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Showing results for tags 'Organisational culture'.
Found 1,093 results
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Content Article
It has become imperative that we discuss the issue of mental health in doctors and other healthcare staff. The mental wellbeing of a healthcare staff forms the bedrock of patient safety. It takes a safe and supported person to deliver safe healthcare and we must give this attention as we try to find ways to improve the quality of care within our healthcare systems. Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, reflects on the increasing workload and pressure healthcare professionals face, the impact this has on patient safety and why we need to start 're-humanising' the workplace. -
Content ArticleThis study by Sexton et al. was performed to determine whether health care worker (HCW) assessments of good institutional support for second victims were associated with institutional safety culture and workforce well-being. They found that perceived institutional support for second victims was associated with a better safety culture and lower emotional exhaustion. Investment in programmes to support second victims may improve overall safety culture and HCW well-being.
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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 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 ArticleWhen good people raise serious concerns employers can welcome them as gold dust, as "canaries in the mine" or do the opposite. This is an unfinished account of what happened when Karen Rai, Strategic Research & Innovation Manager at The Christie Hospital NHS Trust, wrote to the Trust Chair setting out concerns about governance, financial conduct, and bullying...
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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. -
Content ArticleThis is the National Guardian's Office annual data report covering the 1 April 2020 to 31 March 2021. It analyses the themes and learning from the speaking up data shared by Freedom to Speak Up Guardians across this period. There are over 700 Freedom to Speak Up Guardians in the NHS and there were 20,388 cases raised with them in 2020/21.
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Content Article
To err is human, to apologize is hard (JAMA, July 2021)
PatientSafetyLearning Team posted an article in Culture
This article, published in JAMA, tells the story of a 6 year-old boy who was initially misdiagnosed, which led to months of agony. Here, his mother, Thalia Margalit Krakower MD, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologise as essential to the healing process. "A deep cultural shift is needed in medicine to openly acknowledge and understand that imperfection is part of being human – no one knows everything, makes every diagnosis without delay, answers every patient message, or even delivers an apology just right. It is our humanity that makes us vulnerable to make mistakes and also empowers us to connect and heal." Read the article in full Related content Safety of candour: how protected are apologies in open disclosure? When the Duty of Candour becomes personal by Sarah Seddon Mothers Instinct: Reframing Duty of Candour in our hearts and minds – a blog by Joanne Hughes (15 October 2020) AvMA: Regulating the duty of candour. Requires improvement (October 2018) Barts Health NHS Trust: Duty of Candour training film (April 2016) Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour (June 2015) -
Content Article
In this video, Tim McDonald, Chief Patient Safety and Risk Officer at RLDatix, Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland, and Helen Hughes, Chief Executive of Patient Safety Learning, talk about the relationship between human factors, high reliability in healthcare and patient safety. -
Content ArticlePsychological safety (speaking up about ideas and concerns, free from interpersonal risk) is essential in high-risk environments, such as healthcare settings. This study, Enhancing psychological safety in mental health services, considers this issue within the context of mental health services. It provides an overview of the types of strategies and interventions for increasing the ethos of psychological safety and setting the foundations for delivering an organisation-wide programme on this topic. It also lists of key targeted areas in mental health that would maximally benefit from increasing psychological safety, both in clinical and non-clinical settings. Psychological safety as a cornerstone of improvement: blog by Joe Rafferty, Mersey Care Psychological safety and the critical role of leadership development (McKinsey and Company) The role of psychological safety in diversity and inclusion (Amy Edmondson) Three ways to create psychological safety in healthcare (Institute for Healthcare Improvement)
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Content ArticleIn this 30 minute film, Adrian Plunkett introduces the concept and history of learning from from excellence. Content also includes: Safety-II Positivity language Negativity bias.
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Content ArticleThis blog looks at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety. This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
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Content ArticleCommunity engagement is an iterative, on-going, long-term investment that is foundational to the work of demonstrating trustworthiness. It’s more than building trust in one project or community interaction, but rather building trust in the organisation and in the system. This guide from the Association of American Medical Colleges is for personal self-reflection or as a tool to help your organisation reflect upon all 10 Principles of Trustworthiness as you engage with your community.
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Content ArticleA "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
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Content ArticleIn this report, Exploring Freedom to Speak Up: Supporting the introduction of the Freedom to Speak Up Guardian role in Primary Care and Integrated Settings, the National Guardian's Office illustrates the challenges and benefits of implementing Freedom to Speak Up in different primary care settings. In 2019, the National Guardian’s Office began a two-year project working with primary care providers to understand how the Freedom to Speak Up Guardian role could be introduced in primary care and integrated settings. This report describes some of the variety of organisations, and the different Freedom to Speak Up models they have adopted.
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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Content ArticleJoe Rafferty, Chief Executive of Mersey Care NHS Foundation Trust, explains Mersey Care's strategy to pursue 'perfect care' and why it requires a cultural shift that is dependent on a paradigm shift in mind-set, behaviour and practice.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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Content ArticleSkip the inspirational speeches and culture committees. Meaningful culture change comes about only when companies rethink how they manage, lead, and pursue strategic goals, says Michael Beer in this Harvard Business School.
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Content ArticleImproving patient safety culture (PSC) is a significant priority for OECD countries as they work to improve healthcare quality and safety—a goal that has increased in importance as countries have faced new safety concerns connected to the COVID-19 pandemic. Findings from this OECD benchmarking work in PSC show that there is significant room for improvement.
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Content ArticleA recent survey has found that one in four doctors in the NHS are so tired that their ability to treat patients has become impaired. In this Guardian article, doctors reveal how tiredness, fatigue and sleep deprivation are affecting their ability to provide the best care for patients in the NHS.
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Content ArticleAlthough debate continues over estimates of the amount of preventable medical harm that occurs in healthcare, there seems to be a consensus that healthcare is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in healthcare. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: the need to limit the discretion of workers, the need to reduce worker autonomy, the need to make the transition from a craftsmanship mindset to that of equivalent actors, the need for system-level (senior leadership) arbitration to optimise safety strategies, and the need for simplification. Finally, healthcare must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.
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Content ArticleThe “WHO handbook for national quality policy and strategy” outlines an approach for the development of national policies and strategies to improve the quality of care. Such policy and strategy can help clarify the structures, roles and responsibilities within national quality efforts, support the institutionalisation of a culture of quality, and secure buy-in from health system leaders and stakeholders. The handbook is not a prescriptive process guide but is designed to support teams developing policies and strategies in this area, and very much recognizes the varied expertise, experience and resources available to countries. It outlines eight essential elements to be considered by teams developing national quality policy and strategy: national health goals and priorities; local definition of quality; stakeholder mapping and engagement; situational analysis; governance and organizational structure; improvement methods and interventions; health management information systems and data systems; quality indicators and core measures. The NQPS handbook was co-developed with countries each finding themselves at different stages of the development and execution of national quality policies and strategies and was informed by the review of a sample of more than 20 existing quality strategies across low-, middle- and high-income countries globally.
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Content ArticleBurnout is a serious problem for clinicians as well as the patients who rely on them for safe care, and the challenge has only been compounded by the stresses and trauma of the pandemic. A recent study by Pearl et al. showed that healthcare administrators could use a single survey item to see how their clinicians are doing. The question it asked was, “Are there individuals at your work location who are so burned out that the quality or safety of research, clinical care, or other important work product is impacted?” The respondents’ perception of the impact of burnout on quality safety of healthcare was self-reported using a 5-point system, ranging from 1 (“no burnout or it doesn’t impact safety and quality”) to 5 (“a serious impact on quality and safety”). This nonproprietary, single-item burnout-impacting safety scale showed a sensitivity of 82% using 4 on the scale as a cutoff (“there is quite a bit of impact of burnout on safety and quality”), indicating this tool may be effective in helping determine what healthcare providers may be at high risk for safety events affecting patients.
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Content ArticleIn this opinion piece for The Hill, the authors argue that urgent action is needed to prevent huge amounts of avoidable harm in the American healthcare system. They point to successful strategies under the Obama administration to demonstrate that the right political will can both improve patient safety and save money. They highlight actions that policy makers, official bodies and patients should take to promote the patient safety agenda.
