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Showing results for tags 'Organisational learning'.
Found 542 results
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Content ArticleThis report is a practical guide to developing an organisation-wide approach to improvement. It summarises the benefits of such an approach and outlines the key elements and steps that NHS trust leaders should adopt when pursuing this agenda.
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Radio Ombudsman
Patient Safety Learning posted an article in Recommended video and audio resources
The Radio Ombudsman features full and frank conversations with special guests on a range of topics such as NHS investigations, good complaint handling and improving public services. Hosted by Parliamentary and Health Service Ombudsman Rob Behrens, it generates lively discussion and interesting ideas. The Ombudsman makes final decisions on complaints about government departments, other public organisations and the NHS in England. -
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 ArticleThis guide aims to support NHS organisations to apply a framework for measuring and monitoring safety. It describes some broad principles to bear in mind when using the framework and provides some prompts for each of the framework’s dimensions to help people focus on some of the main challenges to understanding safety. The guide also provides a brief summary of the research underpinning the framework and details of further resources available to find out more.
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What is the World Health Organization (WHO)?
Claire Cox posted an article in WHO
The World Health Organization (WHO) began when the Constitution came into force on 7 April 1948 – a date that is now celebrated every year as World Health Day. The WHO are now more than 7000 people from more than 150 countries working in 150 country offices, in six regional offices and at headquarters in Geneva. -
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What is NHS Resolution?
Claire Cox posted an article in NHS Resolution
Healthcare provision in the NHS is very safe but, on rare occasions when things go wrong, it is important that those involved are properly informed and supported, compensation is paid fairly, unnecessary costs are contained and that we learn in order to improve. -
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What is NHS Improvement?
Claire Cox posted an article in NHS Improvement
NHS Improvement supports foundation trusts and NHS trusts to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. From 1 April 2019, NHS England and NHS Improvement came together to act as a single organisation. -
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What is the National Institute for Health and Care Excellence (NICE)?
Claire Cox posted an article in NICE
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. -
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 ArticleThe Healthcare Safety Investigation Branch (HSIB) became operational on 1 April 2017. Their purpose is to improve safety through effective and independent investigations that don't apportion blame or liability. Although funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement, HSIB operates independently. It is also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations, they aim to drive positive change at a wider level.
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Content ArticleMaintaining momentum highlights failings in specialist mental health services in England, and the devastating toll this takes on patients and their families. The report's findings provide fresh impetus to deliver on the recommendations set out in the NHS Five Year Forward View for Mental Health.
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Content ArticleThe Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analysing and/or learning from patient safety incidents in any healthcare setting. The aim is to increase the effectiveness of analysis in enhancing the safety and quality of patient care.
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Content ArticleA lack of medical engagement is known to represent a significant barrier to quality improvement within NHS England. In the context of clinical audit, securing medical engagement is critical to its long-term success because it helps to facilitate organisational learning so that the same errors are not subsequently repeated by others. By fostering open cultures medical engagement can help doctors to re-frame error as a learning opportunity. By engaging doctors in this process, clinical audit goes beyond being a tool of quality control by providing a vehicle for continuous improvement in standards of diagnostic reporting. This study from Ross, Hubert and Wong identified the barriers and facilitators of doctors’ engagement with clinical audit and explores how and why these factors influenced doctors’ decisions to engage with the NHS National Clinical Audit Programme. The study documents performance feedback as a key facilitator of medical engagement with clinical audit. It found that medical engagement with clinical audit was associated with reduced levels of professional anxiety and higher levels of perceived self-efficacy.
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Content ArticleIn this interview with Nick Robinson from the BBC, Jeremy Hunt (then Foreign Secretary) speaks passionately about patient safety and the statistics surrounding avoidable patient deaths. Listen from 9:30 for this section. They veer away from the topic but return to it at 12:20 where he speaks about the importance of learning from mistakes in healthcare.
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Content ArticleINQUEST's groundbreaking evidence-based report is based on our work with families of those who have died in mental health settings and related policy work. It identifies three key themes: 1. The number of deaths and issues relating to their reporting and monitoring. 2. The lack of an independent system of pre-inquest investigation as compared to other deaths in detention. 3. The lack of a robust mechanism for ensuring post-death accountability and learning.
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Content ArticleDr Michael Leonard and Dr Allan Frankel explore how effective leadership and organisational fairness are essential for patient safety within healthcare services. They discuss how leaders can influence their organisations to help create a robust safety culture.
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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 ArticleStaff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
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Content ArticleSerious Incidents in healthcare are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This procedure describes the circumstances in which such a response may be required and the process and procedures for achieving it This policy provides managers with the process and procedures into the management and investigation of a Serious Incident, including guidance, templates and information.
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Content ArticleThis action plan from the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group follows on from an infection control norovirus outbreak.
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Content ArticleA guide supporting clinical, patient experience and quality teams to draw on patient experience data to improve quality in healthcare.
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The case for employee engagement in the NHS: three case studies
Claire Cox posted an article in Good practice
This report by The Point of Care Foundation, looks at staff engagement in three NHS hospital trusts and provides insights into the views of staff and managers. -
Content ArticleThis research project from Oikonomou et al. sought to map out the regulatory landscape for patient safety in the English NHS. Results were published in BMJ Open.
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Content ArticleIn this podcast by the University of Oxford, Ms Sarah Kessler (producer of the feature-length documentary ‘The Checklist Effect’ and past Lead for Lifebox) discusses and shows clips from ‘The Checklist Effect’, the award-winning documentary inspired by the WHO Surgical Safety Checklist. Professor Shafi Ahmed (Consultant Laparoscopic Colorectal Surgeon at the Royal London Hospital and Associate Dean at Barts and the London Medical School) talks about his passion around innovation, technology, global health and education, and how they marry together.
