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Showing results for tags 'Organisational learning'.
Found 540 results
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Content ArticleCovid has been a traumatic experience for many who work in the NHS. Battlefield scenes, redeployment and it can seem there is little end in sight. However, there have been positives. Improved team work, new ways of delivering care and better use of technology. How can we use this learning? How can we ensure that we capture the good stuff, and make sure that we don’t go back to old habits? Improvement Cymru, the all-Wales Improvement service for NHS Wales, has developed a ‘Learning from COVID’ toolkit’. It is based on the idea that bringing teams together to consider these questions in a facilitated discussion is not only practically helpful in supporting the service to develop – it is important in helping those individuals involved reflect on and come to terms with what they have experiences.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
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Content ArticleA set of 5 infographics describing the the factors that influence the risk of nosocomial transmission of infections (such as Covid19), and how health and care staff can take action to manage the risks and reduce the infection rate. The factors explained are: People Equipment Task Environment Organisation
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Content Article
Cyberattacks in health care can threaten patient safety.
lzipperer posted an article in Organisational
Large-scale organisational disruptions threaten patient safety. This essay from Lisa Croke in the AORN Journal shares privacy, physical space operation and medical device function concerns that could result from cyberattacks. -
Content ArticleHealthcare settings have been using collaboratives to improve quality in healthcare, enhance patient safety and drive organisational change since the mid-1990s, when they became popular via the Institute for Healthcare Improvement’s (IHI) Breakthrough Series model. QI Collaboratives are groups of people from different units or organisations who work together in a structured way and share learning and experience in order to create more efficient services. Collaboratives are generally set up to enhance patient safety, quality and efficiency of care. This Life QI article gives tips on how to run an Improvement Collaborative. Life QI is the global web platform where tools, people and data come together to make improvement happen.
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Content Article
NICE: Shared learning case studies
Sam posted an article in Suggest a useful website
The National Institute for Health and Care Excellence (NICE) have over 800 examples of shared learning, showing how NICE guidance and standards have been put into practice by a range of health, local government and social care organisations. -
Content ArticleThis document from the World Health Organization (WHO) is to urge the readers to understand the purpose, strengths and limitations of patient safety incident reporting. Data derived from incident reports can be very valuable in understanding the scale and nature of harm arising from health care, provided that the properties of the data are reviewed carefully and conclusions are drawn with caution. The use of incident reporting systems for true learning in order to achieve sustainable reductions in risk and improvements in patient safety is still work in progress. It can be and has been done, but not yet on the scale and with the speed that compares with some other high-risk industries. That is what we must all strive for. This technical guidance will help the journey to a position where we can show patients and their families how we used this learning to give them care that is safe and dependable, every time they need it.
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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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Content ArticleWith the National Learning from Deaths Programme Board stalled, the bereaved families who were to be involved in its work have once again been left harmed and without any answers, write Dr Josephine Ocloo and David Smith in this HSJ article.
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Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Ergonomics to support the COVID-19 response
Patient Safety Learning posted an article in Process improvement
Without embedded experience within healthcare organisations the application, evidence and business case for human factors in NHS decision-making will not be developed. The concerns about availability of ventilators offered the first opportunity to support the NHS. A rapid response project was initiated to support the design, development, usability testing and operation of new ventilators. This article from the Chartered Institute of Ergonomics & Human Factors looks at their response to the rapidly manufactured ventilators and their five-step approach response that was used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with ventilator manufacturers. It also discusses organisational learning and achieving sustainable change and the next steps in patient safety. -
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Why learn from everyday work? (Steven Shorrock, 2020)
Sam posted an article in Improving patient safety
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath? Steven Shorrock explores this in an article for HindSight. -
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Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the second part of a two-part roundtable Q&A on the topic of human performance in pharmaceutical operations. Part 1 evaluated the underpinnings of human performance and provided advice to those individuals managing rapid production scale-up to support COVID-19 production demand. Here in Part 2, human performance in the context of investigation and CAPA programmes is considered.
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the first part of a two-part roundtable Q&A focused on human performance in pharmaceutical operations. Part 1 discusses key drivers for human performance improvement, compares lean manufacturing and human performance programmes, and provides perspectives on human performance in the context of the rapid scale-up and production of COVID-19 therapeutics and vaccines. Part 2 reviews human performance in the context of company investigation and CAPA programmes.
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The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleIn response to the coronavirus disease of 2019 (COVID-19) pandemic, healthcare systems worldwide have stepped up their infection prevention and control efforts in order to reduce the spread of the infection. Behaviours, such as hand hygiene, screening and cohorting of patients, and the appropriate use of antibiotics have long been recommended in surgery, but their implementation has often been patchy. The current crisis presents an opportunity to learn about how to improve infection prevention and control and surveillance (IPCS) behaviours. The improvements made were mainly informal, quick and stemming from the frontline rather than originating from formal organisational structures. This paper from Toccafondi et al. aims to illustrate how adopting a human factors and ergonomics perspective can provide insights into how clinical work systems have been adapted and reconfigured in order to keep patients and staff safe.
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Content ArticleThe Care Quality Commission (CQC) has published the second report of Professor Glynis Murphy’s independent review of its regulation of Whorlton Hall between 2015 and 2019. CQC commissioned Professor Murphy to conduct an independent review to look at whether the abuse of patients at Whorlton Hall could have been recognised earlier by the regulatory process and to make recommendations for how CQC can improve its regulation of similar services in the future. In addition, CQC asked Professor Murphy to conduct a review of international research evidence to look at how abuse is detected within services for adults with a learning disability and autistic people and how such detection can be improved. The first report of Professor Murphy’s review made a number of recommendations for CQC to strengthen its inspection and regulatory approach for mental health, learning disability and/or autism services. This second report outlines the progress that CQC has made to implement the recommendations. This includes publication of the final report of its review of restraint, seclusion and segregation; work on closed cultures and the development of a tool for rating support plans.
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Content ArticleIn the summer of 2019, following a televised Panorama programme showing abusive care of people with learning disabilities and/or autism in Whorlton Hall (an independent hospital in the north of England), the Care Quality Commission (CQC) requested an independent review of its inspections of Whorlton Hall. Professor Glynis Murphy was appointed to conduct the review.
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Content ArticleThe Great Ormond Street Hospital for Children is one of London’s most respected health care institutions. Despite their long history of success, hospital leaders wanted to explore new ways to improve patient safety and decrease medical errors. In their efforts to deliver the best possible outcomes, they turned to a surprising source of inspiration. It turns out that many health care errors occur during transitions, such as transporting a patient into surgery. In rapidly changing, high-stakes moments, split-second errors can lead to disastrous outcomes. Instead of studying other hospitals, the leaders at Great Ormond Street turned to Ferrari’s Formula One pit crew team.
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Content ArticleJames Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
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Content ArticleSerious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past. The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
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Content ArticleA culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings.
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Content ArticleLearn how the key principles of safe design – standardize care, create independent checklists for important processes, and learn from defects – can be applied to create safer systems that benefit patients, health care teams, and hospitals.
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Content ArticleThis infographic is from Katie Martin's book, Learner-Centered Innovation: Spark Curiosity, Ignite Passion and Unleash. It highlights four key elements as key to creating a culture of learning and innovation. Give permission Offer protection Reduce and remove policies Eliminate perfectionism. This graphic can be used to spark conversation around safety culture within health and care teams, organisations and the wider healthcare service.
