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Content ArticleThe NHS is in the process of changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system learning. The changes are set out in NHS England/Improvement’s Patient Safety Strategy, released in July 2019 and updated in February 2021. This was followed by the Patient Safety Investigation Framework in March 2020, due for full implementation by Spring 2022. They are important not just in relation to incident management but also because of the implications they have for strategy and board responsibilities in relation to patient safety. So they need careful attention at all levels of NHS organisations. This article from the Good Governance Institute highlights the safety roles and responsibilities of organisations and moving to a proactive approach to safety management.
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Content ArticleMoira Durbridge, Director of Quality Transformation & Efficiency Improvement for University Hospitals of Leicester NHS Trust, describes her typical day.
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Content ArticleIn this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
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- Organisational culture
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Content ArticleImproving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable. It’s about giving the people closest to problems affecting care quality the time, permission, skills and resources they need to solve them. As we shift from the emergency phase of COVID-19 it is vital that health and care workforces are able and supported to lead radical service change and improvements through re-starting, re-designing or developing new processes, pathways and services.
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Content ArticleHundreds of healthcare organisations around the world are Schwartz Center healthcare members and conduct Schwartz Rounds® to bring doctors, nurses and other caregivers together to discuss the social and emotional side of caring for patients and families. This video explains more.
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Schwartz Rounds publications
Patient Safety Learning posted an article in Research papers
Attached is a list of research papers on Schwartz rounds that you might find useful.- Posted
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Content ArticleProviding high quality healthcare has an emotional impact on staff. Often they experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges of their work. Rounds are a monthly staff forum (not attended by patients) where three to four employees (panellists) present short accounts of their experiences of delivering patient care. This organisational guide is based upon the findings from an evaluation of Rounds in the UK, undertaken between 2014 and 2016. The evaluation was commissioned by the National Institute for Health Research and led by Professor Jill Maben at King’s College London (now at the University of Surrey). The evaluation aimed to distil the findings and learning for practical application by organisations seeking to implement and/or sustain Rounds in their organisations.
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Content ArticleAmy Edmondson, the Novartis Professor of Leadership and Management at Harvard Business School, talks about building a psychological safe workplace for staff in this TEDx talk.
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- Staff safety
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Research: Why managers ignore employees’ ideas (8 April 2019)
Patient Safety Learning posted an article in Culture
When employees share novel ideas and bring up concerns or problems, organisations innovate and perform better. But managers do not always promote employees’ ideas. In fact, they can even actively disregard employee concerns and act in ways that discourage employees from speaking up at all. While much current research suggests that managers are frequently stuck in their own ways of working and identify so strongly with the status quo that they are fearful of listening to contrary input from below, new research offers an alternative perspective: managers fail to create speak-up cultures not because they are self-focused or egotistical, but because their organisations put them in impossible positions. They face two distinct hurdles: they are not empowered to act on input from below, and they feel compelled to adopt a short-term outlook to work.- Posted
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Content ArticleIn his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
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Content ArticleIn healthcare, leadership is decisive in influencing the quality of care and the performance of hospitals. How staff are treated significantly influences care provision and organisational performance so understanding how leaders can help ensure staff are cared for, valued, supported and respected is important. Research suggests ‘inclusion’ is a critical part of the answer, as Roger Kline explains further in this BMJ Opinion article.
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Content ArticleCOVID-19 presents many challenges to healthcare systems internationally, none more so than the significant reporting among healthcare workers (HCWs) of occupational fatigue and burnout or Long COVID related symptoms. Consensus on the extent of HCW fatigue during the pandemic remains largely unknown, as levels of Long COVID related fatigue in HCWs appears to be on the rise. What is known is that, among current levels, impacts of fatigue on HCW well-being and performance is likely. Developing strategies to mitigate fatigue are the responsibilities of all healthcare system stakeholders. Leadership that goes beyond organisational efforts of mitigating fatigue through mandated working hour limits alone are needed.
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Content ArticleThe Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
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Content ArticlePresentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.
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Content ArticleAlthough midwifery-led continuity of care is associated with superior outcomes for mothers and babies, it is not available to all women. Issues with implementation and sustainability might be addressed by improving how it is led and managed – yet little is known about what constitutes the optimal leadership and management of midwifery-led continuity models. Hewitt et al. carried out a scoping review on leadership and management in midwifery-led continuity of care models.
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Content ArticleWhile the benefits of psychological safety are well established, a new survey suggests how leaders, by developing specific skills, can create a safer and higher-performance work environment.
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Content ArticleWe have probably all suffered from imposter syndrome at some point during our career. Doubted our self and our abilities. However, if we aren't confident in ourselves and how we do our jobs it could impact on the patients we look after. Here are my tips on how to get to grips with your imposter syndrome.
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Patient Leadership Training Programme (InHealth Associates)
Patient Safety Learning posted an article in Leadership
Patient Leadership signals a breakthrough in healthcare that moves beyond traditional engagement and uncovers the pioneering and transformative work of patient leaders - those affected by life-changing illness, injury or disability who want to lead change in the healthcare system. Or ‘those who have been through stuff, who know stuff, who want to change stuff’. This course lays the foundation for understanding patient leadership – it is designed for both patients and non-patients to explore together different facets of this emerging social movement. It is for Patient and Carer Leaders, health professionals, managers, non-clinical staff and those from the independent, voluntary and charitable sector. And open to international attendees. 4 x weekly sessions of 2.5 hours £195 delivered by David Gilbert, InHealth Associates Director.- Posted
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Content ArticleEvidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. Alidina et al. explored the factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings. They found that performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. The authors conclude that future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.
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- Surgery - General
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Content ArticleThe Workforce Race Equality Standard (WRES) programme has now been collecting data on race inequality for five years, holding up a mirror to the service and revealing the disparities that exist for black and minority ethnic staff compared to their white colleagues. The findings of this report do not make for a comfortable read, and nor should they. The evidence from each WRES report over the years has shown that our black and minority ethnic staff members are less well represented at senior levels, have measurably worse day to day experiences of life in NHS organisations, and have more obstacles to progressing in their careers. The persistence of outcomes like these is not something that any of us should accept. It is in recognition of these realities that the People Plan 2020/21 has ‘belonging’ as one of its four pillars.
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- Workforce management
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Content ArticleHaugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
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Content ArticleThere is widespread consensus that learning is crucial for the performance of health systems and the achievement of broader health goals. However, this consensus is not matched by shared knowledge and understanding of how health systems learn, or of how to improve health systems learning across different contexts. The report is aimed at an audience of diverse stakeholders invested in strengthening health systems, and aims to achieve two things. First, to move towards a shared language and frameworks to discuss the problems and solutions of learning, as they apply to health systems. Second, the report seeks to advance action on learning – by providing stakeholders with clarity on steps that they can undertake to advance learning for health systems. This report is intended to be a starting point for gaining a shared understanding of learning health systems as an actionable agenda. The hope is that it will spur useful conversations and fuel the movement for better informed, more analytical and more self-reliant health systems – especially in the context of low- and middle-income countries.
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Content Article"The biggest struggle I had to overcome was the lack of confidence caused by microaggressions over time", says Samantha Tross, the first Black female orthopaedic surgeon in Britain. In the latest episode of the Royal College of Surgeons of England Health inequalities podcast series, Samantha considers how diverse leadership can be better developed and supported within surgery, with a focus on widening opportunities and creating a more positive training environment.
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Content ArticleThis is the response submitted by the Patients Association to the Department of Health and Social Care as part of its consultation seeking views on the proposed legislative details on the appointment and operation of the Patient Safety Commissioner for England. In this they argue for arrangements for the Commissioner's appointment and operation to guarantee their independence as securely as possible, and express disappointment that the role will not cover all aspects of patient safety.
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Health equity resource series
PatientSafetyLearning Team posted an article in Health inequalities
To support hospitals and health systems starting from different points on their journey to strengthen health equity, the American Health Association's Institute for Diversity and Health Equity (IFDHE) is preparing four new guidance and resource toolkits to share evidence-based practices to inform organisational next steps.- Posted
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- Health inequalities
- USA
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