women at Hysteroscopy Action to build on their campaigning to demand safer and pain free care with women being fully informed before they consent.

@Claire Cox and I have been a little deflected with the pandemic but we're very keen to re-active our work on this important issue. Thanks for sharing. 

We must stop this happening.

Helen

Thanks David. I’ve promoted on my FB and LinkedIn accounts too. Hope you’re well and safe. Helen 

Think I’d do the same! Need a clinician’s input here @Claire Cox what do you think?

There is much that is well intentioned in this framework. I think there is much that will not achieve the aims and may result in serious unintended consequences. I'm drafting a blog to kick off discussion.  

Interesting there’s a bbc 3 and bbc 2 programme on SW London MH Trust tonight 

Hi Claire, this must have been awful for everyone. Is this a legal requirement, that a consultant must sign a form?  

Hi Jon, thanks for kicking this off.
We’re going to be sharing a blog on this shortly and to help inform discussions. I met briefly with the Academy of Medical Royal Colleges on this yesterday so have some insight to contribute. Btw the consultation response is limited to 500 characters as they want themes not detailed comments. Personally I don’t think this is appropriate stakeholder engagement and consultation on such a vital contribute to patient safety. 
 

Patient Safety Learning will update and tweet soon.

@Sue Hignett Definitely one for you to review 

Helen 

Hi Jon

I've heard directly from Aidan that there won't be an implementation plan as such for the NHSI PS strategy, they're just getting on with it. Aidan says they are reporting back through the National Quality Board. I met with Ted Baker this morning from CQC, he jointly chairs the NQB. I said there were a lot of interested people in the service (clinicians, ps and risk managers in providers and commissioners) who want to know what the NHSI PS strategy implementation means for them and in particular the incident framework. 

I'd also heard at a meeting with @Amelia from Browne Jackson that the framework will be released to pilot sites only at this stage and only wider after pilot evaluation. 

Would love to know more if anyone else has any insights to share.

Thanks for raising Jon, sorry I can't help more with the answers.

Helen

@Annie Hunningher this is excellent, thank you so much for sharing. 

@PatientSafetyLearning Team let's add this to the Learn section of the hub and tweet it. This is Bart's Local Safety Standards for Invasive Procedures (LocSSIPs) - these are minimum standards based on best practice that apply to all staff and all services.  They include 8 sequential steps that are reinforced with clear organisational standards. Let's get everyone to share their standards.

@Annie Hunningher at the excellent recent session with the UCLP AHSN, you outlined the peer review process that you've been developing to assess and provide feedback on performance. Anything that you can share  with us on this? Either the aims, the peer review process that you're developing and progress/commitment/barriers/opportunities or indeed the guidance for peer reviewers that is being drafted.

Helen

There are huge communications issues in an industry as complex as healthcare: and as @Steph O'Donohueand @Claire Cox point out, these can have a serious impact on service delivery. Worse, poor communication can result in unsafe care whether:

• within and between disciplinary teams
• between clinicians and patients
• between patients and carers
• between managers and clinicians

And that's communication that is verbal, non-verbal, written, electronic. And whether in diagnosis, consent, handover, escalation, medication management  etc

In your example Steph, I'm not sure how easy it is for clinicians to hear themselves. Maybe ask a patient! When I worked at the Alzheimer's Society, we had groups of service user volunteers who would review written communication for the NHS, Local Authority and other service providers. They were brilliant and they simplified and clarified so many leaflets, advice and guidance notes, official forms etc.

I think, if we don't already have this on there, that we should have a section on communication and patient safety on the hub. And highlight some great resources: see below

Much work by prof. dr. annegret hannawa, professor of health communication - interested in the conceptual and empirical intersections between human fallibility, interpersonal communication science and healthcare. https://annegrethannawa.com/

https://bmjopenquality.bmj.com/content/8/3/e000742

https://improvement.nhs.uk/resources/improving-safety-critical-spoken-communication/

https://www.researchgate.net/profile/Douglas_Brock/publication/257838524_Interprofessional_education_in_team_communication_Working_together_to_improve_patient_safety/links/00b7d52cad52c4ff23000000.pdf

https://www.sciencedirect.com/science/article/abs/pii/S0012369208601610

https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf

https://www.nursingtimes.net/clinical-archive/patient-safety/tools-and-techniques-to-improve-teamwork-and-avoid-patient-harm-12-12-2016/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4134163/

https://patientengagementhit.com/news/patient-provider-communication-strategy-may-boost-education

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/TeachBack-QuickStartGuide.pdf

etc etc

Helen

Thanks @Peter Walsh. And that accountability is also organisational. A just and learning culture means that organisations learn from unsafe care and good practice, taking action to reduce the risk of future harm. And to share that learning, widely.

A very valuable comment, thanks Eve. 

Some questions:

• How are others responding to the challenge of setting and monitoring safe staffing levels?
• How is the acuity and dependency of patients assessed at ward/operational level across all care sectors?

Let's encourage people to share their perspectives; challenges and how they are developing approaches

@alisonleary And a research and academic perspective would be invaluable.

@Mark Hughes Let's post a distillation of Eve's comments and these questions on social media and encourage responses and on the hub

Helen

What is Civility Saves Lives? 'We are a collective voice for the importance of respect, professional courtesy and valuing each other. We aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours.'

@Patient safety Hub If you go on the site, they reference in their tweets quite a lot of resources including videos. Would be great to get these all on the hub