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Showing results for tags 'Accountability'.
Found 189 results
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Content ArticleA new medical examiner system is being rolled-out across England and Wales to provide greater scrutiny of deaths. The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one. Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation. The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths ensure the appropriate direction of deaths to the coroner provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased improve the quality of death certification improve the quality of mortality data.
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Supporting second victims: breaking the cycle of harm
Claire Cox posted an article in Second victim
'Second victim' is the term used to refer to healthcare workers who are impacted by patient safety incidents. Whilst patients and families will always be the first priority following safety incidents, the well-being of the staff involved is often overlooked but can leave staff lacking confidence, unable to perform their job, requiring time off or leaving their profession. -
Content ArticleThe Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analysing and/or learning from patient safety incidents in any healthcare setting. The aim is to increase the effectiveness of analysis in enhancing the safety and quality of patient care.
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CPSI: Communicating after harm in healthcare (2009)
Claire Cox posted an article in Healthcare Excellence Canada
Communicating after harm in healthcare was developed by the Canadian Patient Safety Institute to assist organisations throughout the process of communicating after patient safety incidents that resulted in harm. -
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Video of a Schwartz round
Claire Cox posted an article in Good practice
In 2017, The Point of Care Foundation made a film of a Schwartz round at Ashford and St Peter’s Hospitals NHS Trust. The full session lasted one hour – this is an edited version which aims to show what happens in a round. Schwartz rounds often tackle difficult emotional situations. This film deals with a particular case about a sick baby, which some viewers may find upsetting. -
Content ArticleThis report evaluates Schwartz Center Rounds® (rounds) in England. Rounds were introduced into the UK in 2009 to support healthcare staff to deliver compassionate care, something the Francis report (Mid Staffordshire NHS Foundation Trust Public Inquiry) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of healthcare work, with the aim of improving staff well-being and patient care.
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The case for employee engagement in the NHS: three case studies
Claire Cox posted an article in Good practice
This report by The Point of Care Foundation, looks at staff engagement in three NHS hospital trusts and provides insights into the views of staff and managers. -
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JAMA: Time of day and the decision to prescribe antibiotics (December 2014)
Claire Cox posted an article in Culture
This research paper discusses the problem of decision fatigue and how it can impact patient safety. The authors hypothesised that decision fatigue, if present, would increase clinicians’ likelihood of prescribing antibiotics for patients presenting with acute respiratory infections as clinic sessions wore on. -
Content ArticlePolicy to date has mostly focused on the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), Tarrant et al., in a paper published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice.
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The STEP-up programme: Engaging all staff in patient safety
Claire Cox posted an article in Clinical leadership
Hamblin-Brown and Ingram, in the Journal of Patient Safety and Risk Management, discuss how Aspen Healthcare have reduced patient harm by engaging staff in ‘STEP-up’: a programme to improve the culture of patient safety. -
Content ArticleThis document sets out the General Medical Council's (GMC) expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.
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Content ArticleEmpowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson in this BMJ article. They discuss how healthcare can learn a lot from aviation and other high risk organisations, particularly in how they’ve embraced and applied human factors, the importance of looking after ourselves at work, and reducing hierarchy.
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Safety, Skills and Improvement: Patient Safety Zone
Claire Cox posted an article in NHS Scotland
NHS Education for Scotland's multi-disciplinary information and resources to help you understand more about patient safety and your contribution to making care safer. -
Content ArticleThis review of the literature by Mianda and Voce, published in BMC Health Services Research, was conducted towards identifying a model to inform clinical leadership development interventions among frontline healthcare providers, particularly for improved maternal and newborn care. The purpose of the literature review was to synthesise published evidence on frontline clinical leadership development and its evaluation, and included multiple frontline-care contexts.
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Fixing a toxic work culture: How to encourage active bystanders
alisonleary posted an article in Good practice
This article looks at encouraging better workplace cultures by encouraging people to be active bystanders. With a few simple facilitated sessions, many organisations have given their workforce the tools to provide interventions when toxic behaviours are displayed. -
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HCPC standards in practice: how to report concerns about safety
Tony Glazier posted an article in Whistle blowing
Following the publication of the Health and Care Professions Council (HCPC) whistleblowing policy, this blog post provides more details on who to raise your concerns with, and how and when to do so.- Posted
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Content ArticleThe government's response to the ‘Promoting professionalism, reforming regulation’ consultation. The consultation set out proposals to make professional regulation faster, simpler and more responsive to the needs of patients, professionals, the public and employers.
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Content ArticleWe launched our green paper, 'A Patient-Safe Future’, in September 2018 for two reasons: first to help us develop our strategy and work programme to ensure we are focused on areas that will help make a real difference and, second, to develop a clear and consistent message about how the wider system needs to change to better support patient-safe care.
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Content ArticleDespite 20 years of effort, every year avoidable unsafe care still leads tens of thousands of patients to suffer death or serious, life-changing harm. A Blueprint for Action, a report from Patient Safety Learning, furthers the analysis of the systemic causes of this harm and describes actions to make patient care safer. Last September, health and patient safety professionals and patients overwhelmingly welcomed the analysis of avoidable unsafe care offered in Patient Safety Learning’s Green Paper, A Patient-Safe Future. Matt Hancock, Secretary of State for Health and Social Care described it as “…the blueprint for action that we need.” Following widespread consultation on the Green Paper, A Blueprint for Action extends this analysis to identify actions to address the systemic causes of unsafe care.
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Content ArticleThis policy was written by Sussex Partnership NHS Foundation Trust. It is designed to ensure that concerns regarding the conduct or performance of staff which require formal investigation are investigated in a fair and consistent manner. Such an investigation may arise during the operation of other policies such as Dignity at Work, Grievance or Freedom to Speak Up. The outcome of the investigation may lead to further action such as a disciplinary hearing or use of the Managing Performance and Capability Policy. The policy identifies the circumstances in which an investigation will be necessary, the steps which should be taken in carrying out an investigation, the rights of staff during the process and potential outcomes.
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Content ArticleDeveloping the right people with the right skills and the right values is recognised as a key priority to enable the sustainable delivery of health services, as leadership is one of the most influential factors in shaping an organisational culture. Ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental. The aim of this document, developed by NHS England and Health Education England, is to give both Integrated Urgent Care (IUC)/NHS 111 service employers and employees some guidance about this key topic.
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Content ArticleA presentation by Shelia Yates on root cause analysis and Just Culture. Shelia is trained and educated in the performance of behaviour health services through interpersonal communications and analysis.
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Content ArticleThis resource supports organisations wishing to organise training exercises on how to use a 'just culture' guide. To help with the training, NHS Improvement have developed a series of case scenarios that facilitators can use to walk people through practical steps taken to achieve a just culture.
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Content Article
Just Culture: The movie
Patient Safety Learning posted an article in Good practice
This film documents the amazing transformation in one organisation — Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey towards a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organisation to a place where hurt doesn’t get met with more hurt, but with healing. -
Content ArticleThis regulation has been put in place by the Care Quality Commission (CQC) in 2014. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.
