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Showing results for tags 'Organisational culture'.
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Content ArticleThe NHS Resolution Just and learning culture charter has been developed as a resource to support the creation of a person-centred workplace that is compassionate, safe and fair when care in the NHS goes wrong. Most of the time, care received by patients in the NHS is safe. Sometimes, even with our best intentions, things can go wrong. When things go wrong, support, care and understanding for everyone involved must be a priority. At no time is there an excuse for incivility, bullying and harassment within the NHS. We accept the evidence that the NHS will provide safer care and be a healthier place to work if we address all of the components of a learning organisation and this underpins our charter. The hope is that this charter will act as a tool to help organisations take a consistent approach towards staff in relation to incidents and errors.
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Content ArticleHow can improvement-led delivery enhance the quality of outcomes for our patients, communities and our health and care workforce? In April 2022, Amanda Pritchard requested a review of the way in which the NHS, working in partnership, delivers effectively on its current priorities while developing the culture and capability for continuous improvement. Led by Anne Eden, NHS Regional Director South East, with a steering group chaired by Sir David Sloman, Chief Operating Officer, NHS England, the review team co-developed 10 recommendations with health and care leaders that have been consolidated into three actions.
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Content ArticleThis BMJ Leader article from Roger Kline looks at how to tackle structural racism in the NHS, discussing psychological safety and inclusion, and the role leaders need to play.
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Content ArticleMany healthcare leaders are governed by deep-set habits, behaviours and lessons learned over many years in an environment that was much less complex than today's. This creates barriers to success, perpetuating the challenges that we strive to overcome. The author of this article, published by NHS providers, argues that before we can adopt new habits, behaviours and processes, we have to "unlearn" the lessons of old.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety. -
Content ArticleAqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
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Content ArticleIf a manager approaches your desk, do you feel a sense of anxiety? If your team wants to challenge an idea or offer a different perspective, do they feel free to speak up? These are both examples of psychological safety - or a potential lack thereof - in the workplace. Organisations have focused heavily on mental health and well-being at work over the last few years, but many still lack an awareness of psychological safety, how it can impact your team and the consequences of an unsafe culture. This article looks at how you can measure and improve psychological safety.
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Content ArticleImperial College Healthcare share a poster on their strategic goals and their values and behaviours.
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Content Article
Kindness in healthcare website
Patient Safety Learning posted an article in Good practice
This 'Kindness in healthcare' website is the home for ‘conversation for kindness’, which is a monthly meeting that was set up in the summer of 2020 by a group of colleagues and friends working in healthcare across Sweden, the UK and the USA. The initial purpose of getting together was to have some time together to continue some initial conversations around kindness, and to explore its role at the ‘business end’ of healthcare. As the conversation has developed, interest in this work has grown and it now has contributors from almost 30 different countries across the globe. The monthly virtual call takes place the 3rd Thursday of every month (6-7pm GMT) and its focus is on listening, learning, thinking differently and mobilising for action It's an open culture of sharing of resources, energy and ideas. -
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In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content Article
In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire. -
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NHS Employers: Improving staff retention (April 2022)
Patient Safety Learning posted an article in Culture
As organisations navigate the ongoing impact and fallout of the COVID-19 pandemic, they must focus on strengthening the supply of our highly valued workforce and ensure that both new and existing staff are supported and encouraged to remain. In partnership with NHS England and NHS Improvement, NHS Employers has refreshed their retention guidelines. There are two main objectives for this guide: first, ensuring it continues to draw on the latest learning and innovation from the COVID-19 pandemic, which has forced employers to critically re-examine how to retain NHS staff. Second, ensuring it supports the ambitions set out within the NHS People Promise, so that employers can work to make this a lived reality for all NHS staff. To help achieve these objectives, this guide explores the experiences of organisations NHS Employers has worked with on retention. -
Content ArticleAqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
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Content ArticleThis plan from NHS England sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. NHS England has engaged a wide range of stakeholders who supported the development of this plan. This includes women and families who have used or are using maternity and neonatal services, members of the maternity and neonatal workforce, leaders and commissioners of services, NHS systems and regional teams, and representatives from Royal Colleges, charities and other organisations.
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Content ArticlePoster presentation from Dr Felicity Brokke and Ken Spearpoint at the recent GOSH Patient Safety and Human Factors Conference.
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Content ArticleOn 24 August 2022, the Employment Tribunal found that Mr Shyam Kumar, a consultant orthopaedic surgeon employed at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB), had been disengaged from his role as a Specialist Advisor within the Care Quality Commission (CQC) on account of having made “protected disclosures” to the CQC. This means he had raised concerns with CQC about the health of patients and other important issues and had done so in the public interest. The Employment Tribunal found that the fact that he had raised these various concerns with CQC had materially influenced its decision to disengage him. It awarded him £23,000 in damages for injury to feelings, on account of what it described as “the inevitable impact” of CQC’s actions upon Mr Kumar’s reputation among his peers and the shock, confusion and concern it caused to him. The CQC has accepted these findings and apologised to Mr Kumar. CQC’s Chief Executive, Ian Trenholm, issued a public statement on 6 September 2022 about what occurred, including a recognition of the importance of the concerns Mr Kumar raised, the importance of the information raised by staff and the public generally, and the “vital role” played by Specialist Advisors in CQC’s inspections. Following this, Zoe Leventhal KC was appointed by CQC’s Executive Board to carry out an independent review into whether CQC took appropriate action as a regulator in response to the protected disclosures that Mr Kumar made, and whether it dealt appropriately with a sample of other instances where concerns have been raised with CQC.
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Content ArticleThe concerns that health and care workers and the public share with the Care Quality Commission (CQC) about health and care services are critical to its work. It is also vital that CQC listens to its own staff. This review explores whether there are areas of culture or process within CQC that need to be improved in relation to listening, learning, and responding to concerns. The review focused on these key areas: Organisational findings Reviewing how well we listen to whistleblowing concerns. Reviewing our Freedom to Speak Up policy. Learning from the tribunal case. Reviewing how we listen to our staff. Reviewing the expectations and experiences of people who raise concerns with us.
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Content Article
Leadership in the NHS (BMJ Leader, 20 December 2019)
Patient-Safety-Learning posted an article in Leadership
In healthcare, leadership has a big influence on 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. In this article, Roger Kline looks at how creating a compassionate, inclusive culture improves patient safety—and by contrast, how a culture of fear and bullying has a negative effect. He examines why toxic leadership cultures develop and what can be done to transform leadership in NHS organisations. -
Content ArticleA number of serious concerns have been raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022. In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. This report outlines the outcomes of the first of these reviews, which is focused on clinical safety. It identified a number of issues which require attention, setting out 17 recommendations for further action.
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In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS. -
Content ArticleGPs in the UK are under extreme strain and public satisfaction with general practice has plummeted. Pressures on general practice are not unique to the UK and GPs around the world are contending with the impact of the pandemic on their patients and working lives. The 2022 Commonwealth Fund survey compares perspectives from GPs across 10 high‑income countries. The survey asked GPs’ views about their working lives and wellbeing, quality of care and how services are delivered. The Health Foundation analysed the survey data to understand the experiences of GPs in the UK and how they compare to other countries.
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Content ArticleNiche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.
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Content ArticleEvery day, healthcare professionals face the risk of traumatic events — such as an unexpected death, a medical error, or an unplanned transfer to the ICU. Yet few hospitals have programmes to support “second victims.” Too often, these employees experience self-doubt, burnout and other problems that cause personal anguish and hinder their ability to deliver safe, compassionate care. The Caring for the Caregiver programme from John Hopkins Medicine in the USA guides hospitals to set up peer-responder programmes that deliver “psychological first aid and emotional support” to health care professionals following difficult events. Modelled on the Resilience in Stressful Events (RISE) team at The Johns Hopkins Hospital, the programme prepares employees to provide skilled, nonjudgmental and confidential support to individuals and groups.
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Content ArticleThe aim of this article is to enable nurses to understand the powerful role of organisational culture in influencing the effectiveness of healthcare delivery, primarily within the NHS.
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