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Found 66 results
  1. Content Article
    The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.
  2. Content Article
    This is the report of a review conducted by the Health and Social Care Select Committee’s Independent Expert Panel, examining progress the UK Government has made against accepted recommendations from public inquiries and reviews on patient safety. It focuses on five recommendations, giving the Government for each a rating in the style used by national bodies such as the Care Quality Commission. The overall rating across all recommendations is ‘requires improvement’.
  3. Content Article
    The Patient Safety Indicators (PSIs) are a set of quality indicators developed by the Agency for Healthcare Research and Quality (AHRQ) providing information on potential hospital complications and adverse events after surgeries, procedures, and childbirth. They have been used for the past two decades in the USA for monitoring potentially preventable patient safety events in the inpatient setting through the automated screening of readily available administrative data. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied.
  4. Content Article
    This study from Jalilian et al., published in the BMJ, evaluated the length of stay difference and its economic implications between hospital patients and virtual ward patients. It found that the use of a 40-bed virtual ward was clinically effective in terms of survival for patients not needing readmission and allowed for the freeing of three hospital beds per day. However, the cost for each day freed from hospital stay was three-quarters larger than the one for a single-day hospital bed. This raises concerns about the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management.
  5. Content Article
    On the 24 October 2023 the Health and Social Care Select Committee announced that its independent Expert Panel would be undertaking an evaluation of government progress on implementing accepted recommendations to improve patient safety. As part of this review, the Committee wrote to the Secretary of State for Health and Social Care requesting a list of key independent public inquiry and review recommendations pertaining to patient safety and whistleblowing in the NHS that that the Government has accepted since 2010. This letter sets out the response to this request from Maria Caulfield MP, Parliamentary Under Secretary of State.
  6. Content Article
    Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. The Safer Tracheostomy Care in Adults bundle was a programme of 18 interventions implemented across 20 hospitals in England between August 2016 and January 2018. These interventions were designed to improve the quality and safety of care for patients who have had tracheostomies. This evaluation report outlines why the interventions were needed and assesses their impact, including an estimated reduction in total hospital length of stay per tracheostomy admission of 33.02 days, corresponding to a potential reduction of over £27,000 per admission.
  7. News Article
    The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
  8. Content Article
    The Covid-19 pandemic had an adverse impact on the detection and management of cardiovascular disease (CVD) risk factors including hypertension. In June 2022, nearly two million fewer people with hypertension were recorded as being treated to target, compared with the previous year. As a result, NHS England commissioned the AHSN Network to deliver a new national Blood Pressure Optimisation (BPO) programme building on its portfolio of work around cardiovascular disease. This report lays out: evidence about the impact of the BPO programme how it has been received by frontline staff how it has been implemented nationally.
  9. Content Article
    The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 aimed to: minimise burdens on public, independent and third sector employers and ensure businesses in UK are not placed at competitive disadvantage relative to EU counterparts offer good standards of protection to healthcare workers from risk of sharps injury at work see a fall in sharps injury numbers. This post implementation review (PIR) aimed to assess the success of these objectives. It found that: stakeholder consultation provided evidence of the increasing use of safer sharps across all healthcare sectors. evidence from RCN research and HSE inspections indicates that risks to healthcare workers from sharps injuries remains high. The policy conclusion from this evidence is that the Regulations are still required, and that the Regulations’ objectives cannot be met with a system that imposes less burden to business.
  10. Content Article
    The role of Patient Safety Specialist was introduced by the NHS in England in 2019, as part of wider plans designed to help improve patient safety. There are currently several hundred Specialists in place. All NHS organisations in England are required to identify at least one Patient Safety Specialist, and they will play a key role in delivering the NHS Patient Safety Strategy. The This Institute wants a detailed understanding of the background to the Patient Safety Specialist role and its implementation to date. This study aims to offer insights into the challenges and opportunities associated with delivering improvement though a designated role like the Patient Safety Specialist. The study aims to highlight ways to support Patient Safety Specialists and provide recommendations to NHS England about future policy and strategy around their role.
  11. Content Article
    The Learning Together Evaluation framework for Patient and Public Engagement (PPE) in research is an adaptable tool which can be used to plan and to evaluate patient engagement before, during and at the end of a project. The Learning Together Framework can be used in multiple ways with the purpose of mutual learning and understanding by all partners. It is rooted in seven guiding principles of patient engagement defined by the patient-oriented research community: Relationship building Co-building Equity, diversity and inclusion Support and barrier removal Transparency Sustainability Transformation
  12. Content Article
    The number of patients who die from post-surgical complications in low- and middle-income countries is shockingly high. In Africa alone, more than 600,000 people die each year after surgery, mostly from causes that are relatively easy to treat. This blog by Pierre Barker, Chief Scientific Officer at the Institute for Healthcare Improvement (IHI) looks at a method for reducing post-surgical death called the '5Rs for rescue': Risk stratification Recognise deterioration Respond Reassess Reflect/Redesign He describes how the IHI will test how to support the reliable implementation of the '5Rs for Rescue', which aims to reduce mortality by 25%.
  13. Content Article
    This long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
  14. Event
    until
    Health and care, and academic environments can have specific expectations that influence the evaluation of public involvement. These expectations may shape why the evaluation takes place and the approaches deemed ‘valid’. The hosts of this ‘Necessary Conversation’ argue that these environments and the approaches that they tend to favour, can lead to public contributors being absent from the conversation about what matters. Lynn Laidlaw leads this session with Niccola Hutchinson-Pascal and others to be confirmed. Lynn will be asking who is pushing the impact and evaluation agenda, where does the power lie, and what are the different forms of impact that exist? Sign up for this event
  15. Content Article
    This systematic review in BMJ Open synthesised evidence on the impacts of insufficient sleep and fatigue on health and performance of physicians in independent practice, as well as on patient safety. The authors also assessed the effectiveness of interventions targeting insufficient sleep and fatigue. The authors found that fatigue and insufficient sleep may be associated with negative physician health outcomes, but concluded that current evidence is inadequate to inform practice recommendations.
  16. Content Article
    This article by The Health Foundation looks at an evaluation carried out by Warwick Business School of a partnership between The Virginia Mason Institute and five NHS trusts. The partnership aimed to develop a ‘lean’ culture of continuous improvement which puts patients first by developing a localised version of the Virginia Mason Production System in each of the trusts. The objective was to embed and sustain a culture of continuous improvement capability within each of these five trusts and the NHS more broadly.  Outcomes from the evaluation include insight on progress and achievements in each trust, helping them to further embed a culture of improvement capability. The learning will also enable systems leaders to maximise knowledge on how to support providers to embed and spread a culture of continuous improvement in the NHS.
  17. Content Article
    How can NHS provider organisations and systems reliably and sustainably improve care? Historically, most improvement interventions have been discrete, small-scale efforts run by individual teams, often without reference to what else is taking place in their trust. However, it is now widely accepted that a patchwork of local interventions is unlikely to deliver sustained improvement or efficiencies on the scale that policymakers and local leaders want. This report by the Health Foundation outlines learning from the evaluation of the NHS partnership with Virginia Mason Institute, which examined how five NHS trusts in England attempted to build a culture of continuous improvement.
  18. Content Article
    This document by the World Health Organization (WHO) outlines an easy to follow country approach to developing or adapting an infection prevention and control guideline. It gives guidance on five steps countries can take: Prepare for action Baseline assessment Develop/adapt and execute Evaluate impact Sustain over the long term
  19. Content Article
    Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are used to assess the quality of healthcare experiences, focusing on patients. These measures help healthcare providers, commissioners and other stakeholders to make informed changes to their services. Showing the benefits of your intervention to the patient and healthcare delivery is important if you aim to have your digital product or service embedded within the healthcare system. The Office for Health Improvement and Disparities has collated guidance on how to use a patient-reported outcomes and experiences study to evaluate your digital health product.
  20. Content Article
    Patients with head and neck cancer may be required to travel significant distances for treatment, follow up and rehabilitation. This article in thr journal Cancer Nursing Practice presents findings from an evaluation of a pilot head and neck cancer service redesign in Thames Valley Cancer Alliance to enable patients from Swindon and Wiltshire to receive follow up and rehabilitation closer to home. The evaluation identified a decrease in overall outpatient visit time for these patients, resulting in reduced travel costs and improved quality of life.
  21. Content Article
    This article describes perceptions of the culture of safety in paediatric primary care in the US, and evaluates whether organisational factors and staff roles are associated with these perceptions. The authors found that perceptions of the culture of safety and quality in paediatric primary care practices were generally positive, but differences in perceptions did exist based on staff role.
  22. Content Article
    Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors of this narrative review in BMJ Quality & Safety aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature. They argue that securing improvement may be hard and slow and faces many challenges, but formal evaluations assist in recognising the nature of these challenges and help in addressing them.
  23. Content Article
    The Improvement Analytics Unit (IAU) was set up in 2016 as an innovative partnership between the Health Foundation and NHS England and NHS Improvement. It was tasked with evaluating the impact of some of the major new initiatives in health care in order to support learning and improvement in the NHS.   Arne Wolters is Head of the IAU, leading a team of analysts across the Health Foundation and NHS England and NHS Improvement. Together they work on detailed evaluation studies and provide rapid feedback to NHS leaders and decision makers, helping to identify what’s working well to improve outcomes. Here Arne discusses what the unit has achieved over the last 6 years, and what new plans are forming for the future. 
  24. Content Article
    Thousands of patients worldwide have experienced extreme pain and life-altering side effects as a result of surgical mesh implants. This report was commissioned by the New Zealand Ministry of Health to evaluate the project  ‘Hearing and responding to the stories of survivors of surgical mesh: Ngā korero a ngā mōrehu – he urupare’, which addressed issues raised by people injured by mesh in New Zealand.  A restorative approach to addressing harm in healthcare seeks to provide a collaborative, non-adversarial approach to resolving disputes. It recognises the need for relational interaction and conversation to support healing.  The project's restorative process was co-designed in 2019 by the Ministry of Health, advocacy group Mesh Down Under, and researchers and facilitators from Te Ngāpara Centre for Restorative Practice at Te Herenga Waka, Victoria University of Wellington. The evaluation was led by a team at the Te Ngāpara Centre, who evaluated the experiences of 230 people who took part in the restorative process. They aimed to find out if the project objectives were met and whether a restorative approach could be used in other health contexts.
  25. Content Article
    The Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology document provides comprehensive recommendations on how one may integrate human factors evaluations into procurement processes. While it is a relatively new aspect to consider in healthcare supply management, and may entail robust change management to implement, incorporating human factors evaluation in purchasing will enable best value and outcomes in health care.
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