Tom Rose
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Content Article CommentA SMS is certainly a prerequisite for patient safety in healthcare. The NHS must not go down the track of designing a SMS in each Trust. The NHS SMS must be universal and be designed by people that really understand management systems. A universal management system framework has been in use, Internationally, for many years and in 2023 a version of this MS was developed and published specifically for healthcare. Our NHS should be International leaders on its application in our Trusts. Within the UK, but not the NHS, there is a vast amount of knowledge on this MS that could be used to make our NHS that World leader in patient safety management. WHY ARE YOU NOT INTERESTED NHS?
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Content Article CommentThe NHS has an appalling record on Patient Safety. Nothing changes are investigation recommendations remain un-implemented. Why Patients put up with this situation I don't know. The solution has been around for many years and is well proven in many other organisations. The solution is the implementation of a Management System. The problem is that the NHS think they know better. Over the last 76 years they have proven to us Patients that this is definitely not the case. The stupid thing is that Trusts are using Management Systems already in some areas and they don't even realise it as I've previously illustrated. Is no one brave enough to stand up and say lets at least give it a try. Some Trusts say that they already have a Management System, this just goes to show the total lack of knowledge regarding Management Systems within NHS leadership.
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Content Article CommentGreat post. Process design, process management, and process continuous improvement are so important in healthcare delivery. It all starts and finishes with good, simple, process documentation. Without process documentation process design, process management, and process continuous improvement are not possible; it is a prerequisite. Process documentation is not difficult, I've talked about my preferred method on many occasions. What is important is that the process documentation represents 'Work as done' and that 'Work as done' is the same as 'Work as imagined'. I just don't understand how they are allowed to be different in the NHS. There can be no patient safety if this is the case. The solution is not 'rocket science' and does not require any more 'research' papers; it's basic stuff.
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Content Article CommentTom Rose commented on Patient Safety Learning's article in Patient Safety Incident Response Framework (PSIRF)A vary useful list. Thanks
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Content Article CommentBetter process visibility/documentation would help. The new British standard, BS ISO 7101:2023 would help with this. Currently it's a case of the blind leading the blind. Documenting healthcare processes is not difficult if it's kept simple. It would be a big step towards a Learning Health System.
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Content Article CommentI agree that the NHS's version of quality is not sustainable nor effective. For WAD to equal WAI in the NHS will take a lot of work and careful design. The current situation with WAD must change, and, I should add, WAI. I'm looking forward to Parts 2 and 3. Thanks.
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Content Article CommentThe NHS is a long way from the aviation industry when it comes to safety and you have hit the nail on the head with this blog. A solution for the NHS will not be found until two two conditions are first met. For simplicity I have come up with two formula. Fist: WAD=WAI, and second: QI=CI. There is a great deal of change required for the NHS to meet these two conditions, far too much to show here. WAD is Work as Done. WAI is Work as Imagined. QI is Quality Improvement as interpreted by the NHS, and CI is Continuous Improvement. Once these two conditions are met then the NHS can start to implement three, universally recognised systems. These are Process Management System (PMS), Quality Management System (QMS) and finally a Safety Management System (SMS). Clinicians', on there own, will not achieve this, they need to seek help from outside the NHS.
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Content Article Comment'Health and Care processes' and 'assuring processes are safe' are mentioned during the video. Lots of work required here in the NHS. Are you talking about 'work as imagined' or 'work as done'? because in the NHS they are very much not the same thing. You can't design a SMS without Process Management. You will find that all the industries that you listed above have very strict Process Management Systems as the key foundation to their SMSs.
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Content Article CommentTom Rose commented on Patient Safety Learning's article in Patient Safety Incident Response Framework (PSIRF)This is a great blog. very well done. Fantastic imagination in putting it together. Work-as-done is so important. Much more important than work-as-imagined as this is very rarely to current practice. Have you seen my Roadmap and Framework for change?
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