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Content ArticleThe West Suffolk Review, commissioned by NHS England on behalf of the Department for Health and Social Care, was published last month. NHSE/I asked the West Suffolk Board to produce an action plan for the 28 January meeting of the Board of Directors. This paper summarises the current position in relation to the learning, reflection and response thus far, including the organisational development actions that have already been taken and require further embedding. It also highlights the engagement undertaken to date, and what more needs to happen, to ensure our plans are based on the priorities for staff, governors, patients and teams and can carry the confidence of stakeholders. The report, 'West Suffolk Review – organisational development plan (p. 217)', sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
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Content ArticleHealthcare is recognised as a high-risk industry, involving complex systems, vulnerable individuals, and constantly evolving clinical treatments and healthcare products. This is the recording of a webinar hosted by NHS Supply Chain which looked at key patient safety issues in the NHS. It includes examples of learning related to patient safety and assurance priorities for safe healthcare products and services. Speaker panel: Helen Hughes, Chief Executive of Patient Safety Learning Tracey Cammish, NHS Supply Chain Heather Tierney-Moore OBE, NHS Supply Chain Dave Fassam, Healthcare Safety Investigation Branch (HSIB)
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Content ArticleA new report by the NHS Race and Health Observatory makes robust recommendations—we must act on them, write Mohammad S Razai and colleagues in this BMJ opinion piece. The magnitude of racial health inequalities reported in the NHS Race and Health Observatory’s recent review comes as no surprise. It highlighted the overwhelming, stark, widespread, and longstanding inequalities that people from ethnic minorities in the UK experience in access to healthcare and outcomes. The report found that this occurs “at every stage, throughout the life course, from birth to death” and is “rooted in experiences of structural, institutional, and interpersonal racism.” This evidence has been known for a long time, with the disproportionate impacts of Covid-19 on people from ethnic minorities drawing even greater attention to and wider recognition of these facts. Will evidence, however, be enough to compel those charged with the nation’s health to acknowledge and take urgent action to redress these egregious inequalities?
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Content ArticleFor about two decades, the U.S. healthcare system was making strides in improving patient safety, as demonstrated by the reduction of healthcare-associated infections and other complications of care. Though there was still room for improvement, the trends were certainly in the right direction. Since the Covid-19 pandemic began, however, many indicators make it clear that healthcare safety has declined. The public health emergency has put enormous stress on the health care system and disrupted many normal activities in hospitals and other facilities. Unfortunately, these stressors have caused safety problems for both patients and staff. The fact that the pandemic degraded patient safety so quickly and severely suggests that our healthcare system lacks a sufficiently resilient safety culture and infrastructure. The authors of this article in the New England Journal of Medicine believe the pandemic and the breakdown it has caused present an opportunity and an obligation to reevaluate healthcare safety with an eye toward building a more resilient health care delivery system, capable not only of achieving safer routine care but also of maintaining high safety levels in times of crisis.
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Content ArticleThis dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. This dissertation uses case studies to show the interweaving of organisational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sense making at both the field and organisational leadership levels of the organisation.
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Content ArticleCurrent UK health policy recommends the transition of maternity services towards provision of Midwifery Continuity of Carer (MCoCer) models. Quality of healthcare is correlated with the quality of leadership and management yet there is little evidence available to identify what is required from midwifery managers when implementing and sustaining MCoCer. Turner et al. developed a theoretical framework that represents midwifery managers’ experiences of implementing and sustaining MCoCer models within the UK’s National Health Service (NHS).
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Content ArticleThe Berwick report asks the NHS to change its culture and continuously improve patient safety, but this is not always easy. It takes Herculean will-power from right-minded leaders, constant coaching of the middle managers and it takes time. In this Health Foundation article, Stephen Singleton, a former NHS medical director and Chief Executive, and a former member of the Don Berwick advisory group, asks is it the sheer hardness of the challenge that allows us to tolerate doctors and nurses who are poor role models, incompetent managers and bullies? Or is it something else?
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Content ArticlePosters submitted to the Learning from Excellence Conference. The posters were grouped into three sessions, based on the topic of the poster and the session theme.
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Content ArticleJohn Drew, Director of Staff Experience and Engagement at NHS England and Improvement, presented at the NHS Health at Work Network Conference on how the NHS are supporting the health and wellbeing of staff by growing and developing NHS-delivered Occupational Health services. View the presentation slides below.
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Content ArticleNHS Improvement and NHS England presentation at the NHS Health at Work Network Conference on health and wellbeing in the NHS. View the presentation slides below.
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Content ArticleJulie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.
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Content ArticleDevelop your understanding of how to lead with compassion and kindness within the health and social care sectors in this free King's Fund course. This introductory three-week course is for anyone working in or interested in health and social care in its broadest sense, regardless of experience or role. It’s designed to introduce you to some of the foundations of leadership, kindness, and compassion. You’ll explore why these qualities matter now more than ever, and how to develop your personal practice of kind and compassionate leadership. As well as deepening your understanding and knowledge of leadership in health and care, this course will help you develop your own practice of kind and compassionate leadership. You’ll hear from leaders and experts from across the health and care system and explore some practical ways that you can develop a compassionate mindset and cultivate kindness and compassion in your relationships with others.
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Content ArticleAn example of how After Action Reviews are used by the US Army. An After Action Review (AAR) is a professional discussion of a training event that enables Soldiers/units to discover for themselves what happened and develop a strategy for improving performance. Facilitators provide an overview of the event plan (what was supposed to happen) and facilitate a discussion of what actually happened during execution.
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Content ArticleRisks should be reduced to the lowest reasonably practicable level by taking preventative measures, in order of priority. This table from the was developed by the construction industry’s Leadership and Worker Engagement Forum and sets out an ideal order to follow when planning to reduce risk from construction activities. This could be adapted for healthcare.
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Content Article
House of Commons Debate - NHS Allergy Services (29 October 2021)
Mark Hughes posted an article in Allergies
This is the transcript of an Adjournment Debate from the House of Commons on the 29 October 2021 on NHS Allergy Services, tabled by Jon Cruddas MP. -
Content ArticleThe All Party Parliamentary Group for Allergy, in conjunction with the National Allergy Strategy Group (NASG), has launched a new report which calls for the appointment of an influential lead for allergy who can implement a new national strategy to help the millions of people across the UK affected by allergic disease. This report brings to Ministers’ attention the growing allergy epidemic and the lack of NHS services for people with allergic disease. 20 million people in the UK, a third of the population, are living with allergic disease with five million of these severe enough to require specialist care yet our allergy services remain inadequate, often hard to access and are failing those who need them the most. Change is required and is now long overdue. For the growing number of people living with allergic disease in the UK, their condition can have a significant and negative impact on their lives. It is frightening and restrictive to live with a condition which could cause a severe or life threatening reaction at any time.
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Content Article
This white paper sets out the symbiotic relationship between healthcare worker safety and patient safety. It makes the case for a new focus on improvements in patient and healthcare worker safety, and on the relationship between them, to prevent safety incidents and deliver better outcomes for all. It has been published by the Safety for All campaign, set up by the Safer Healthcare and Biosafety Network (SHBN), an independent forum focused on improving healthcare worker and patient safety, including Patient Safety Learning and the Association of British HealthTech Industries. -
Content ArticleThis guide, produced by the NHS Staff Council Equality, Diversity and Inclusion Group, is aimed at equality, diversity and inclusion leads, HR and learning and development professionals, and trade union representatives. It provides a framework of good practice for the delivery of mandatory NHS equality, diversity and inclusion training for all staff, This training should be an integral part of the organisation’s wider cultural change and organisational development activities. Planning and monitoring of training delivery should be done in partnership with trade unions and staff networks, this can also support wider staff engagement.
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Content ArticleToo often in healthcare, when effective solutions to prevent avoidable harm are found, there is a lack of means to share these more widely. This gap between learning and implementation means that while we may we know what improves patient safety, this information can often remain siloed in specific organisations and health care systems. This results in patients continuing to experience harm from problems that have already been addressed by others. This article published in the Journal of Patient Safety and Risk Management describes how the charity Patient Safety Learning created the hub, a platform to encourage and support shared learning for patient safety. Designed by and for patient safety professionals, clinicians and patients, the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.
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Content ArticleThe Virginia Mason (VM) Medical Center based in and around Seattle consists of one 350 bed hospital facility and 9 satellite units. They employ 5000 staff, 500 of which are physicians. The Patient Safety Alert (PSA) system was introduced in 2002 following a staff survey. This showed that staff were fearful of speaking-up about concerns. Also, staff doubted that information generated from concerns would improve the safety of care. At the time of the survey VM staff wishing to raise concerns had to complete a quality incident report (QIR). Typically, QIRs would sit on a shelf collecting dust for months, then filed away and forgotten. As we know from countless reports and commentaries into safety failures in healthcare and other industries, perceptions of fear and futility around speaking-up are inimical to creating a positive speak-up or open culture. Virginia Mason share their results of implementing the PSAs and 10 lessons for speaking up in the NHS.
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Content ArticleWhen the history of the COVID-19 pandemic is written, it is likely to show that the mental models held by scientists sometimes facilitated their thinking, thereby leading to lives saved, and at other times constrained their thinking, thereby leading to lives lost. This paper from Trisha Greenhalgh explores some competing mental models of how infectious diseases spread and shows how these models influenced the scientific process and the kinds of facts that were generated, legitimised and used to support policy.
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Content Article
Organisational culture and patient safety poster
Hugh Wilkins posted an article in Good practice
Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.- Posted
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Content ArticlePeople in Place highlights the fundamental skills and people issues which will determine the future of health and care in the UK. The Covid-19 pandemic has made these issues clearer and more pressing, but it has also revealed an appetite for change and resulted in innovative ways of working. This report argues that building effective collective leadership into systems and places is vital to overcome staffing and governance issues in the NHS. Focusing on building long-term frameworks for change rather than responding to immediate pressures, it suggests practical tools and resources that could be used to bring about transformation within the system.
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Content ArticleThis maturity matrix from the Good Governance Institute is a resource designed to support organisations to self-assess whether they are appropriately applying the key principles of good governance practice in relation to quality assurance.
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Content ArticleThis report by Roger Kline brings together a range of research evidence to suggest practical steps NHS employers can take to reduce inequalities in staff recruitment and career progression. It specifically focuses on the treatment of female, disabled and BAME staff. Written for practitioners, it summarises some of the research evidence on fair recruitment and career progression. It highlights principles drawn from research that underpin the suggestions made for improving each stage of recruitment and career progression.
