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Showing results for tags 'Organisational culture'.
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Content ArticleThe objective of this Australian paper, published in the International Journal for Quality in Health Care, was to develop, implement and evaluate a system-wide 'challenge' with the aim of improving safety and quality.
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From Safety-I to Safety-II: A White Paper (2015)
PatientSafetyLearning Team posted an article in Organisational
This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II). -
Content ArticleThe current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
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Patient Safety, a book by Charles Vincent
Claire Cox posted an article in Recommended books and literature
When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in healthcare. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients, it also impacts positively on healthcare delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that it is a revelation of the pervading influence of healthcare errors and a guide to how these can be overcome. -
Content ArticleCharles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
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Content ArticleAt the second annual Patient Safety Learning conference we interviewed Douglas Findlay. Patient Leader at the Royal Berkshire NHS Trust, Douglas discussed why culture is important for patient safety, why it so hard to change the culture of an organisation and what we can do to help make culture better for patients and staff.
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Content ArticleWorkplace incivility is low level and often not intended to cause harm. It can come from managers, colleagues and patients. Examples might include: eye rolling abrupt emails being interrupted, excluded or ignored hostile looks refusing to assist a colleague publicly criticising a colleague. See how incivility at work affects NHS staff and how that can impact negatively on patient safety. In this short film, join the staff of Epsom and St Helier University Hospitals NHS Trust on their journey as they reflect on the real-life effects of both incivility and active kindness.
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Content ArticlePatient-centred, high-quality health are relies on the well-being, health and safety of healthcare clinicians. However, alarmingly high rates of clinician burnout in the US are detrimental to the quality of care being provided, harmful to individuals in the workforce and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organisation, and culture of healthcare. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.
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Content ArticleIn the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment. There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors. There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes. A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors. However, progress has been slower in translating policy into action at the level of the frontline clinician. Are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done? Wu and Steckelberg discuss this further in an Editorial published in BMJ Quality and Safety.
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Content ArticleThere are a number of fundamental weaknesses in governance around patient safety and the quality of care at Cwm Taf Morgannwg University Health Board, a joint review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office found. Following well-publicised concerns about maternity services at the Health Board, the joint review examined the organisation’s overall approach to quality governance. It found that whilst there has been a strong focus on financial balance and meeting key targets, less attention has been paid to the overall quality and safety of its services. The report highlights the need for stronger and broader leadership in respect of quality and patient safety and worryingly, points to a culture of fear and blame in some parts of the organisation that has prevented staff from speaking out and raising concerns.
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Content ArticleFor over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also watch the short video kindly made for me by Knowlex UK.
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Patient Safety: 20 Years After “To Err is Human” (2019)
PatientSafetyLearning Team posted an article in Culture
In this US based eMagazine Patient Safety: 20 Years after ‘To Err is Human,’ sees thought leaders from across the healthcare industry examine how shifting to patient-centred care has helped organisations across the country sustain a deeper culture of patient safety. By implementing strategies such as optimising health IT usability, advocating on behalf of patients and supporting healthcare workers, patient safety continues trending upward, leading to better outcomes. -
Content ArticleAmy Edmondson, PhD, Harvard professor and speaker at Learn Serve Lead 2019: The AAMC Annual Meeting, talks about how to create an interpersonal climate that encourages input from all members of the patient care team.
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Content ArticleAbout one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
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Content ArticleSteve Turner is a healthcare professional, a nurse prescriber with experience in senior management in both the NHS and private sectors. He works as a clinician with vulnerable adults on the margins of society. In this blog, published on Care Right Now, he reflects on the situation in England based on his experiences and those of the many people he has met as a result. All of whom experienced the backlash that can happen when organisational reputation trumps patient safety. One thing many of us have in common is that, put simply, we never intended to become known as ‘whistleblowers’ we were just trying to do our job to the best of our ability.
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Why is psychological safety being ignored?
Claire Cox posted an article in Motivating staff
John Dobbin is the editor of Thinking Digitally. Here he has written a blog on some of the barriers to psychological safety and why it is being ignored in the work place. -
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The Kings Fund: Improving NHS culture
PatientSafetyLearning Team posted an article in Incentives and techniques
It is now accepted that healthy cultures in NHS organisations are crucial to ensuring the delivery of high-quality patient care. The Kings Fund developed a tool to help organisations assess their culture, identifying the ways in which it is working well, as well as the areas that need to change. -
Content ArticlePublished in the BMJ journal Quality & Safety, the authors draw out high-level learning about culture and behaviour in NHS organisations; what influences culture and behaviour; and what needs to change to give effect to the vision of a safe, compassionate service in which patients and their families could have trust and confidence.
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Content ArticleFollowing the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019, chaired by Helen Hughes of Patient Safety Learning, I am pleased to share the speaker presentations on the hub. A new London conference has been announced for 29 April 2020. Telephone: 0161 376 9007; Email: info@openforumevents.co.uk for further information.
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Henrietta Hughes: The importance of speaking up in the NHS
Claire Cox posted an article in Speak Up Guardians
Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians. -
Content ArticleSpeaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you.
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Content ArticleReport of handling of complaints by NHS hospitals in England by Ann Clwyd MP and Professor Tricia Hart.
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Content ArticleThis independent review looked into the way NHS Wales handled concerns. The review was led by Keith Evans, the former chief executive and managing director of Panasonic UK and Ireland, and supported by Dr Andrew Goodall, Chief Executive, Aneurin Bevan University Health Board. A report was compiled making 109 recommendations.
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Content ArticleOver the last two decades across the globe we have seen a multitude of programmes, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached. Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely. This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. This book builds on the author’s first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the ‘how’.
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Content ArticleThe Safety Attitudes Questionnaire (SAQ) was developed in the US with funding from the Robert Wood Johnson Foundation and Agency for Healthcare Research and Quality. It is commonly used to assess healthcare workers' perceptions of patient safety related attitudes in various clinical areas and healthcare settings.
