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Showing results for tags 'Implementation'.
Found 186 results
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Content ArticleProviders deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. Here is a case study from the Countess of Chester Hospital NHS Foundation Trust. It shows: Development of a trust wide roster for medical staff. Staff engagement – making the case for patient safety. Cultural shift – shared understanding across staff groups.
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Content ArticleProviders deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. This report showcases eight examples of great ideas put into action by trusts through the dedication and ingenuity of staff. One of the main themes in the report is the value of staff empowerment, where trust leaders support ideas and approaches developed within their workforce. Other themes such as innovation and collaboration also emerge. The case studies in this report are a timely reminder of the resilience and resourcefulness that has characterised the response of trusts and their staff to the challenges posed by the pandemic.
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Content ArticleThe African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme concerned with building sustainable hospital to hospital patient safety partnerships. The programme is focused on countries of the WHO African Region but has also opened the network and programme resources to all hospitals in all regions of the world. It sits within the programmatic area of Global Partnerships for Patient Safety. APPS is concerned with advocating for patient safety as a precondition of health care and catalyzing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts. APPS has taken place in a dynamic context in which insights are emerging on multiple dimensions of patient safety in African settings and political changes have seen shifts in approaches to patient safety in the United Kingdom. What is clear however is that the published literature on evidence-based patient safety interventions in the African context still lags behind high-income countries. This report highlights that issues and solutions from high income settings cannot simply be applied to African countries, and there is a need to understand the insights presented here from front-line partners to ensure that culture and context are addressed and the necessary adaptation made to existing approaches moving forward.
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Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
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The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticleFalls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
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Content ArticleIn this blog, Patient Safety Learning look at why complaints are important to improving patient safety and sets out its response to the Parliamentary and Health Service Ombudsman (PHSO) consultation on a new Complaint Standards Framework for the NHS.
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Content ArticleClinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery. This book is written primarily for staff leading clinical audit and clinical governance projects and programmes in the NHS. It should also prove useful to many other people involved in audit projects, large or small and in primary or secondary care.
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NHS Education for Scotland: Driver diagram
Patient Safety Learning posted an article in Quality Improvement
A driver diagram visually presents a team's theory of how an improvement goal will be achieved. -
Content ArticleThis report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. The report recommends a number of urgent actions to address these risks to patients.
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Content ArticlePatients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper, published by Social Science & Medicine, draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework – PFRF) which outlines why staff may find it problematic to respond to patient feedback.
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Content ArticleWhen it was initiated in 2001, England's national patient survey programme was one of the first in the world and has now been widely emulated in other healthcare systems. The aim of the survey programme was to make the National Health Service (NHS) more 'patient centred' and more responsive to patient feedback. The national inpatient survey has now been running in England annually since 2002 gathering data from over 600,000 patients. The aim of this study is to investigate how the data have been used and to summarise what has been learned about patients' evaluation of care as a result.
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Content ArticleResponding to online patient feedback is considered integral to patient safety and quality improvement. However, guidance on how to respond effectively is limited, with limited attention paid to patient perceptions and reactions. The objectives of this paper, published by Health Expectations, were to identify factors considered potentially helpful in enhancing response quality; coproduce a best‐practice response framework; and quality‐appraise existing responses.
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Content Article‘Safety differently’ is about relying on people’s expertise, insights and the dignity of 'work as actually done' to improve safety and efficiency. It is about halting or pushing back on the ever-expanding bureaucratisation and compliance of work. The cost of compliance and bureaucracy can be mind-boggling, with every person working some eight weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety. Over the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy.
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Content ArticleThe framework for safe, reliable, and effective care, set out by the Institute for Healthcare Improvement, provides clarity and direction to health care organisations on the key strategic, clinical, and operational components involved in achieving safe and reliable operational excellence, a 'system of safety', not just a collection of stand-alone safety improvement projects.
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NHS East London: QI Essentials. Beyond Projects
Claire Cox posted an article in Implementation of improvements
Improvement is now becoming a way of life and a way of being. How do we hold onto and strengthen our approach to QI projects? Have a read of Amar’s latest QI Essentials Blog. Amar Shah is a consultant forensic psychiatrist and Chief Quality Officer at East London NHS Foundation Trust. -
Content ArticleThis alert describes the procedure which must be taken within Alberta Health Services (AHS) when a clinical adverse event (CAE) occurs.
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Content ArticleOne important strategy for system-wide safety improvement involves investigating and addressing the system-wide sources of risk that contribute to unsafe care. Carl MaCrae in his paper published in the Journal of the Royal Society of Medicine highlights five strategies to ensure patient safety investigations actually improve patient safety.
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Content Article"...many factors can hinder effective implementation, including: failure to appreciate the complexity of a problem or the context in which change is required; complicated or unclear guidance; or using an inappropriate method of dissemination such as top-down instruction." In this blog for the Kings Fund, Suzette talks about the barriers to implementation and the importance of choosing the right approach.
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Content ArticleA US based study to determine whether medical errors, family experience and communication processes improved after implementation of an intervention to standardise the structure of healthcare provider-family communication on family centered rounds.
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
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Content ArticleReport of handling of complaints by NHS hospitals in England by Ann Clwyd MP and Professor Tricia Hart.
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Content ArticleThe phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.
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Swab safe management to prevent retained swabs
Kathy Nabbie posted an article in Improving systems of care
Implementation of the Swabsafe™ management system at the The Princess Grace Hospital following a never event.
