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Showing results for tags 'Organisational culture'.
Found 1,089 results
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Content ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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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 ArticleSuzanne Banks presented at the NHS Health at Work Network Conference on menopause in the workplace and highlighted the case study of Sherwood Forest Hospitals. View her presentation slides below.
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Content ArticleResearch shows that patient safety walk rounds are an appropriate and common method to improve safety culture. This observational study in The Joint Commission Journal on Quality and Patient Safety combined walk rounds with observations of specific aspects of patient safety and measured the safety and teamwork climate. Healthcare workers were observed in specific aspects of patient safety on walk rounds in eight settings in a Swiss hospital. They were also surveyed using safety and teamwork climate scales before the initial walk rounds and six to nine months later. The authors evaluated the implementation of planned improvement actions following the walk rounds. The authors found that walk rounds with structured in-person observations identified safe care practices and issues in patient safety. However, improvement action plans to address these issues were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate.
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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 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 ArticleIt can be difficult to turn down requests to cover rota gaps. However, you must balance your own needs against those of the service discusses Emmeline Lagunes-Cordoba, Partha Kar and Tharusha Gunawardena in this BMJ article.
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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 ArticleThis National Guardians Office report analyses the themes and learning from their review of the speaking up culture at Blackpool Teaching Hospitals which was undertaken 2020. The National Guardians Office received information indicating that a speaking up case may not have been handled following good practice. The information received also suggested black and minority ethnic workers had comparatively worse experiences when speaking up. Based on focus groups and interviews with Trust workers, and analysis of internal processes and data, the report reviews information about the trust’s speaking up culture and arrangements and the trust’s support for its workers to speak up.
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Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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Content ArticleAppreciative inquiry is a collaborative, strengths-based approach to change in organisations and other human systems. It identifies the positive strengths of an organisation or system and builds on these, rather than focusing on problems that need to be fixed. This article for PositivePsychology.com outlines the history, theory and framework of appreciative inquiry, as well as looking at real-life examples.
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Article: Culture, kinship and intelligent kindness (2013)
Patient-Safety-Learning posted an article in Culture
This article by Penny Campling for the Royal College of Psychiatrists suggests that cultivating a culture of 'intelligent kindness' within the NHS will result in more safe and humane care. The author proposes a 'virtuous circle of compassionate care' and highlights systemic barriers that prevent organisations achieving this ideal. She argues that to create this virtuous circle, healthcare professionals need to acknowledge - and consciously work against - structures that undermine kindness. This requires a greater understanding the emotional impact of healthcare work, an acknowledgement that market culture undermines compassionate care and a renewed focus on relationships between professionals. -
Content ArticleResearch shows that peer support is an effective way to help healthcare staff recover when something goes wrong in patient care. The Betsy Lehman Center for Patient Safety has developed a toolkit that aims to help healthcare organisations create or expand peer support opportunities for staff. Each section of the online toolkit focuses on key elements of a successful peer support program - from gaining leadership buy-in to creating policies and collecting data.
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Content ArticleThis article published in Patient Safety discusses the role of patients and families in supporting a culture of safety. It looks at the concept of 'preoccupation with failure', a feature of high reliability organisations (HROs) and examines how patients can contribute to safety by being engaged in this process. The authors discuss a case study in which a patient contributes to safety improvements by sharing specific concerns. They draw out the importance of encouraging and empowering patients and their families to raise issues.
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Content ArticleThis article in The Joint Commission Journal on Quality and Patient Safety reports on the findings of a pilot programme to improve healthcare staff wellbeing. Between November 2018 and May 2020, researchers engaged five healthcare sites to take part in a pilot intervention. The pilot used evidence-based approaches to wellbeing including a comprehensive culture assessment, redesigning daily workflow and leadership and team development. The researchers found that healthcare worker wellbeing improved when: an integrated, skills-based approach was taken there was a focus on team culture, interactions and leadership workflows were redesigned to promote positive emotions. This study suggests that combining a number of these approaches at the same time can improve healthcare working environments and reduce levels of staff burnout.
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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 chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses describes a framework for understanding how human factors affect patient safety. It illustrates how different cumulative factors result in errors and suggests that nurses have a unique role to play in identifying problems and their causes. The authors highlight staff mindfulness as a tool to transform healthcare organisations into 'highly reliable organisations'.
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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.
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Content ArticleHealthcare settings are inherently hazardous places, with very unpredictable and complex working environments. These hazards and risks not only result in a range of injuries and ill-health among workers but also jeopardise the safety of patients. The COVID-19 crisis has amplified the importance of ensuring that the healthcare that is provided is safe—for patients and health workers alike. A sufficient, and capable, workforce, is the foundation of resilient systems. Policy makers need to focus now on how to build and support an appropriate workforce to respond to future shocks. This includes health workers beyond the hospital—including those in community, long-term, and primary care. The safety of both patients and health workers should be protected through appropriate mechanisms to ensure the safety of protective equipment and sufficient supplies, appropriate staffing levels, training and support at the workplace. These governance mechanisms are even more relevant when policy makers face trade-offs between health, safety and economic concerns. This is part of series of health working papers from the OECD on the economics of patient safety. The preceding paper, focusing on Long-term care, can be found here.
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In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships. -
Content ArticleThis paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
