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Jon Holt

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About Jon Holt

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  • First name
    Jonathan
  • Last name
    Holt
  • Country
    United Kingdom

About me

  • About me
    Patient Safety Manager at Birmingham and Solihull CCG who wants to connect with CCG colleagues in similar roles and share tools, resources, information etc.
  • Organisation
    Birmingham and Solihull CCG
  • Role
    Patient Safety Manager

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  1. Content Article
    Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff. Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS. Work-as-im
  2. Content Article Comment
    @HelenH the network of patient safety managers is essentially already happening via the creation of patient safety specialists, they will be the key group to take initiatives from the national strategy forward. so it's essential they have the right training, support, networks and opportunities to take things forward. time will tell but think it is a positive step
  3. Content Article Comment
    @Jerome P I think the national strategy and new framework can help here - they certainly have the right ambitions. Trusts need to build more expertise and knowledge in human factors, systems thinking, quality improvement, safety science etc which can be applied to lead to more effective investigations which identify the genuine root causes and appropriate solutions. Ultimately though to achieve the kind of change required it will require sustained support and focus including from national and regional teams to continue to drive this agenda
  4. Content Article Comment
    @Clive Flashman this doesn't surprise me. ultimately, it is down to providers and commissioners what contractual requirements they locally identify. I think in this instance the provider really needs to be more assertive when it comes to negotiating this to identify that this is something which isn't helpful. Equally some of the behaviours of CCG's when it comes to what they measure and the requirements they place on providers can be unhelpful and counterproductive even if well intentioned. This is where the new framework is intended to help - the idea is that where the underlying causes
  5. Content Article Comment
    @Jerome P in my experience most trusts do have mechanisms in place for tracking actions and do endeavour to see things through but things can also fall by the wayside where there are other competing pressures and priorities and the immediate time pressure to complete the RCA has subsided. However, I think the bigger problem is that the recommendations and actions generated from the RCA are often not addressing genuine root causes and are not system focused. They can be supeficial or ineffective actions focused on individuals and developing and revising policies etc. This is because invest
  6. Community Post
    @Mary-Jo Patterson a contact from NHSE&I has advised me that they are looking at some kind of event up in new year to share learning from early adopters although nothing has been communicated formally yet so don't think this is set in stone. It may be worth putting the feelers out with any contacts you have at NHSE&I whether anything is being planned in your region too
  7. Community Post
    Hi Helen My understanding of the guidance is that in-depth investigations will be limited to incidents of greatest severity and potential for learning. To support this organisations will have to develop an investigation strategy which defines what they would prioritise for investigation which links to national priorities too. There will be scope for organisations to investigate incident types that aren't in their priority list but idea is they focus on areas of highest risk. So, in reality the most severe forms of incident would still trigger an in-depth investigation. For less seve
  8. Community Post
    What are the unintended consequences and risks of failure that you foresee? I think it's positive that they are piloting this and intend to make changes based on experiences from the early adopters. My main concern is that in order to drive up quality of investigations you need to professionalise investigation and have much more rigorous training. Can organisations currently churning out poor quality investigations make a step change to something much better? Will there be a national commitment to support that? A national patient safety syllabus, patient safety specialists and accredited
  9. Community Post
    Yes, Trusts and CCGs have been written to asking them to identify their patient safety specialists by November 2020 with intention that those identified will be working full time in the role by April 2021.
  10. Community Post
    I know that trusts and CCGs have been contacted regard identifying patient safety specialists. Once these are established there will be nationally supported networks set up. I would guess patient safety specialists will have a role in supporting effective implementation of PSIRF
  11. Community Post
    Early adopters are identified on the national website here and I've copied below: https://www.england.nhs.uk/patient-safety/incident-response-framework/ If anyone has contact details for any of them and are happy to share (not via a public post) it would be really appreciated List of early adopters We are working with groups of organisations in each NHS region as early adopters, together with one organisation that works nationally. Listed by region, the early adopter organisations are: East Norfolk and Suffolk NHS Foundation Trust East Suffolk and
  12. Community Post
    The introductory version has been published today here with guidance below: https://improvement.nhs.uk/resources/patient-safety-incident-response-framework/ "Introductory version of the PSIRF While we are not asking organisations other than the early adopters to transition to the PSIRF yet, we want to help providers outside of the early adopter areas to plan for this change. We have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to d
  13. Community Post
    Hi A national consultation on the patient safety specialist role has now opened until 12th March 2020. You can view the patient safety specialist role draft requirements document and access the online survey to feedback here: https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-specialists/ NHS organisations have until June 2020 to identify who their patient safety specialist will be
  14. Community Post
    Hi The 500 character limit is excessively restrictive in my opinion for something which is supposed to be a key driver for achieving a step change in patient safety across the NHS. There is the facility to send comments via e-mail which I have done instead. I've reproduced my feedback below in case it is of interest to others. Overall, I think what is there is good but it seems to be missing some key elements in terms of supporting the kind of changes described in the national patient safety strategy: "Positive aspects: - The syllabus focuses on the role of or
  15. Community Post
    The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0)
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