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Showing results for tags 'Organisational learning'.
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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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- Mental health unit
- Mental health - forensic
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Content ArticleIn this issue of HSJ's fortnightly briefing, Emily Townsend looks at why we are still not listening to patients and their families after harrowing reports of abuse and poor care at NHS mental health facilities surfaced last year.
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- Mental health
- Investigation
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Content ArticleThe LeDeR programme, funded by NHS England and NHS Improvement, was established in 2017 to improve healthcare for people with a learning disability and autistic people. LeDeR aims to: Improve care for people with a learning disability and autistic people. Reduce health inequalities for people with a learning disability and autistic people. Prevent people with a learning disability and autistic people from early deaths. LeDeR summarises the lives and deaths of people with a learning disability and autistic people who died in England in annual reports. The 2021 reports were made by researchers at King’s College London collaborating with academic partners at the University of Central Lancashire and Kingston-St George’s University, London, copies of which can be accessed from the link below along with a video summary of the findings and “TakeHome” posters.
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- Learning disorders
- Learning disabilities
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Content ArticleThis policy aims to set out for the first time for the NHS the core aims and values of the LeDeR programme and the expectations placed on different parts of the health and social care system in delivering the programme from June 2021.
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- Patient death
- Organisational learning
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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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- Learning disabilities
- Collaboration
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Content ArticleIn March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019. One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia). This was identified as an area where further analysis could benefit system-wide learning.
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- Organisational learning
- Baby
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Content ArticleThe NHS is looking for patients, carers and staff to talk about their positive or negative care experiences with participants on NHS Leadership Academy programmes. Being an experience of care partner is a voluntary role.
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- Patient engagement
- Training
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Content ArticleThis study in the International Journal of Nursing Studies looked at the role of primary care nurses in coaching patients in shared decision making about their treatment. It evaluated an approach to support nurses in coaching patients, which was found to have a positive impact overall. Nurses became more aware of their own attitudes and learning needs and reported more in-depth discussions with patients. However, nurses struggled to integrate the approach in routine care and highlighted the need to receive support from their practice to implement the new approach.
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Content ArticleIn this blog, Becki Meakin, Involvement Manager with Shaping Our Lives, a non-profit making user-led organisation that enables individuals to have a stronger voice, writes about why all patients should think about speaking up about their health experiences. She talks about the difference sharing your story can make, and how to get started.
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- Patient engagement
- Feedback
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Content ArticlePatients are increasingly feeding back about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. This study in the journal Digital health aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback. The authors identified a range of barriers facing organisations who ignore or provide generic responses to patient feedback online and demonstrated the sociocultural context in which online interactions between staff and patients can be used to inform improvement. However, they highlight that this represented a slow and difficult organisational journey.
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- Patient engagement
- Feedback
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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- Patient safety incident
- Investigation
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Content Article
NHS England Learning Handbook: After action review
Patient Safety Learning posted an article in NHS Improvement
First used by the US army on combat missions, the after action review is a structured approach for reflecting on the work of a group and identifying strengths, weaknesses and areas for improvement. This NHS Improvement document explains what an after action review and when and how to use it.- Posted
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- After action review
- Feedback
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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- Medication
- Patient death
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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- Just Culture
- Organisational learning
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Content Article
What is a whistleblower?
Hugh Wilkins posted an article in Whistle blowing
hub topic lead, Hugh Wilkins, explores attitudes towards and repercussions of whistleblowing, with emphasis on healthcare professionals who suffer retaliation after raising patient safety concerns. He draws attention to damaging discrepancies between written policy and actual procedure. Hugh urges all healthcare leaders to welcome the concerns that 'whistleblowers' raise in the public interest and respond positively to them, which would lead to substantial improvements in staff engagement, organisational culture, quality of care and patient safety. *Whilst much of the information in this article is referenced and in the public domain it is not legal advice.- Posted
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- Culture of fear
- Leadership
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Content ArticleSince April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for initiating over 1000 independent safety investigations in NHS maternity services in England. This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations, and how HSIB will explore these themes in more detail during the coming year.
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- Safety report
- Organisational learning
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