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Showing results for tags 'Organisational learning'.
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Event
Learning from Excellence - Adrian Plunkett
Patient Safety Learning posted an event in Community Calendar
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Event
The future of healthcare investigations
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will explore what the future looks like for this critical area of human factors investigation. The presenters will each talk about a different aspect and there will be time for you to ask questions. The future of healthcare investigation: focus on learning and improvement Mark Sujan will talk about the new NHS England Patient Safety Incident Response Framework (PSIRF) which puts emphasis on learning and improvement. You’ll hear about the limitations of existing approaches to learning from incidents in healthcare, which PSIRF tries to overcome. You’ll then find out about the principles of organisational learning for achieving sustainable change, based on the CIEHF guidance. Transition: HSIB to HSSIB and MNSI HSIB’s Deinniol Owens will reveal that in April 2023, the Healthcare Safety Investigation Branch (HSIB) will transition into two new organisations: The Health Services Safety Investigation Body (HSSIB) and the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. You’ll get insight into the roles of the new organisations and hear about the additional focus on the new powers and opportunities available to HSSIB now that it’s been confirmed in statute by the Health and Care Act 2022. Investigation education: The transfer of knowledge Andrew Murphy-Pittock will explore one of the key objectives of HSIB, which is to transfer knowledge to those undertaking and overseeing patient safety investigations. You’ll find out how HSIB has developed a flexible, agile programme, working with colleagues at PSIRF, to help healthcare organisations on the move away from the Serious Incident Framework to a systems-focused approach to learning, involving those affected by incidents in the process. You’ll also hear about current and future plans for the education programme. Who will this be of interest to? This webinar should be of interest to healthcare professionals, investigators, change managers, process designers and anyone with an interest in patient safety. Register- Posted
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EventThe new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how induction and mandatory training can be improved for patient safety. It will look at the case for change and how we can develop a culture of learning. Key learning objectives: share learning culture person centred care lifelong learning. The course is facilitated by Perbinder Grewal. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape. Understand the need for proportionality of investigation. Learn how to use a range of techniques for conducting PSIIs. Understand how to write an impactful improvement plan. Consider how your current approach to patient safety investigations compares to the agreed national standards. Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. Register
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- Organisational learning
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Event
Safety-II Practical Applications conference
Patient Safety Learning posted an event in Community Calendar
untilThe 2023 Safety-II Practical Applications Conference is an opportunity for shared learning to advance organisational safety maturity. Traditional methods for safety management, while important, are limiting and often reactive. Many safety professionals have focused on Safety-II as an expanded, more proactive approach that focuses on maximizing learning. The intent of this conference is to provide practical tools for implementation of Safety-II and other next generation strategies. Major themes: Maximising proactive learning opportunities. Developing effective management and cultural systems. Observing and managing high-risk and/or error-likely situations. Learning to shift narratives and distinctions to influence culture. Case studies from many organisations. Register- Posted
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- Organisational culture
- Organisational learning
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Event
Learning from patient safety incidents
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register- Posted
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EventThis conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-community or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningfromdeathsPC
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
- Behaviour
- Resources / Organisational management
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- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?- Posted
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- Behaviour
- Resources / Organisational management
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(and 24 more)
Tagged with:
- Behaviour
- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
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Community Post
Is the word 'Whistleblowing' taboo?
Steve Turner posted a topic in Speak Up Guardians
- Patient safety / risk management leads
- Teacher / lecturer
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- Board member
- Unconscious bias
- Gaslighting
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- Transparency
- Whistleblowing
- Communication problems
- Perception / understanding
- Leadership
- Just Culture
- Leadership style
- Organisational culture
- Organisational learning
- Team culture
It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.- Posted
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- Patient safety / risk management leads
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- Board member
- Unconscious bias
- Gaslighting
- Accountability
- Bullying
- Speaking up
- Transparency
- Whistleblowing
- Communication problems
- Perception / understanding
- Leadership
- Just Culture
- Leadership style
- Organisational culture
- Organisational learning
- Team culture
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Content ArticleIn the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
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- Whistleblowing
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Content ArticlePatients are increasingly describing their healthcare experiences publicly online. This has been facilitated by digital technology, a growing focus on transparency in healthcare and the emergence of a feedback culture in many sectors. The aim of this study was to identify a typology of responses that healthcare staff provide on Care Opinion, a not-for-profit online platform on which patients are able to provide narrative feedback about health and social care in the UK. The authors used framework analysis to qualitatively analyse a sample of 486 stories regarding hospital care and their 475 responses. Five response types were identified: non-responses, generic responses, appreciative responses, offline responses and transparent, conversational responses. The key factors that varied between these response types included the extent to which responses were specific and personal to the patient story, how much responders' embraced the transparent nature of public online discussion and whether or not responders suggested that the feedback had led to learning or impacted subsequent care delivery. Staff provide varying responses to feedback from patients online, with the response types provided being likely to have strong organisational influences. The findings offer valuable insight and have both practical and theoretical implications for those looking to enable meaningful conversations between patients and staff to help inform improvement. The authors suggest that future research should focus on the relationship between response type, organisational culture and the ways in which feedback is used in practice.
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Content ArticleIn this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
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- Organisational learning
- Organisational culture
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Content ArticleFrom September 2023 all organisations who previously reported to NRLS should make the switch to recording to the new Learn from Patient Safety Events (LFPSE) service, which will replace the NRLS. From Autumn 2023 organisations will also make the transition from the Serious Incident Framework (SIF) to the Patient safety incident response framework (PSIRF). This means there will be changes to the expectations and processes associated with recording information about the response to patient safety incidents This document provides detail into where incident responses are to be recorded during the transition to LFPSE and PSIRF.
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Content ArticleOn the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.
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- Baby
- Patient death
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleThis procedure describes the Trust wide process of retrospective case review that is to be implemented following an in-hospital death. The document outlines roles and responsibilities and provides guidance on the process of identifying, reviewing, sharing and escalating mortality case reviews.
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Content ArticleThis policy sets out a framework describing how the Trust and its staff will respond to and learn from deaths that occur under their care.It will provide guidance for all staff involved in the mortality review process ensuring clarity on roles, responsibilities and expectations. Reviewing mortality can help make improvements to the quality of care received by patients at the Trust by identifying care related issues. This enables the identification of learning themes and provides evidence of a high standard of care. Mortality is a fundamental component of clinical effectiveness, one of the three dimensions of quality described by Lord Darzi in High Quality Care for all (2008). The Trusts aims are to: Have continuous improvement of our Hospital Standardised Mortality Ratios (HSMR) and the Trusts Standardised Hospital-Level Mortality Index (SHMI) Achieve a year-on-year reduction in avoidable mortality Improve learning from mortality reviews Ensure robust and timely governance processes regarding mortality outcomes and reviews Provide assurance of mortality processes in the Trust.
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- Coroner reports
- Patient death
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Content ArticleCoroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending ‘Reports to Prevent Future Deaths’ (PFDs) to interested persons. This systematic review in Pharmaceutical Medicine aimed to establish whether Coroners’ concerns about medications are widely recognised. The authors found that PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. The research suggests that information from English and Welsh Coroners’ PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.
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Content ArticleIn this video, Chief Digital Officer Clive Flashman talks about the hub as a patient safety innovation as part of Patient Safety Learning's entry to the Digital Health Hub Foundation Digital Health Awards 2023.
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Content ArticleClive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. The presentation slides include basic principles, how to involve the patient and public in design, key issues and Clive's ten top tips for digital health innovators.
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- Digital health
- Innovation
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Community PostRestorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. This approach is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. What are your thoughts on how this approach would work in a healthcare setting? Does anyone have any experience of using restorative practice?
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- Communication
- Just Culture
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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 -
Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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- Patient safety strategy
- Safe staffing
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