JULES STORR

A highly recommended watch for anyone interested in leadership, patient safety, quality improvement and implementation. That is, if you haven'y yet come across it. Mary Dixon-Woods' lecture Can improvement and innovation save the NHS? is both thought-provoking and refreshing. It provides an opportunity to pause and reflect on where we are in our improvement journey. Among the many nuggets is a reflection on the "priority thickets" described in recent NHS literature, and the reality that health systems are often trying to improve everything, everywhere, all at once. One observation particularly resonated with me. Reflecting on decades of inquiries and reports into healthcare failings, she notes that sometimes the only thing that changes between one report and the next is the font. A sobering thought. The good news is that this lecture is not simply a critique. It also points towards practical ways forward, supported by evidence, resources and examples. An hour very well spent. Watch the video here: https://www.thisinstitute.cam.ac.uk/blog/can-improvement-and-innovation-save-the-nhs/

Building on some of the issues that I outlined in the blog, I've been working on a visual in an effort to conceptualise some of this “compassionate IPC thinking”. This was also inspired a little by a recent paper I read by Jennifer Collins and colleagues - a scoping review that explores the role of nursing care interventions in the prevention of non-device-associated healthcare-associated infections. As you can see - this is very much a work in progress but I think gets across the message and sometimes a visual can be better than many words. For those interested, the Collins et al paper can be found here, it's open access and starts to address some important issues: https://www.ajicjournal.org/article/S0196-6553(25)00707-2/fulltext

Thanks Amy. Having written on change management in health care from a more theoretical perspective in Claire Cox and colleagues recent book, I especially appreciate how this translates the complexities of change management in health care into lived experience. It’s a really insightful and engaging contribution that many can learn from.

“While policies, governance structures, data and digital tools co-enable reforms, it is healthcare professionals who bring quality strategies to life in practice – guided by the insights, needs, and expectations of the people and communities they serve.” (Fonseca et al 2025) At the end of last year, I was drawn to a paper in the European Journal of Public Health by Válter Fonseca and colleagues from WHO: Quality of care in an era of global challenges: A transformational vision for the WHO European Region and beyond. The paper proposes a bold reframing of quality of care, one that moves decisively beyond traditional, compliance-driven models. What particularly caught my attention was its strong focus on leadership and its clear relevance to patient safety. The authors argue that leadership at all levels is essential to catalyse the transformation required: shifting from fragmented expert silos to integrated care pathways, and from guideline adherence alone to patient-centred, continuously improving systems. The paper reflects on how the concept of quality has expanded over recent decades to encompass safety, effectiveness, efficiency, equity, and people-centredness. Yet it also makes a persuasive case that many quality approaches still fall short, too often prioritising service volume and process compliance over outcomes, coherence, and purpose across complex health systems. Grounded in a review of major global reports - including WHO Regional Office for Europe’s Taking the Pulse of Quality of Care (2024), which highlights persistent disparities across European countries, the paper underscores why incremental change is no longer enough. To address this, the authors propose three key enablers for sustainable quality reform: 1. people, leadership, and a drive for change; 2. data and transparency; and 3. innovative solutions and tools. Together, these enablers point to a simple but powerful message: quality health systems are built on empowered professionals, trustworthy data, and responsible innovation. Leadership, learning, and culture enable safer, more integrated care; data and transparency support accountability and trust; and digital solutions can accelerate progress when ethically guided and designed around people. Importantly, the paper does not stop at vision. It offers concrete country examples from across the WHO European Region, showing how these ideas are being put into practice, with active support from the WHO Regional Office for Europe and its Athens Quality of Care and Patient Safety Office. I found the paper stimulating and focused on real world practice. Its emphasis on competencies, leadership support, motivation, and co-design resonates strongly with patient safety work. I was particularly struck by the authors’ reminder that “quality of care cannot be separated from the quality of health systems as a whole” and by their reframing of quality not as a technical add-on, but as a core principle underpinning health system effectiveness, resilience, and equity. For anyone interested in leadership, patient safety, and meaningful quality improvement, this paper is well worth the read.

I came across this new book Courageous Leadership in Infectious Diseases and Public Health During Challenging Times by two American colleagues via the Infection Control Matters podcast and it takes an interesting approach, unlike many conventional textbooks on leadership and management. The editors sat down, interviewed and recorded many of the leading lights in the field of infectious diseases and public health to tap into their leadership wisdom. Each chapter is essentially a transcript of the questions and answers that emerged from these interviews so it's not formulaic or dry but very personal and fresh. Many of the issues touched on are relevant to the patient safety community, particularly those in or aspiring to leadership positions. A 30 page taster sample is available to read, to test the water, so to speak and I would highly recommend it.

Yes Lorri - it will be recorded - if you register you will be sent a link to the recording. Best Jules

Let me check - they usually are. J

An interesting webinar will take place on Tuesday 8 April 1-2pm UK time (2pm - 3:30pm CEST): Humanizing health care through relationality: Exploring the science and practice of community engagement. You can register for the webinar here: https://us02web.zoom.us/meeting/register/lXMLhE6MRhiOlrnLKoe8Uw#/registration It’s part of a series being run by WHO and the Global Health Partnerships (GHP) (formerly THET), building on last year’s policy report on this issue launched at the World Innovation Summit for Health (WISH) https://wish.org.qa/wp-content/uploads/2024/09/Relationality-in-Community-Engagement.pdf We seem to have been taking in patient safety circles about the criticality of building a culture of safety for my entire career – but achieving this seems ever elusive. This work jumps out as offering something new. I will be writing a blog for PSL on this in the coming weeks.

Tuesday 17 September 2024. Another year, another World Patient Safety Day. This years theme “Improving diagnosis for patient safety”. Last years' report by the World Health Organization https://www.who.int/publications/i/item/9789240095458 first introduced the theme and talked about the need for multifaceted interventions rooted in systems thinking, human factors and active engagement of patients, their families, health workers and healthcare leaders. Improving healthcare processes that will result in improvements to diagnosis requires action at every level of the health system and looking at this years' calls to action https://www.who.int/campaigns/world-patient-safety-day/world-patient-safety-day-2024/calls-to-action leadership is both implied and front and centre. Focusing on these calls to action, here is what the campaign suggests individuals/entities across a range of settings can do to help improve patient safety in diagnosis. Patients, families and caregivers are - be informed, involved, and proactive in your diagnosis Be actively engaged in the diagnostic process and with your health care team: share accurate and comprehensive information about your symptoms and medical history; make sure you understand the diagnostic process, your illness’ or symptoms expected progression, and next steps; check your information is up-to-date, and keep track of your symptoms, medical visits, tests and treatments. Share your questions and concerns: don’t be afraid to ask questions; speak up, ask about alternative options or seek a second opinion if you need to; share your experiences and contribute to making diagnosis safer for others. Health workers providing clinical care - make diagnostic excellence integral to your daily practice Keep focussed on the person at the centre of the diagnosis: listen to your patient, ask them about their concerns and tailor the interventions to their needs; take a careful and thorough history and physical examination of your patient; talk openly and empathetically with your patients, and encourage them to ask questions. Leverage available technology, tools, and tests to reach a diagnosis. Be a good team player and contribute to a safe and collaborative professional environment, where information is shared in a timely manner. Keep learning: participate in regular training and seek feedback from your peers and patients; contribute a culture of continuous improvement by sharing best practices, and information about errors and near misses with peers. Healthcare facility leaders and managers - implement safer systems to improve diagnosis, support your clinical teams and empower patients Empower the health workforce through policy, culture and practice: ensure adequate staffing, resources and regular capacity development; make sure quality and well-maintained tests and technologies are available; implement and monitor the use of diagnostic safety guidelines, protocols and practices to ensure errors are minimised; promote a culture of continuous learning and safety, and take action to address problem areas; establish a conducive, collaborative and safe work environment free from distractions. Continually seek feedback from patients and their families and reserve space for advocates on advisory bodies. Celebrate diagnostic excellence within your teams. Policy-makers and programme managers - champion diagnostic excellence in health policy Prioritise patient safety in policy, legislation and regulation: ensure that appropriate guidelines and protocols to support diagnostic processes exist at a national level and are implemented; provide the necessary budget, staff, training and access to tools and technologies for national health systems. Establish national collaboration mechanisms to sustainably engage stakeholders. Promote accountability through monitoring and evaluation mechanisms, and ensure health leadership prioritize transparency. Set up national knowledge-sharing systems and encourage continuous learning. Invest in research into diagnostic errors, patient harm and the development of diagnostic tools and technologies. Patient organizations and civil society - advocate for quality and safe diagnosis Champion diagnostic safety in health policy and practice: work with patients, policy-makers and health care leaders to build health systems that deliver correct and timely diagnosis; facilitate patient advocacy and support their role in promoting and improving diagnostic safety; work with policy-makers, academics, health care leaders, health workers and patients to help identify areas for improvement. Contribute to the development of educational and training resources for health workers and patients. Diagnostics and medical devices’ regulators, manufacturers, innovators and managers - innovate for smart solutions and diagnostic excellence Drive research and development for diagnostic tools and technologies. Ensure diagnostic solutions meet the highest standards of safety, quality, and reliability. Create user-friendly products and instructions and provide regular training for health workers and patients. Collaborate with patients, health workers and health care leaders to build products tailored to the needs of end-users. I'm a strong believer in the power of campaigns. They act as a tool to raise awareness on important matters and trigger action that will result in change and improvement and there is evidence that they can have an impact on patient outcome. Before the end of 2024 there will be many more awareness days and weeks all of which will use campaigning to get their messages across in the noisy world of health care. It will be interesting to see the evaluation of WPSD 2024. More on this in due course.

Last week in Geneva the World Health Organisation Executive Board approved the “draft global action plan for infection prevention and control, 2024‒2030: draft global action plan and monitoring framework” and this will now proceed to the World Health Assembly in May for ratification by all WHO Member States. This very detailed action plan with its set of indicators, outlines a plan for countries and health care facilities to achieve the global vision that by 2030, everyone accessing or providing health care is safe from associated infections. A set of annexes go into the detail on the indicators and key players that will be instrumental in implementation of the plan once it has been ratified. There's a big focus on ensuring that in each country, IPC programmes are aligned with and contribute to other complementary national programmes’ strategies and documents, this is where the IPC-patient safety-quality-AMR interlinkages, relationships and collaborations (to name but a few programmes) come into play. The plan also addresses the need for political commitment, health worker knowledge, data for action, advocacy and communications, research and development and collaboration and stakeholders’ support. A theory of change is available. 2024 offers to be an interesting year for those working to improve infection prevention and control as one part of patient and health worker safety and quality.