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EventGovconnect are delighted to announce that the 3rd Annual Improving Patient Safety & Care Conference, will be held at the RSM in partnership with Patient Safety Learning. Supporting STPs/ICSs and healthcare providers to implement features of the NHS Patient Safety Strategy can only be achieved through the joint efforts of multiple organisations, and for the last 3 years, the Govconnect’s Patient Safety series of webinars has provided the platform for discussion to shape a better policy in order to better deliver the commitments of the strategy. Improving Patient Safety & Care 2022 allows government departments, arms-length bodies, the NHS and local authorities, research institutions, and the charity and voluntary sector to hear from senior leaders from many of the key partner organisations involved in implementing the patient safety strategy. Speakers at this event include: Dr Una Adderley, National Wound Care Strategy Programme Director, AHSN Network Cheryl Crocker, Patient Safety Director, AHSN Network Sir Robert Francis, Chair, Healthwatch England Dr Nigel Acheson, Deputy Chief Inspector of Hospitals, Care Quality Commission Helen Hughes, Chief Executive Officer, Patient Safety Learning Peter Walsh, Chief Executive, Action Against Medical Accidents & WHO Patients for Patient Safety Champion Agenda Register We are delighted to announce we have a number of fully funded tickets to offer. Please use the following code when asked at the cart on the registration page: IPSC22GUEST
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EventThis one day masterclass will focus on culture with healthcare organisations. It will look at effective ways to encourage healthcare organisations to unlock culture to improve both patient safety and staff safety. The Ockendon report (2022) reports a ‘Toxic culture’ of “undermining and bullying” left staff struggling to finish shifts and crying at work. Two thirds of staff said they had witnessed or experienced bullying. The report identified an “us and them” divide between doctors and midwives. Key learning objectives: Psychological safety Safety culture Toxic cultures Trust and safety Compassionate leadership. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/unlocking-culture or email kerry@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
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EventThis Westminster conference discusses the Government’s Women’s Health Strategy for England and the next steps for implementing ambitions in the context of a new Prime Minister. Delegates will look at the priorities for improving women’s health outcomes, service delivery and workforce education. Areas for discussion include: the strategy - scope and emphasis - implementation - the leadership and accountability to achieve progress service development - improving diagnosis - integration - tackling variation in access and other areas of inequality stigma - improvement of the first points of contact in primary care sexual and reproductive health - care and support across the life cycle - diagnosis rates - accessibility of services and information - patient-centred approaches research - areas of focus for women’s health - improving the data and the evidence base inequalities - tackling disparities in health outcomes - building a responsive environment for women’. Register
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EventThis on-demand conference focuses on supporting staff who have been involved in patient safety incidents, or are the subject of complaints or claims. Involvement in an incident, complaint or claim can have severe consequences on staff who may experience a range of reactions including stress, depression, shame and guilt. This conference will enable you to: Network with colleagues who are working to support staff following incidents, complaints or claims. Understand national developments including the requirements in the 2020 Patient Safety Incident Response Framework. Reflect on how we can better support staff experiencing these issues through Covid-19. Deliver a just culture that supports consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents. Reflect on a healthcare’s professionals personal experience of being the subject of an incident investigation. Improve immediate support and debriefing when an incident occurs. Develop your skills in providing the staff member involved in a patient safety incident specific individual support or intervention to work safely. Understand how you can improve processes for ensuring candour and supporting staff. Identify key strategies for interviewing staff and taking statements and preparing staff for Coroner’s Inquests. Ensure you are up to date with the latest developments in psychological support for staff including building resilience. Self assess and reflect on your own practice. Gain CPD accreditation points contributing to professional development and revalidation evidence. For more information https://www.healthcareconferencesuk.co.uk/on-demand-training/patient-safety-incident-complaint-claim or email kerry@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #SupportingClinicians
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Community PostAbout 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken to Perth Children’s Hospital the next day, but had to wait about two hours in the emergency department before she received treatment. She died soon after from a bacterial infection. An internal report into the tragedy made 11 recommendations — including improvement to the triage process, a clear way for parents to escalate concerns and a review of cultural awareness for staff — but Aishwarya’s parents said the report raised more questions than it answered. The family wants a broader independent inquiry to look at all 21 near-misses in the past 15 months – not just their daughter’s case. Some people have been referred to medical authorities, while Child and Adolescent Health Service chair Debbie Karasinski resigned after the report.' I am encouraged to see the way healthcare staff reacted to this tragedy. Imagine a similar event in England, would nurses protest outside the hospital and stand up to authority like this? I doubt it very much, which is very sad reflection on the prevailing culture and health leadership in England. What do others think? Source: The Australian. 9 July 2021 Picture: Picture: 9 News
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Community PostIt's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
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Community PostEarlier this summer the Independent Medicines and Medical Devices Safety Review, led by Baroness Cumberlege, published its report First Do No Harm, which looked at how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. One of the central recommendations of this report was the proposed appointment of a Patient Safety Commissioner who would “would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices”. The UK Government has yet to respond to the recommendations of the report and on the specific suggestion of Patient Safety Commissioner the Care Quality Commission’s chief executive Ian Trenholm recently suggested he was not sure such a role was needed. However today in their new Programme for Government the Scottish Government have confirmed that they will seek to “establish the role of a Patient Safety Commissioner”, following the Health Secretary Jeane Freeman suggesting they were looking into this in August. While its still early days – we’re yet to hear details on the proposed Commissioner's responsibilities, resources and reporting lines – would be keen to hear other people’s thoughts on this. Do you think a proposed Patient Safety Commissioner in Scotland or any of the other three countries in the UK would be a positive development? If so, what would this type of role need in order to be successful and really make a difference?
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Community Post
Coexistence of Accreditation and Regulation in Healthcare
Dr Akhil Sangal posted a topic in Innovation programmes in health and care
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Community Post
Resetting priorities for Safer Healthcare
Dr Akhil Sangal posted a topic in Leadership for patient safety
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Content ArticleIn February 2022, NHS England published its Delivery Plan for Tackling the Covid-19 Backlog of Elective Care, aiming for an unprecedented 30% rise in elective activity by 2024-25. In an effort to cut waiting times and the number of people waiting for first appointments, the plan set an improbably ambitious target of reducing follow-up outpatient visits by 25% by March 2023 from 2019-20, to leave more capacity for first appointments. All first appointment waits of over 52 weeks were to be abolished by 2025. In this BMJ opinion piece, David Oliver looks at why the targets are unlikely to be met.
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Content ArticleThe majority of safety failures in the NHS are caused by bad systems not by malicious or incompetent staff, writes Steve Black in this HSJ opinion piece. The Letby case has provoked plenty of discussion of the way the NHS handles safety critical issues. But there were some hints that the way the case was handled was too typical of how the NHS thinks about safety issues both culturally and procedurally. One part of the issue is how the system resists ideas that work elsewhere, the other is how the standard approach to problems makes learning hard and vastly increases the expense of handling safety errors.
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Content ArticleEven those at the top admit the NHS can’t do what is being asked of it today. But it is far from unsalvageable – we just need serious politicians who will commit to funding it, writes Gavin Francis, who shares his experience as a GP in this Guardian long read.
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Content Article
National Health Executive Podcast
Patient-Safety-Learning posted an article in Leadership
The National Health Executive Podcast brings you closer to the leaders, influencers and decision makers responsible for building, shaping and delivering transformational health and social care services across the UK. Covering everything from the net-zero, digital transformation, mental health, pharma, estates, workforce and training, our hosts brings you unique and exclusive podcast episodes packed full of news, views and insight from healthcare professionals and experts responsible for shaping the future of the UK health sector. -
Content ArticleIn June 2022, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. This briefing by NHS Providers summarises the key areas covered by the report, grouping recommendations under the following headings: Training Development Equality, diversity and inclusion Challenged trusts, regulation and oversight
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Content ArticleThis is the report of a review into how the executive leadership of the NHS could be better supported and empowered to ensure the best possible service is delivered for patients. Sir Ron Kerr was commissioned by the Department of Health and Social Care (DHSC) to conduct the review, which focused on three issues in particular: The expectations and support available for leaders - particularly those in challenging organisations and systems The scope for further alignment of performance management expectations at the organisational and system level The options for reducing the administrative burden placed on executive leaders The report describes the methodology of the review, outlines its findings and makes a number of recommendations around these issues.
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Content Article
A Kind Life website
Patient-Safety-Learning posted an article in Suggest a useful website
A Kind Life works with NHS organisations to help them shape a culture that cultivates kindness and nurtures high performance. The company offers a range of training courses and programmes focused on areas such as recruitment, leadership, feedback and conflict resolution. -
Content ArticleWe now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
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Content ArticleIncreasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board in the USA. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modelled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organisations. The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection. Three patient safety professionals shared their takes in Becker's Hospital Review.
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Content ArticleThe State of Integrated Care Systems 2022/23 examines the progress that local systems have made, and opportunities for further development. The NHS Confederation’s ICS network collected the views of 47 integrated care board chairs and chief executives, and integrated care partnership chairs, in the spring, as well as holding roundtables. The results found they are generally positive about relationships – with 88% agreeing that “partners within my ICS are working collaboratively”. However, when asked about whether a range of organisations in their area “have the requisite level of resourcing and maturity to deliver the ambitions outlined in your integrated care strategy”, there were signs of concerns about primary care networks, provider collaboratives and place-based partnerships, all of which saw less than 50% of leaders agree.
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Content ArticleSome of the same people that noted surgical masks were useless for airborne viruses also made decisions to limit the use of effective respirator masks: a decision that had devastating ramifications when the pandemic struck. In this article in the Byline Times, Josiah Mortimer delves deeper into a hub blog written by David Osborn: 'The pandemic – questions around Government governance' and questions the decisions made by the Government during the pandemic.
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Content ArticleThis NHS dentistry and oral health update has a special focus on patient safety. It includes an introduction by newly appointed Interim Chief Dental Officer (CDO) for England, Jason Wong and covers the following topics: Quality and safety in dental care Contributing to patient safety learning Using the Learning from Patient Safety Events (LFPSE) service Patient safety incidents and harm Patient Safety Incident Response Framework (PSIRF) Spotlight on Project Sphere Regulatory support Clinical leadership in patient safety
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Content ArticleThis paper attached clarifies what statutory duties, accountabilities and responsibilities providers, Integrated Care Boards (ICBs) and NHS England hold for quality. Please note this is a working document and will be updated.
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Content ArticleAccording to the last AHPRA Medical Training Survey, a third of doctors in training in the USA had experienced or witnessed bullying, harassment or discrimination in the workplace. The person responsible was usually a colleague and concerningly, only a third of those who witnessed or experienced this behaviour reported it. In this article, Josh Inglis explains why we can’t continue to overlook unprofessional behaviour in our workplace, because doing so is causing harm to ourselves, our patients and the profession, and what we can do about it.
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Content ArticleThe Fit and Proper Person Test (FPPT) Framework has been developed by NHS England in response to recommendations made by Tom Kark KC in his 2019 review of the FPPT (the Kark Revew). This framework introduces a means of retaining information relating to testing the requirements of the FPPT for individual directors, a set of standard competencies for all board directors, a new way of completing references with additional content whenever a director leaves an NHS board, and extension of the applicability to some other organisations, including NHS England and the CQC. It will help prevent directors who have been involved in or enabled serious misconduct or mismanagement from joining a new NHS organisation.
