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Jon Holt


Everything posted by Jon Holt

  1. 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 do to prepare ahead of the full introduction of the PSIRF in 2021. Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework."
  2. 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
  3. 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 organisational culture and its impact on patient safety - The inclusion of hierarchy of control when thinking about interventions to make services safer - It refers to proactive risk management rather than simply reacting when things have gone wrong, however, this element needs to be strengthened (see below) - There is a strong focus on systems, human factors and just culture when investigating incidents in order to promote learning and move away from a blame culture. Areas for development: - The syllabus does not mention Safety II or associated key concepts such as difference between work as imagined and work as done - The syllabus builds on and reinforces what we already have in place within the NHS rather than setting out a step change - It needs to describe more of how we would learn from things which go well (learning from excellence) and day to day work rather than focusing simply on accidents and incidents where things have gone wrong, i.e. via utilising techniques from Safety II. - No mention of appreciative enquiry, quality improvement methodology or other methodologies which could be used to deliver improvements which can enhance safety of services. This would be an important part of a proactive focus when it comes to safety Overall I think Safety II and quality improvement are key elements for inclusion in a patient safety syllabus and should be included to reinforce the direction of travel set out in national patient safety strategy"
  4. 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) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey
  5. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  6. Community Post
    Hi Claire I have mixed feelings about the concept and it really depends on how it is implemented. You're right that a specialist without knowledge of the working environment and culture won't be much use but this is where human factors should help as the focus should be understanding work at the sharp end and difference between work as imagined and work as done. I do worry though that having a 'patient safety specialist' means everything could get pushed to that person which isn't right. I think the focus should be less on having individual specialists but building more expertise amongst the workforce and those in existing patient safety / governance roles rather than inventing a new role. I think there is an idea that this role will help drive culture change with more focus on quality improvement, human factors and safety-II but without clear direction as to what these roles are for you'll end up with more of the same or responsibilities tagged on to someone's already heavy workload. I guess it is a case of watch this space, I think there has to be a lot of support, guidance and training for this role to deliver what is intended in the NHS patient safety strategy Jon
  7. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  8. Community Post
    Yes, this would be a good idea. Would be interested to have a forum where we can share tools, resources, information etc.