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Showing results for tags 'Organisational learning'.
Found 542 results
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Content ArticleRecording of Ted Baker's presentation at The Royal Society of Medicine's Improving Patient Safety & Care Conference.
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Content ArticleOrganisations around the world are using 'Lean' to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems. Lean Hospitals, Third Edition explains how to use the Lean methodology and mindsets to improve safety, quality, access, and morale while reducing costs, increasing capacity, and strengthening the long-term bottom line. This updated edition of a Shingo Research Award recipient begins with an overview of Lean methods. It explains how Lean practices can help reduce various frustrations for caregivers, prevent delays and harm for patients and improve the long-term health of your organisation.
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey- Posted
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News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
Content ArticleA problem solving tool that captures everything you need on one piece of paper. Now that sounds pretty useful. In her latest blog, Sally Howard, Topic Lead for the hub, summarises 'A3', a problem solving tool that does exactly that. She draws on her own experience of using the tool to improve patient outcomes and provides both rich insight and practical examples to help others maximise it's potential.
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Content ArticleSix monthly summaries of how the NHS reviewed and responded to the patient safety issues you reported.
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Content ArticleIn this article, published by Birmingham City University, Criminologists Professor Elizabeth Yardley, Professor David Wilson and Emma Kelly discuss the report found that 450 patients died after being given powerful painkillers inappropriately at Gosport War Memorial Hospital. "To kill multiple people requires not just the presence of a determined killer but the absence of protectors and guardians. When no one is looking out for the interests of the vulnerable, the vulnerable become the victims. Within organisations, failed protectors and guardians find strength in each other, denying responsibility, eschewing accountability and playing ping-pong until (they hope) people will just go away and stop demanding answers."
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Content ArticleShifting the mindset (2020), a report from Healthwatch, investigates how hospitals report on complaints and whether current efforts are sufficient to build public trust. In this bog, Sir Robert Francis QC explains how hospitals can cultivate public trust in complaints.
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Content Article
Learning from excellence (2017)
Claire Cox posted an article in Organisational
Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. -
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 Article
Immunity to change, a blog by Sally Howard
Sally Howard posted an article in Culture
The New Year often encourages us to talk about change and to look ahead at what we want to achieve in the coming months as individuals, teams and organisations. In her latest blog, Sally Howard, topic leader for the hub, draws attention to the Immunity to change theory and outlines four key steps for realising our aspirations and making change happen. -
Content ArticleAction against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
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Content ArticlePatients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper, published by Social Science & Medicine, draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework – PFRF) which outlines why staff may find it problematic to respond to patient feedback.
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Content ArticleThere is little research focusing on how bereaved families experience NHS inquiries and investigations. Despite this gap, there is a consistent assumption that these processes provide families with catharsis. Drawing on her personal experiences of NHS investigations over a five‐year period after the death of her son, Connor Sparrowhawk, the author suggests the assumption of catharsis is misplaced and works to erase the considerable emotional ‘accountability’ labour that families undertake during these processes. She further question whether inquiries or investigations are an effective way of holding stakeholders to account. She concludes with two points: first, qualitative research is needed to better understand bereaved family experiences of inquiries and investigations and second, the ‘lessons learned’ objective underpinning inquiries should be replaced with ‘leading to demonstrable change’, which is what families typically want.
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Content ArticleThis paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
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Content ArticleThis paper explores how patient-reported experience measures (PREMs) are collected, communicated and used to inform quality improvement (QI) across healthcare settings.
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Content ArticleThis presentation, delivered by Margaret Murphy, Lead Advisor for the World Health Organization, took place at the Patient Safety Learning conference. In this short video, Margaret argues that the hear of the matter is in the patient'd and families experiences of care and how this, alongside true engagement, can be used to drive improvement.
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Content ArticleINQUEST's evidence-based report Stolen lives and missed opportunities: the deaths of young adults and children in prison, documents the deaths of 65 young people and children in prison between 2011 and 2014. In the four years covered, INQUEST reveals an average of more than one young death each month.
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Content ArticleMany people with learning disabilities are not getting their annual health check, facing increased risk factors to a number of diseases as a result. This article, by Jim Blair and published by the British Journal of Family Medicine, considers what more can be done to help those most at risk
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Content ArticleSam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
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Content ArticleA study showed that when doctors tell heart patients they will die if they don't change their habits, only one in seven will be able to follow through successfully. Desire and motivation aren't enough: even when it's literally a matter of life or death, the ability to change remains maddeningly elusive. Given that the status quo is so potent, how can we change ourselves and our organisations? In Immunity to Change, authors Robert Kegan and Lisa Lahey show how our individual beliefs, along with the collective mind-sets in our organisations, combine to create a natural but powerful immunity to change. By revealing how this mechanism holds us back, Kegan and Lahey give us the keys to unlock our potential and finally move forward. And by pinpointing and uprooting our own immunities to change, we can bring our organisations forward with us. This persuasive and practical book, filled with hands-on diagnostics and compelling case studies, delivers the tools you need to overcome the forces of inertia and transform your life and your work.
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Content ArticleA just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimise the negative impact, and maximise learning? This edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the decriminalisation of human error.
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Content ArticleIn this blog, Steven Shorrock discusses Learning Teams, small group conversations and action, and makes a case for learning in the following ways: talk about everyday work start with what’s strong, not what’s wrong find ways to cross departmental boundaries and get multiple perspectives understand first what can be done by teams.
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Content ArticleThis report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations. It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.
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Content ArticleHelen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
