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Showing results for tags 'Clinical governance'.
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Content ArticlePlans to establish integrated care systems (ICSs) as statutory bodies in the health and care bill foreshadow further changes to the organisation of the NHS. Unlike previous reorganisations, the changes expected to occur in 2022 have developed from within the NHS rather than being imposed by the government. Not only this, but leaders in the NHS have also played a major part in shaping the nature of these changes in partnership with the centre. This paper from the NHS Confederation focuses on the changes needed to create the conditions in which ICSs can improve outcomes for patients and the public and outlines a series of simple rules to guide those leading the reform programme. The ideas put forward are intended to provide a basis for debate with healthcare leaders and others in England about next steps. The paper starts from the premise that a key role of leaders is to harness the intrinsic motivation of health and care staff and public health teams to perform to the best of their abilities. The distinctive contribution of ICSs is to work with partners in making use of all available assets and leading improvements in patient care and outcomes that require actions across the organisations and services that make up the health and care system. Staff must be fully engaged in this work as it is through their actions that patients and the public will experience improvements
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News Article
Is the CQC giving the NHS an easy ride?
Patient Safety Learning posted a news article in News
The purpose of Care Quality Commission (CQC) ratings has been a hotly contested question since the creation of the four category classifications in the last decade. The original idea was to give the public a sense of how good their local hospital was, as well as providing commissioners, system managers and government with an idea of whether the local, regional or national health services they had responsibility for were getting better or worse. The practicality of the first aim was always questionable given the public’s inability and unwillingness, in most cases, to take their custom elsewhere. The second ran into the lack of desire and/or courage on behalf of most commissioners to challenge their local provider, but it did seem to have traction at the top of the shop. Jeremy Hunt, told HSJ, once they had been dished out across the sector, that their CQC classification now mattered much more then whether or not it had achieved foundation status or not. Another function, whether intended or not, was that by splashing “inadequate” and unsafe care on the front pages, in the wake of the Francis report, CQC ratings fuelled a drive to put more staff on the wards (forcing the Treasury to pay for the consequent agency bills and deficits, and curtailing Simon Stevens’ transformation funds). Whatever your take on their purpose, however, they only make sense if they accurately reflect the state of the service. And the latest data suggests that may not be the case. Read full story (paywalled) Source: HSJ, 17 March 2022- Posted
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Content ArticleThis guidance provides further clarity to guide the development of quality governance arrangements in integrated care systems (ICSs), particularly System Quality Groups (SQGs), which all ICSs must have. It sets out the National Quality Board’s requirements for quality governance in ICSs. Provides model terms of reference for SQGs and place-based meetings. Outlines suggested relationships with the integrated care boards (ICBs) and local authority assurance in relation to wider quality governance. Provides advice on administrating SQGs, including conflicts of interest. Sets out key principles for the approach to risk management within SQGs. This will be supplemented by further NHS England and NHS Improvement guidance on risk response and escalation, due in early 2022. See also the National Quality Board's Position Statement: Managing Risks and Improving Quality through Integrated Care Systems
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Content ArticleThis report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.
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EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #NHSSeriousIncidents hub members can receive a 20% discount. Email info@pslhub.org discount code.
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Content ArticleIn this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013.
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Content ArticleThis document by the National Institute for Clinical Excellence sets out the principles for best practice in clinical audit and includes; preparing for audit, selecting criteria, measuring level of performance, making improvements and sustaining improvement.
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Content ArticleJoint meeting with the British Medical Journal on establishing a register of financial and non-pecuniary interests for doctors.
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Content ArticleExternal clinical harm reviews aim to give assurance to patients, patient groups, commissioners and the public as to whether any patients have been harmed as a result of an incident, as well as to avoid future harm to patients. This handbook by Dr Henrietta Hughes, NHS Medical Director for London North, Central and East, outlines an approach to conducting clinical external harm reviews. It identifies the factors which make external clinical harm panels successful and provides example agendas and terms of reference for the process.
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News ArticleNHS hospitals have been forced to pay millions of pounds to regulators after wrongly claiming their maternity units were among the safest in the country. Seven NHS trusts, including some now at the centre of major care scandals, will have to pay back a total of £8.5m after self-assessments of their maternity services were found to be false. Families whose babies died as a result of avoidable errors at some of the hospitals told The Independent it was further evidence of poor governance and management failings. NHS Resolution, which acts as the health service’s insurer for clinical negligence, launched the maternity incentive scheme in 2018 in an effort to focus action on 10 key safety areas in maternity, including ensuring they have systems in place to review deaths, monitor women and plan staffing levels as well as reporting incidents to the Healthcare Safety Investigation Branch which investigates maternity incidents in the NHS. Among the trusts forced to give money back over the first two years of the scheme include Shrewsbury and Telford Hospital Trust, which paid back £953,000. An inquiry into its maternity service found a dozen women and more than 40 babies died as a result of poor care in one of the largest maternity scandals in NHS history. East Kent Hospitals University Trust, which is facing an inquiry into baby deaths and a criminal prosecution by the Care Quality Commission over the death of baby Harry Richford in 2017, face paying back £2.1m over two years. Derek Richford, who helped expose failings at East Kent after the death of his grandson, told The Independent it was “abhorrent” that the trust claimed “vital NHS funds by falsely claiming that they had achieved 10/10 for maternity safety when the truth was in fact 6/10. East Kent Trust did this two years running and even when asked to check their submission, reconfirmed the erroneous data to NHS Resolution.” An evaluation of the scheme by NHS Resolution said it was “recognised that recent examples of poor governance from trusts in relation to the certification of submissions require further action”. Read full story Source: The Independent, 7 March 2021
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Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleIn this article, published by BMJ Opinion, James Titcombe and Joanne Hughes provide an overview of the Patient Safety Commissioner role and suggest it's remit should go beyond medicines and medical devices to wider patient safety issues.
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Content ArticleThis reading list has been produced by The King’s Fund Information and Knowledge Services and is a list of links and abstracts to useful publications on clinical governance.
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Content ArticleThis review in the Journal of Clinical and Diagnostic Research explains the basics of audit and describes in detail how a clinical audit should be performed and monitored. It includes information on the 'Audit Cycle' and 'Ten Tips for Successful Audits'.
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Content ArticleTowards the end of December 2020 the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, indicated that the Government would be accepting one of the key recommendations made in the First Do No Harm report, published earlier this year by the Independent Medicines and Medical Devices Safety Review, by creating a Patient Safety Commissioner for England. In this blog, Patient Safety Learning Chief Executive, Helen Hughes, sets out some early thoughts on this proposal and considers what impact it may have on patient safety.
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Content Article
In this interview, Lesley Andrews reflects on her role as Head of Governance for the Cromwell Hospital in South West London. Lesley tells us how patient safety is central to her work and why culture, data and leadership are key to improving outcomes. -
Content Article
RightCare Pathway: Falls and Fragility Fractures
Claire Cox posted an article in Patient management
The Falls and Fragility Fractures Pathway defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures.The Falls and Fragility Fractures Pathway has been developed in collaboration with the National Clinical Director for Musculoskeletal Services, Peter Kay, Public Health England (PHE), the National Osteoporosis Society (NOS) and a range of other stakeholders from across the health and care system. The pathway defines the key interlocking components for an optimal system for prevention and management and the priority higher value interventions that systems should focus on to address variation, improve outcomes, reduce cost and contribute toward a sustainable NHS. -
Content ArticleA report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS.
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News Article
NHS England reinstates central control powers as covid risk rating is increased
Patient Safety Learning posted a news article in News
The NHS has been returned to the highest level of risk on its emergency preparedness framework, a move which allows national leaders tighter control over local resources and decision making. NHS England chief executive Sir Simon Stevens announced the decision at a press conference this morning. He said: “Unfortunately, again we are facing a serious situation [due to rising coronavirus infections and hospital admissions]. That is the reason why at midnight tonight the health service in England will be returning to its highest level of emergency preparedness, EPPR level 4, which of course we had to be at from the end of January to the end of July.” Placing the NHS on level 4 of Emergency Preparedness Reslience and Response framework allows system leaders to take control of decisions over mutual aid and other local priorities. Sir Simon was joined by NHSE/I medical director Steve Powis and Alison Pittard, dean of the Faculty of Intensive Care Medicine. They used the press conference to stress the threat the NHS faced from the second covid peak, but also set out more positive news on the covid vaccine programme. Read full story Source: HSJ, 4 November 2020 -
Content ArticleElderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
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Content ArticleIn this podcast from The Health Foundation, Chief Executive Dr Jennifer Dixon talks to Jeremy Hunt about his tenure as the longest-serving health secretary. Jeremy speaks about his passion for patient safety, a topic which became his professional focus following the Mid-Staffs investigations. He highlights the importance of the patient safety agenda and the need to learn from past experiences. With the challenges of the COVID-19 pandemic holding the world’s attention, what would Hunt have done differently? And what are the key lessons for government as we enter a new phase of the pandemic?
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Content ArticleHow many of you know the full history of duty of candour in healthcare in the UK? It was Will Powell who, after the tragic death of his son Robbie, brought to light that there was none. Even today we only have an institutional duty of candour in place, leaving clinicians with the right to lie as no specific law exists to prevent this.
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Content ArticleThe NHS Leadership Academy recognises the crucial importance of effective, engaged, accountable board leadership and has commissioned this refreshed edition of ‘The Healthy NHS Board 2013 - Principles for Good Governance’. This guidance supports the NHS Leadership Academy’s mission to develop outstanding leadership in health in order to improve people’s health and their experience of the NHS.
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Content ArticleIn this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future.
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Content ArticleMany mental health service providers around England are meeting complex challenges with exceptional innovation, energy and creativity. NHS Improvement has drawn on this experience, skill and expertise to develop a national model to support continuous improvement in service delivery. This practical resource offers experience from those that have travelled the journey already, in the hope of supporting and encouraging other mental health trusts or any healthcare provider wishing to improve its services. Chapter 7 looks specifically at safety, clinical audit and clinical governance. It shows that a structured approach to improvement supported by an open and just culture can make safer ways of working part of an organisation’s DNA. It recognises that organisations also need robust and transparent governance to keep services safe during major change.
