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Showing results for tags 'Accountability'.
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Content ArticleA locally engaged health service can lead to a more open, dynamic and pluralist model of NHS governance and accountability. In weighing up the hopes for better integration and collaboration against concerns around operational pressures, Matthew Taylor, Chief executive of the NHS Confederation, discusses the potential positive impact that local government can have in health service decision-making.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content Article
Yakob Seman Ahmed, former Director General for Medical services in Ethiopia and the chair of national patient safety task force, and a recent Humphrey fellow, Public Health Policy, at the Virginia Commonwealth University, reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies.- Posted
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Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Ehi talks to us about how building a connection with patients makes their care safer, the safety issues caused by lack of regulation, accountability and transparency, and the moral responsibility each of us has to speak up when we spot safety risks or see a patient harmed. -
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In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.- Posted
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticlePromoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
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News Article
Patients will be endangered by flaws in health bill, says NHS ombudsman
Patient Safety Learning posted a news article in News
Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022 -
News ArticleEfforts to end health inequalities should be ‘in the mix’ of metrics used to determine the NHS’ progress against key performance targets, say race inequality experts. In an exclusive interview with HSJ, NHS Race and Health Observatory (RHO) director Habib Naqvi said organisations’ performance on the issue should be scrutinised by an external body to ensure they are held accountable and “not marking their own exam answer”. It comes as the RHO publishes a report that warns the appointment of health inequalities leads across the NHS risks becoming “tokenistic” if they are not adequately supported and held accountable. The report by The King’s Fund think tank has recommended several actions to prevent the introduction of board-level leads from becoming a “hollow gesture”. In August 2020, NHS England asked all NHS organisations to have a named executive board member responsible for tackling inequalities by October that year. The RHO estimates there to be more than 450 of these named leads across the country. The report welcomed this but added “frameworks” of support and accountability should exist to “empower individuals and motivate change”. The recommendations include putting inequalities on an “equal footing” with key performance metrics, as well as a long-term policy focus that puts addressing inequalities “at the heart of system development”. Read full story (paywalled) Source: HSJ, 1 December 2021
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Content ArticleJudy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
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Content ArticleSecond harm is the added psychological distress from an inadequate response by healthcare providers in response to medical errors or neglect. This inadequate response may require patients to seek counselling. The counselling needs of patients who have experienced second harm have received limited research attention. This Q methodology study addresses this gap in knowledge in order to further inform counselling practice.
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Content Article
Organisational culture and patient safety poster
Hugh Wilkins posted an article in Good practice
Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.- Posted
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content ArticleThis new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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Content ArticleTrusts that embed trust-wide improvement successfully throughout their organisations embrace accountability for that improvement and have boards that offer space to leaders at all levels to identify, shape and drive that improvement. They have a consistent and coherent approach. Perhaps most critically, they support their staff to engage in and lead improvement efforts by enabling them to both develop improvement skills and capabilities, and by focusing on relationships and culture. Staff in these organisations come to work to deliver and improve services. But how do boards support this evolution to happen? In our first three virtual webinar sessions as part of our trust-wide improvement programme, supported by The Health Foundation, NHS Providers delved into what it really means to have a systematic approach to improvement and what learning we can draw from the experiences of COVID-19. It explored diverse experiences of organisation-wide improvement, with differing investment levels, and type and rigour of method used. Trust leaders shared practical, actionable insights for peers to consider, with a number of common principles emerging that could help sustain the gains made as a result of the pandemic and respond to the scale of the challenges ahead. This briefing highlights what has been learnt so far
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Content ArticleIn this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
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EventuntilWhen things go wrong in health and social care, there can be significant consequences for patients, staff, and leaders. But, too often, the voices of people who use services and their families have gone unheard, while staff have feared being blamed for mistakes that result from systemic failings or human error. So how can health and social care leaders at all levels create a just culture, where mistakes lead to learning? And how can organisations take accountability for learning and improving after something goes wrong? The King’s Fund is co-hosting this virtual conference in partnership with the Parliamentary and Health Service Ombudsman from 13–16 September, in the lead up to World Patient Safety Day on 17 September, to explore how culture is key to enable professionals, patients and organisations to use the learning from mistakes and serious incidents to drive improvement in the safety and quality of care. Drawing on stories of learning and accountability told from several different perspectives, including case studies, we will examine how taking responsibility for learning offers a positive alternative to a culture of fear or blame. Register
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News ArticleOversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found. Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses. “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.” Read full story Source: The Washington Post, 2 June 2021
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Content ArticleBev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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Content Article
Schwartz Rounds publications
Patient Safety Learning posted an article in Research papers
Attached is a list of research papers on Schwartz rounds that you might find useful. -
Content Article
In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe. -
Event
Sharing accountability for patient safety
Patient Safety Learning posted an event in Community Calendar
Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organisational barriers to implementing an environment of shared learning. Additionally, panelists will discuss stepwise recommendations for the implementation of a Just Culture and will propose strategies for evaluating the impact of the shift from a blaming culture to a systems analysis approach. Register -
Content ArticleThis video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
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