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Content ArticleFreedom to Speak Up Guardians are changing the conversation about what it means to speak up in health. With a network of over 1,100 guardians and champions in England, workers are being supported and positive actions are being taken as a result. Speaking up and listening up should be a natural part of our conversations with colleagues, managers and each other. In health, as in all sectors, the best leaders understand the importance of listening to workers who are the eyes and ears of an organisation. But in health it is even more crucial as speaking up can be a matter of life or death. A positive environment and a supportive culture are key elements of the NHS People Plan. The Freedom To Speak Up Index, a new metric taken from the NHS Annual staff survey, shows that a positive speaking up culture may be correlated with higher performing organisations. The National Guardian Freedom to Speak UP launched the 100 Voices campaign: to share the stories that describe the current reality of speaking up in health. This document highlights and shares best practice in speaking up. Some have been provided by Freedom to Speak Up Guardians, others by workers themselves. Within these pages you will hear a selection of voices. They describe their experiences of speaking up, the impact this has had and how it has led to positive change.
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Content ArticleHow people are treated following their involvement in a workplace accident can have far reaching implications for both the individual and the organisation. This paper, published by Science Direct, examines the impact the use of retributive justice mechanisms within the accident analysis process have on both the individual and the organisation. It analyses the perceptions of those involved in five accidents where retributive justice mechanisms were used. The study of these cases shows retributive justice mechanisms used as part of the accident analysis process negatively impacts three key areas; (1) the mental health of the individual; (2) organisational learning and; (3) organisational performance. The study also illustrates that the language used as part of the accident analysis has a significant impact upon the perception of the process and the willingness to participate.
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Content ArticleProfessor Anne-Sophie Darlington speaks to ecancer at the 2019 EORTC Groups Annual Meeting (EGAM) about the importance of including the patient's experiences and voice during clinical trial assessments. Professor Darlington details the use of questionnaires to measure these patient parameters and how these must be carefully developed to allow flexibility to withstand the evolving environment of clinical trial research.
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Content Article
Resources for setting up learning from excellence reporting
Claire Cox posted an article in Motivating staff
Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. The preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. It is time to redress the balance. It is believed that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale. This page is for useful resources for setting up and maintaining an excellence reporting programme: -
Content Article
Learning from excellence: Entrance interview questionnaire
Claire Cox posted an article in Motivating staff
Here is a template for an entrance interview, produced by Learning from excellence. It has been designed using Appreciative Inquiry (AI) principles. It is envisaged to be used at the start of a new job or rotational placement to guide formation of personal development plans. However it could be adapted for permanent staff at times of appraisal. -
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Ten Thousand Feet: workshops and consultancy
Claire Cox posted an article in Suggest a useful website
Ten Thousand Feet UK is a Consultancy led by Rob Tomlinson in collaboration with the Association for Perioperative Practice. Rob is a clinical nurse in the NHS and is leading the way to improving patient safety through clinician-led culture change in the UK. Rob has already delivered workshops on a national scale with success for teams who have embraced the new procedure. 'Never Events' within the NHS are still on the rise with distraction and a loss of situational awareness still being cited as one of the main causes. Ten Thousand Feet aim to embed new patient safety culture into operating theatre teams nationwide, so at any time, anyone working in the theatre who needs to focus their attention at the task in hand can can use the language tool “Ten Thousand Feet” to improve team efficiency and most importantly patient safety. At the end of the workshop theatre staff will be educated and empowered to use this concept in a safe and effective manner. -
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National NHS staff survey 2019 results
Patient Safety Learning posted an article in Culture
The NHS Staff Survey is one of the largest workforce surveys in the world and has been conducted every year since 2003. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The survey provides essential information to employers and national stakeholders about staff experience across the NHS in England. Participation is mandatory for trusts and voluntary for non-trust organisations (CCGs, CSUs, social enterprises). The survey does not cover primary care staff. The report below provides a concise summary of key national results. Detailed local (organisation-level) results are also available here.- Posted
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Content Article
This is how to not fail at failing – blog by Roi Ben-Yehuda
Patient Safety Learning posted an article in Culture
In this blog, Roi Ben-Yehuda, a trainer at LifeLabs Learning, discusses why learning from failure is so rare and difficult and gives his top tips on what we need to do to stop failing at failing. -
Content ArticleHealthy eating and fitness mobile apps are designed to promote healthier living. However, for young people, body dissatisfaction is commonplace, and these types of apps can become a source of maladaptive eating and exercise behaviours. Furthermore, such apps are designed to promote continuous engagement, potentially fostering compulsive behaviours. This study, published by JMIR Publications, highlights the necessity for careful considerations around the design of apps that promote weight loss or body modification through fitness training, especially when they are used by young people who are vulnerable to the development of poor body image and maladaptive eating and exercise behaviours.
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Content Article
#NHSMeToo
Claire Cox posted an article in Motivating staff
The NHS is Britain’s greatest treasure. Yet it still harbours a culture of hierarchy where bullying, harassment and appalling training environments can go unchallenged. The Doctors Association UK (DAUK) believe that bullying, and discouraging victims from speaking up, goes hand in hand with a blame culture. Often doctors are shamed into silence, and don’t realise other doctors are struggling just as much as they are. Morale is at an all time low in the NHS, with rates of burnout and sadly, even physician suicide on the rise. DAUK are teaming up with the Royal Colleges as part of a wider NHS anti-bullying alliance and are encouraging doctors to speak about their experiences. -
Content ArticleAs part of Patient Safety Awareness Week 2020, the Royal College of Pathologists have released three videos. In these videos, trainees discuss error scenarios and how we can foster a positive culture of learning from those mistakes. Speakers include Dr Mathew Clark, Miss Laura Whitehouse and Dr Hamed Sharaf.
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Content ArticleJames Munro, Chief Executive of Care Opinion, argues that there is extraordinary, yet untapped value in patient feedback which is not being recognised in current policy and practice. His blog follows the launch of the National Institute of Healthcare Research's (NIHR) themed review on using patient feedback to improve care. Gathering feedback from people who use health services sounds like a simple and straightforward matter. Doesn’t everyone love feedback? The NIHR themed review Improving Care by Using Patient Feedback highlights that this is a topic beset by complexity, uncertainty and disagreement. It’s also an area which can provoke strong emotions both from those offering feedback, such as: “why isn’t anyone listening?” and those receiving it: “why am I being attacked when I work so hard?”.
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Content Article
The art of wobbling: Part 2
Sally Howard posted an article in Leadership for patient safety
In her last blog, topic leader for the hub, Sally Howard, talked about our triggers for a wobble and a few strategies to help as we take forward improvements in our services – building yourself a network, being genuinely curious and looking after yourself on the journey. This blog takes it one step further as she looks at what we can do when we hit a brick wall and offers some powerful strategies for dealing with conflict. An important and timely read, as we all look to support and appreciate each other through these difficult times. -
Content ArticleA recent evaluation looked at how an acute hospital trust placed into special measures implemented online patient feedback. Rebecca Baines, a Community Engagement Officer at Well Connected & PhD Student, shares her finding with the Point of Care Foundation.
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Content ArticleImproving experiences and outcomes for children and adults who are autistic or have a learning disability, their families and carers Ask Listen Do resources are designed to: support organisations to listen, learn from and improve the experiences of children and adults who are autistic or have a learning disability, their families and carers make it easier for people, families and paid carers to give feedback, raise concerns and complain.
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Content ArticleThis national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.
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Content ArticleThis report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
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Content ArticleA team of ward nurses from Merseyside took part in the 2018–19 cohort of the Innovation Agency's coaching for culture programme. The team, led by ward manager Sharon Mcloughlin, were all from the Dott Ward at The Walton Centre NHS Foundation Trust, a specialist trust in north Liverpool dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services.
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Content Article
What are Patient Safety Collaboratives?
Claire Cox posted an article in Health Innovation Networks (formerly AHSNs)
England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system. The PSC is a joint initiative, funded and nationally coordinated by NHS Improvement, with the regional PSCs organised and delivered locally by the Academic Health Science Networks (AHSNs). -
Content Article
WHO: Guidance for after action review (1 April 2019)
Patient Safety Learning posted an article in WHO
The WHO guidance for after action review (AAR) presents the methodology for planning and implementing a successful AAR to review actions taken in response to public health event, but also as a routine management tool for continuous learning and improvements. Four formats of AARs are described including the debrief, working group, key informant interview and mixed method AARs, and the accompanying toolkits containing materials to support the designing, preparing, conducting, and following up on each AAR format. Whilst the AAR methodology described in this document can be used for any response, a specific guidance to conduct an AAR following the response to emergencies that were not caused by biological hazards such as natural disasters is also provided to help the health sector to review its specific contribution to the multisectoral response and coordination. -
Content ArticleSee the South West Academic Health Science Network's video from the Institute for Healthcare Improvement (IHI) Patient Safety Officer Training. This training was held over a week for clinical and non clinical staff to understand patient safety and what role they can play.
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Content Article
Patient Experience Library: Patient surveys tracker
Patient Safety Learning posted an article in Patient engagement
The Patient Experience Library's patient surveys tracker offers one-click access to the key patient experience datasets for every Trust in England. -
Content ArticleThe Royal College of Anaesthetists set up PatientsVoices@RCoA to help the College improve the delivery of safe, more effective, patient-centred care to enhance patients’ experience of anaesthesia and perioperative care. This plan by PatientsVoices@RCoA aims to set out a clear direction for our future work which ensures patients’ voices are clearly heard across all relevant activities, as the College delivers its strategic aims over the next five years.
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Content ArticleThe Patients Association's Patient Partnership Week brought together patients, carers and healthcare professionals to talk about patient partnership.
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Content ArticleIn this episode of the Wild Card - Whose Shoes? podcast, Rachel Power, CEO of the Patients' Association talks about the importance of treating patients as equal partners in the health service. She shares insight on how to measure impact in difficult areas and overcoming barriers to shared decision making.
