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Showing results for tags 'Implementation'.
Found 187 results
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Content ArticleThis realist evaluation aimed to explore and explain the ways in which a programme initiated by the Scottish Government, Keeping Childbirth Natural and Dynamic (KCND), worked or did not work in different maternity care contexts. KCND was a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.
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Content ArticleIn this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
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Content ArticleThis mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.
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Content ArticleThe NHS in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. This study looks at the implementation of these policies within NHS organisations, with the aim of identifying key implications for policy and practice.
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Content ArticleThis article in The Milbank Quarterly summarises an extensive literature review addressing the question, "How can we spread and sustain innovations in health service delivery and organisation?" The authors identify three key outputs of the systematic review: A parsimonious and evidence-based model for considering the diffusion of innovations in health service organisations Clear knowledge gaps on which further research on the diffusion of innovations in service organisations should be focused A robust and transferable methodology for systematically reviewing complex research evidence
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Content ArticleThis thesis by Suzette Woodward describes a project that aimed to identify how the National Patient Safety Agency (NPSA) could support improvement in implementing patient safety guidance. It explored the factors that help or hinder successful implementation and its findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance about safer practices.
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Content ArticleIn March 2017 the National Quality Board issued the guidance on the actions all NHS Trusts should undertake to learn from a review of the care provided to patients who die stating it should be integral to a provider’s clinical governance and quality improvement work. Hertfordshire Partnership University Foundation Trust have developed a policy on Learning from Deaths setting out the work to be undertaken to review care provided to service users who die in the Trust's care.
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Content ArticleClinicians play an essential role in implementing infection prevention policy, but little is known about how infection control policy is implemented at an organisational level or what factors influence this process. This study explores the policy implementation process used in the introduction of a national large-scale, government-directed infection prevention policy in Australia.
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EventThis masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty of candour should attend, whether as a health or social care professional or at an organisational level, be it in the NHS, private healthcare or social care. Health and social care professionals; staff with responsibility for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending. See flyer attached below: Implementing the Duty of Candour with Empathy generic leaflet.pdf For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/duty-of-candour or click on the title above or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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LifeQI: Spread and Scale Cheatsheet
Patient Safety Learning posted an article in Implementation of improvements
As you begin to see improvement in the outcomes of your QI project, you might want to think about spreading the improvement in other teams or wards, or scaling it up. However, the successful implementation of the results of an improvement project in other teams requires a well-rounded plan. This Spread and Scale Cheatsheet from LifeQI will enable you to decide whether you're ready to spread or scale the improvement and what you need to consider in both cases. -
Content ArticleThis study in the Journal of Health Organization and Management aimed to explore factors shaping the implementation of five new care model (NCM) initiatives in the North East of England. The study findings demonstrate that all five pilot sites experienced, and were subject to, unrealistic pressure placed upon them to deliver outcomes.
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News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.- Posted
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Content ArticleBetween 2006 and 2009, WHO elaborated and issued the concept of ‘My Five Moments for Hand Hygiene’ in healthcare in collaboration with the pioneering infection prevention and control (IPC) research group at the University of Geneva. The primary objective of this approach is to facilitate behavioural change and prioritise hand hygiene action at the exact times needed to prevent the transmission of pathogens and avoid harm to patients and health workers during care delivery. Importantly, the Five Moments approach overcomes some relevant barriers to hand hygiene practices identified before its launch, such as long lists for hand hygiene action without any consideration of the dynamics of patient, health worker and environmental interactions The Five Moments approach is being constantly tailored to meet the challenges of care locations outside the traditional hospital setting, as well as across all countries and resource levels. The main thrust of the approach remains targeted at patient and health worker safety at the point of care where the risk of acquiring infection can be at its highest. Further work to help meet the Five Moments objectives through its adaptation and adoption worldwide is to be welcomed. WHO committed to further action and research on lessons learnt from field implementation, as well as the active dissemination of available tools to support countries to further understand and accept this proven approach.
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Content ArticleOnline patient feedback is becoming increasingly prevalent on an international scale. However, limited research has explored how healthcare organisations implement such feedback. This research from Baines et al. sought to explore how an acute hospital, recently placed into ‘special measures’ by a regulatory body implemented online feedback to support its improvement journey.
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Content ArticlePoster from the Princess Alexandra Hospital on their Learning from deaths project.
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Content ArticleIn this opinion piece for the BMJ, David Oliver, a consultant in geriatrics and acute general medicine, draws lessons from the Grenfell Tower disaster and subsequent public inquiry. 72 people lost their lives in the fire that destroyed Grenfell Tower in 2017. Evidence to the public inquiry has shown that several residents had raised concerns about the building's safety over many years, and that architects, building contractors, and providers and fitters of cladding material had also expressed concerns about the safety of the exterior cladding used on Grenfell Tower. David Oliver highlights that had these concerns been listened to and acted on, the disaster could have been avoided and many lives saved. He draws parallels with concerns being raised by patients about the safety of the healthcare system and highlights the role of staff in repeatedly raising and keeping a record of concerns. He states that NHS leaders must create a culture where no one is afraid to speak out and act to mitigate safety issues. Leaders must expect to be held accountable for their response - or lack of response - to safety issues raised.
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In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement. -
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NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in NHS England
This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert. -
EventuntilThis conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure Patient Feedback is translated into quality improvement and assurance. Through national updates and case study presentations, the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Sessions will include learning from patients, improving patient experience during and beyond Covid-19, a national update, practical sessions focusing on delivering a patient experience based culture, measuring patient experience, using the NHS Improvement National Patient Experience Improvement Framework, demonstrating insight and responsiveness in real time, monitoring and improving staff experience, the role of human factors in improving quality, using patient experience to drive improvement, changing the way we think about patient experience, and learning from excellence in patient experience practice. Chair and speakers include: Cristina Serrao, Lived Experience Ambassador NHS England and Improvement Clare Enston, Head of Insight & Feedback NHS England and Improvement David McNally, Head of Experience of Care NHS England and Improvement. Book a place Patient experience conference brochure 25 Nov 2021.pdf
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Content ArticleThis report provides an overview of the work of Healthcare Inspectorate Wales (the independent inspectorate and regulator of healthcare in Wales) during 2020-21. It discusses National Reviews undertaken in this period and trends emerging from its quality checks of health services. It also highlights areas of innovation, new methods of public and staff engagement and the delivery of care in new settings as a result of the COVID-19 pandemic.
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News Article‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair. Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator. He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals. Lord Prior said: “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better. “And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report. “I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do.” Read full story (paywalled) Source: HSJ, 9 September 2021
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Content ArticleThis is a study evaluating the implementation of a patient safety programme across a paediatric department at the largest public hospital in Guatemala. In their conclusion, the authors note that implementing such programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives.
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New digital documentation system to be implemented across Wales
Patient-Safety-Learning posted a news article in News
A new nursing digital documentation service is expected to roll out across Wales. Nurses will soon be able to use a mobile tablet to help perform their assessments in adult inpatient settings with the hope the new system will be more time efficient and improve accuracy. The project, led by NHS Wales and funded by the Welsh Government, will see nurses replacing paper documentation with digital ones. As part of the new digital implementation, a clinical nursing informatics lead is now employed in each health board. Hospitals in Hywel Dda University Health Board, followed by Swansea Bay University Health Board and Velindre University NHS Trust have been the first to adopt the new system. Read full story. Source: Nursing Times, 14 June 2021 -
Content ArticleNICE guidance on the management of chronic pain no longer recommends the initiation of many medications (e.g. NSAID’s, gabapentinoids etc) for primary chronic pain. However, there are many patients in the community who are already using these medications and it is important that when implementing this guideline, the recommendations are not used out of context. This joint statement aims to provide information that will help doctors and patients when reviewing medications.
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