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Content ArticleEach year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
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Content ArticleIn this joint statement, National Voices, a coalition of health and social care charities in England, supported by 82 charities and professional bodies, call on the Government to act on the serious challenges faced by the NHS and social care workforce, which it states are badly impacting upon people’s experience of health and care. Patient Safety Learning is one of the signatories of this statement.
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- Workforce management
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Content ArticleIn this podcast, Care Opinion Chief Executive James Munro speaks to Alex Gillespie and Tom Reader of the Department of Psychological and Behavioural Science at LSE about their research paper 'Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents'. Their research analysed over 146,000 stories on Care Opinion using an automated machine-learning approach. Key findings included: automated analysis can reliably detect patient safety issues reported by patients. online patient safety concerns are associated with hospital level mortality. staff reported patient safety concerns are not associated with hospital level mortality.
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Content ArticleThis is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lesley talks to us about how personal stories enrich our understanding of data, drive real quality improvement and remind us that healthcare is all about people. She also explains how her own personal experience drives her work to improve healthcare experiences for patients and their families.
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- Patient engagement
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Content ArticleOxford Health NHS Foundation Trust want your feedback.
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Content ArticleThe Beryl Institute is seeking feedback on its proposed new global experience measure. The aim is to create a simple, clear experience measure set that ensures global accessibility and applicability, and supports tangible action. This survey aims to help the steering group assess the value and importance of their proposed set of questions. They would like to hear the perspectives of: patient, family members and care partners healthcare/experience leaders The survey should take less than five minutes to complete.
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Content ArticleThis editorial in BMJ Quality & Safety argues that patients' perceptions of their safety should not be dismissed when measuring healthcare safety. The authors argue that a differentiation between ‘feeling safe’, as defined through patient experience, and ‘being safe’, as defined through observation and evaluation using clinical outcomes selected by quality experts, creates a power differential and dynamic that degrades the role and value of patient experiences as valid patient safety indicators.
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- Psychological safety
- Safety culture
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Content ArticleThis report summarises the results of the Patients Association's Winter survey 2023, which received 1,933 online responses. The survey aimed to help develop understanding about the experiences of patients during a period of high pressure for the NHS. In addition to the usual winter pressures, the NHS experienced a backlog of care exacerbated by the Covid-19 pandemic, alongside years of underinvestment in the NHS, the absence of a long-term workforce plan and long-standing issues in the social care system.
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- Patient engagement
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Content ArticleThis online course by NHS England helps participants learn how to engage with different people and communities to reduce inequalities and ensure inclusive access to healthcare. It involves three hours of study time per week over two weeks and aims to equip healthcare professionals to: help the people they work with access healthcare services understand how people have different experiences in their access to healthcare explore inclusive engagement activities develop an awareness of implicit bias and underrepresentation
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- Health inequalities
- Health Disparities
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Content ArticleJill White is the practice manager of the Nightingale Practice and has been using Care Opinion since 2018. The Nightingale Practice signed up as part of the City & Hackney GP Confederation pilot of implementing Care Opinion online feedback as a way of gathering feedback from our patients instead of using paper-based surveys.
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News ArticleJust 1 in 4 UK GPs are satisfied with time they are able to spend with patients – appointment times are among the shortest of 11 countries surveyed. A report published today by the Health Foundation paints a picture of high stress and low satisfaction with workload among UK GPs. The report is an analysis of an international survey of GPs from 11 high-income countries, including 1,001 UK GPs, undertaken by the Commonwealth Fund in 2019. Among 11 high-income countries included in the study, only France has lower levels of overall satisfaction with practising medicine, and only Sweden reported higher levels of stress. Over half of UK GPs (60%) say they find their job 'extremely' or 'very' stressful, and almost half (49%) plan to reduce their weekly hours in the next three years. UK GPs also reported significantly shorter appointment lengths than their international colleagues. The average length of a GP appointment in the UK is 11 minutes, compared with a 19 minute average appointment for GP and primary care physicians in the other countries surveyed. Dr Rebecca Fisher, one of the Health Foundation report's authors and a practising GP, says: "These findings illustrate the pressures faced by general practice, and the strain that GPs are under. Right now the health system is in unprecedented territory and mobilising to meet the challenge of Covid-19. This survey shows that over the long term we need concerted action to stabilise general practice. Despite performing strongly in some aspects of care, many GPs consider that appointments are simply too short to fully meet the needs of patients. Too many GPs are highly stressed and overburdened – to the point of wanting to leave the profession altogether." Read full story Source: The Health Foundation, 5 March 2020
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News Article
‘Shameful’ data reveals NHS treatment of minority ethnic staff
Patient Safety Learning posted a news article in News
Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse. Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data. Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality. Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”. Read full story Source: The Independent, 18 February 2020 -
News Article
NHS Staff Survey 2019
Patient Safety Learning posted a news article in News
Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting. It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care. Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.- Posted
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Content ArticleFollowing the Shrewsbury maternity scandal where "at least 201 babies would have survived with better care", outgoing CQC chief inspector of hospitals Ted Baker said the NHS should listen to criticism to be able to change. Ted Baker said the NHS faced a resistance to being challenged and "for anyone to refuse to listen to criticisms of what the NHS does I think is a big mistake." Listen to Ted Baker's, CQC's outgoing chief inspector, full interview on Times Radio.
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- Organisational culture
- Organisation / service factors
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Content ArticleThis is draft material and is not live guidance. It is shared for information and will be tested with organisations who have agreed to pilot the new Complaint Standards. The model complaint handling procedure describes how your organisation will meet the expectations of the NHS Complaint Standards in practice. Download a Word version of the model complaints handling procedure from the link below to test within your NHS organisation.
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- Complaint
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Content ArticlePeople affected by health conditions bring insights and wisdom to transform healthcare – ‘jewels from the caves of suffering'. Yet traditional patient and public engagement relies on (child–parent) feedback or (adolescent–parent) ‘representative' approaches that fail to value this expertise and buffers patients' influence. This editorial from David Gilbert outlines the emergence of ‘patient leadership' and work in the Sussex Musculoskeletal Partnership, its patient director (the first such role in the National Health Service) and a group of patient/carer partners, who are becoming equal partners in decision-making helping to reframe problems, generate insight, shift dynamics and change practice within improvement and governance work.
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- Patient engagement
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Content ArticleRaising a concern is not always easy, but it is the right thing to do. It is about safeguarding and protecting, as well as learning from a situation and making improvements. This guide by the Royal College of Nursing is to help nurses, nursing associates, students and healthcare support workers based in the NHS and independent sector.
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Content ArticleThe Patient Experience Platform (PEP) is a listening tool which offers a new approach to collecting and analysing the views of patients on health services. The platform delivers comprehensive real-time reporting of what patients think about their care and provides actionable insights to inform operational decisions. This second annual report explains how PEP data is collected and analysed and explores some key findings on trends and variations in patient experiences across hospitals in England.
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- Patient engagement
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Content ArticleThis qualitative study in Patient Education and Counseling collected narrative accounts from doctors, nurses and patients to determine whether their perspectives can add new content to quality of care frameworks. The three groups raised the following 'quality of care' aspects: Successful communication among staff, with patients and care companions Staff motivation Frequency of knowledge errors Prioritisation of patient-preferred outcomes Institutional emphasis on building “quality cultures” Organisational implementation of fluid system procedures The study found that respondents primarily referred to care processes, rather than structure or outcomes, in their descriptions of 'quality of care'. 'Hippocratic pride' (in response to care successes) and 'rapid reactivity' (in response to (near) failures) emerged as two new outcome indicators of high-quality care.
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- Staff factors
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Content ArticleThis article by the Patient Safety Network provides an overview of the impact of diagnostic errors on patient safety. It gives examples of incorrect applications of heuristics and suggests ways to overcome cognitive bias in the diagnostic process.
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- Diagnosis
- Diagnostic error
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Content ArticleAppreciative inquiry is a collaborative, strengths-based approach to change in organisations and other human systems. It identifies the positive strengths of an organisation or system and builds on these, rather than focusing on problems that need to be fixed. This article for PositivePsychology.com outlines the history, theory and framework of appreciative inquiry, as well as looking at real-life examples.
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- Feedback
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Content ArticleThis study in BMJ Open considers how the usefulness of internal whistleblowing is affected by other institutional processes in healthcare organisations. The authors examine how the effectiveness of formal inquiries (in response to employees raising concerns) affects the utility of whistleblowing. The study used computer simulations to test the utility of several whistleblowing policies in a variety of organisational contexts. This study found that: organisational inefficiencies can have a negative impact on the benefits of speaking up about poor patient care where resources are limited and reviews less efficient, it can actually improve patient care if whistleblowing rates are limited including 'softer' mechanisms for reporting concerns (for example, peer to peer conversation) alongside whistleblowing policies, can overcome these organisational limitations.
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- Whistleblowing
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Content ArticleWard audit is a specific and common form of audit and feedback used in hospitals around the world. This study in BMC Health Services Research describes the content of ward audits and how they are carried out. The authors found that ward audits can have unintended and sometimes negative consequences, often caused by punitive feedback. They highlight the need to make feedback more constructive, for example, by including suggestions for improvement.
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- Hospital ward
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Content Article
What is clinical audit? (2009)
Patient-Safety-Learning posted an article in Clinical governance and audits
This guide by the University Hospitals Bristol clinical audit team provides a brief summary of what clinical audit is, and what it isn't. It outlines the main stages of clinical audit and describes how it can be used, how to engage patients in the process and which staff members should be involved.- Posted
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- Clinical governance
- Audit
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Content ArticleMany diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.
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- Process redesign
- Clinical process
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