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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist- Posted
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content ArticleWork to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.
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Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email info@pslhub.org for discount code.- Posted
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Event
Root Cause Analysis: 2 day masterclass
Patient Safety Learning posted an event in Community Calendar
untilThis two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email info@pslhub.org for discount code.- Posted
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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 and subsequent Patient Safety Incident Response Framework (PSIRF). 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. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventThe Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation on and Learning and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on learning from improvement. There will also be a extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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EventThis conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-involvement or email kate@hc-uk.org.uk. There are 5 free places for hub members available. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #PatientPSP2023
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Event
SEIPS masterclass in maternity
Patient-Safety-Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place- Posted
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SEIPS masterclass in mental health
Patient Safety Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 2.5 hour masterclass will focus upon using SEIPS in Mental Health. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Priced at £50 per person. Pre and post class materials will be provided. Register- Posted
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SEIPS masterclass in emergency departments
Patient Safety Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 2.5 hour masterclass will focus upon using SEIPS in Emergency Departments. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Priced at £50 per person. Pre and post class materials will be provided. Register- Posted
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Content ArticleThis video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
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EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Compassionate engagement and involvement of those affected by patient safety incidents is central to the PSIRF approach. Building on our workshop that explored different models for engaging with families, this workshop will highlight how different organisations are approaching engaging with staff affected by patient safety incidents. PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, Mrs Christina Rennie, Consultant Ophthalmologist, Clinical Director of Patient Safety and Patient Safety Specialist, University Hospital Southampton NHS Foundation Trust Register for this event Registration closes at 12noon Wednesday 19 April 2023. A link to join the webinar will be sent to registered delegates shortly after registration closes.
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Patient Safety Learning Summits
Sam posted an event in Community Calendar
West Hertfordshire Teaching Hospitals NHS Trust Quality Governance team is hosting a series of Patient Safety Learning Summits. Throughout the year they will be holding four events, focusing on patient safety, with a range of speakers (national and international). WHO are the summits aimed for? All healthcare professionals and students who want to learn more about patient safety, participate in the construction of our new patient safety strategy and gain valuable CPD points (30!). WHAT are the summits? They will be international interactive learning conferences where we delve into the transition into Patient Safety Incident Response Framework (PSIRF), in conjunction with discussing the wider patient safety landscape. These summits will include national and international keynote speakers: Prof Matt Inada-Kim- National Clinical Director – infection, antimicrobial resistance & deterioration / CL Covid oximetry @Home / virtual wards Ron Daniels- Founder and Chief Executive, UK Sepsis Trust Helen Hughes- Chief Executive, Patient Safety Learning Paula Reges – infections disease researcher Fiocruz Brazil / advisor to Health Minister Ass Prof Caline Mattar- Global Health and Infectious Diseases at University of Washington, USA Other speakers to include: Médecins Sans Frontières, Red Cross and NHS England WHEN are the summits? There will be four summits throughout the year with overarching themes: Wednesday 26 April- Corporate and Clinical Governance Tuesday 6 June- IPC/AMR/Stewardship Tuesday 5 September – Deteriorating Patients- event aligned to the WHO theme of Engaging Patients Wednesday 10 January 2024- Enhanced Care Needs WHERE are the summits? The events will be held at Watford Football Club and streamed online. British Sign Language interpreters, inductions loops and captions will be present at all events. WHY The trust fully supports the national agenda change to PSIRF and wants to embed the ethos of this framework into everything we do. Patient safety is everybody's business, and everyone has a vital role to play. PSIRF is replacing the Serious Incident Framework and will lead to a culture shift of continuous learning, patient engagement, and a systems-based approach to learning from incidents. The NHS patient safety landscape is evolving, and these summits will give you the understanding, oversight, and passion to be a driver for improvements within your area. Register -
Event
Patient Safety Learning Summits
Sam posted an event in Community Calendar
West Hertfordshire Teaching Hospitals NHS Trust Quality Governance team is hosting a series of Patient Safety Learning Summits. Throughout the year they will be holding four events, focusing on patient safety, with a range of speakers (national and international). WHO are the summits aimed for? All healthcare professionals and students who want to learn more about patient safety, participate in the construction of our new patient safety strategy and gain valuable CPD points (30!). WHAT are the summits? They will be international interactive learning conferences where we delve into the transition into Patient Safety Incident Response Framework (PSIRF), in conjunction with discussing the wider patient safety landscape. These summits will include national and international keynote speakers: Prof Matt Inada-Kim- National Clinical Director – infection, antimicrobial resistance & deterioration / CL Covid oximetry @Home / virtual wards Ron Daniels- Founder and Chief Executive, UK Sepsis Trust Helen Hughes- Chief Executive, Patient Safety Learning Paula Reges – infections disease researcher Fiocruz Brazil / advisor to Health Minister Ass Prof Caline Mattar- Global Health and Infectious Diseases at University of Washington, USA Other speakers to include: Médecins Sans Frontières, Red Cross and NHS England WHEN are the summits? There will be four summits throughout the year with overarching themes: Wednesday 26 April- Corporate and Clinical Governance Tuesday 6 June- IPC/AMR/Stewardship Tuesday 5 September – Deteriorating Patients- event aligned to the WHO theme of Engaging Patients Wednesday 10 January 2024- Enhanced Care Needs WHERE are the summits? The events will be held at Watford Football Club and streamed online. British Sign Language interpreters, inductions loops and captions will be present at all events. WHY The trust fully supports the national agenda change to PSIRF and wants to embed the ethos of this framework into everything we do. Patient safety is everybody's business, and everyone has a vital role to play. PSIRF is replacing the Serious Incident Framework and will lead to a culture shift of continuous learning, patient engagement, and a systems-based approach to learning from incidents. The NHS patient safety landscape is evolving, and these summits will give you the understanding, oversight, and passion to be a driver for improvements within your area. Register -
Event
Patient Safety Learning Summits
Sam posted an event in Community Calendar
West Hertfordshire Teaching Hospitals NHS Trust Quality Governance team is hosting a series of Patient Safety Learning Summits. Throughout the year they will be holding four events, focusing on patient safety, with a range of speakers (national and international). WHO are the summits aimed for? All healthcare professionals and students who want to learn more about patient safety, participate in the construction of our new patient safety strategy and gain valuable CPD points (30!). WHAT are the summits? They will be international interactive learning conferences where we delve into the transition into Patient Safety Incident Response Framework (PSIRF), in conjunction with discussing the wider patient safety landscape. These summits will include national and international keynote speakers: Prof Matt Inada-Kim- National Clinical Director – infection, antimicrobial resistance & deterioration / CL Covid oximetry @Home / virtual wards Ron Daniels- Founder and Chief Executive, UK Sepsis Trust Helen Hughes- Chief Executive, Patient Safety Learning Paula Reges – infections disease researcher Fiocruz Brazil / advisor to Health Minister Ass Prof Caline Mattar- Global Health and Infectious Diseases at University of Washington, USA Other speakers to include: Médecins Sans Frontières, Red Cross and NHS England WHEN are the summits? There will be four summits throughout the year with overarching themes: Wednesday 26 April- Corporate and Clinical Governance Tuesday 6 June- IPC/AMR/Stewardship Tuesday 5 September – Deteriorating Patients- event aligned to the WHO theme of Engaging Patients Wednesday 10 January 2024- Enhanced Care Needs WHERE are the summits? The events will be held at Watford Football Club and streamed online. British Sign Language interpreters, inductions loops and captions will be present at all events. WHY The trust fully supports the national agenda change to PSIRF and wants to embed the ethos of this framework into everything we do. Patient safety is everybody's business, and everyone has a vital role to play. PSIRF is replacing the Serious Incident Framework and will lead to a culture shift of continuous learning, patient engagement, and a systems-based approach to learning from incidents. The NHS patient safety landscape is evolving, and these summits will give you the understanding, oversight, and passion to be a driver for improvements within your area. Register -
Event
Patient Safety Learning Summits
Patient Safety Learning posted an event in Community Calendar
West Hertfordshire Teaching Hospitals NHS Trust Quality Governance team is hosting a series of Patient Safety Learning Summits. Throughout the year they will be holding four events, focusing on patient safety, with a range of speakers (national and international). WHO are the summits aimed for? All healthcare professionals and students who want to learn more about patient safety, participate in the construction of our new patient safety strategy and gain valuable CPD points (30!). WHAT are the summits? They will be international interactive learning conferences where we delve into the transition into Patient Safety Incident Response Framework (PSIRF), in conjunction with discussing the wider patient safety landscape. These summits will include national and international keynote speakers: Prof Matt Inada-Kim- National Clinical Director – infection, antimicrobial resistance & deterioration / CL Covid oximetry @Home / virtual wards Ron Daniels- Founder and Chief Executive, UK Sepsis Trust Helen Hughes- Chief Executive, Patient Safety Learning Paula Reges – infections disease researcher Fiocruz Brazil / advisor to Health Minister Ass Prof Caline Mattar- Global Health and Infectious Diseases at University of Washington, USA Other speakers to include: Médecins Sans Frontières, Red Cross and NHS England WHEN are the summits? There will be four summits throughout the year with overarching themes: Wednesday 26 April- Corporate and Clinical Governance Tuesday 6 June- IPC/AMR/Stewardship Tuesday 5 September – Deteriorating Patients- event aligned to the WHO theme of Engaging Patients Wednesday 10 January 2024- Enhanced Care Needs WHERE are the summits? The events will be held at Watford Football Club and streamed online. British Sign Language interpreters, inductions loops and captions will be present at all events. WHY The trust fully supports the national agenda change to PSIRF and wants to embed the ethos of this framework into everything we do. Patient safety is everybody's business, and everyone has a vital role to play. PSIRF is replacing the Serious Incident Framework and will lead to a culture shift of continuous learning, patient engagement, and a systems-based approach to learning from incidents. The NHS patient safety landscape is evolving, and these summits will give you the understanding, oversight, and passion to be a driver for improvements within your area. Register -
EventThis national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious Incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. The conference is particularly timely considering the current Essex Mental Health Independent Inquiry which has National Implications. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email: frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
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Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) was launched in 2022 and is intended for full implementation by Autumn 2023. PSIRF requires Integrated Care Board (ICB)’s to work collaboratively with providers to develop a Patient Safety Incident Response Plan (PSIRP) and Patient Safety Incident Response Policy. Within the PSIRP, each organisation must work with their ICB and other stakeholders to identify how it will respond proportionately to all incidents requiring investigation. Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF ICB sign off process.
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EventuntilJoin Stuart Paviour business psychologist and innovator in patient safety since 2000, in conversation with Maria Paviour. Stuart has worked with NHS Vanguards and in Private Healthcare in improving wellbeing, patient safety and reducing costs and was involved in application of the first ‘care pathways’ - see case studies for more information. Maria is a Registered Occupational Psychologist, Neuroscientist (King’s College London), specialist in Human Factors in Healthcare for 25 years, UK and EU Government Award Winner, best-selling author. A former Primary Care Practice Business Manager, Maria is an NHS whistle blower and campaigner for patient safety and Just cultures in the NHS (Patient’s First Charity) and an NHS England Think Tank member for tackling workplace bullying. Maria was an innovator, bringing 'Care pathways' model to the UK for preventative patient safety. Please check out Stuart and Maria's film https://youtu.be/P6nXswcepo0 in which they cover the three game changing approaches that will: 1. Mobilise high performance from your current resources and people. 2. Achieve optimal team responsiveness that delivers safe practice. 3. Accurately measure productivity and forecast increased efficiency for maximum ROI. The event will take a deeper dive into the topic and provide opportunities for Q&A. Register
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Content ArticleSlides from the recent Patient Safety Incident Response Framework (PSIRF) governance workshop giving an update and overview from the national team. Presentations were given from the early adopters: Jacquetta Hardacre, Assistant Director Safety and Risk, East Lancashire Hospitals NHS Trust and Kerry Crowther, Patient Safety Specialist, Cornwall Partnership NHS Foundation Trust. The workshop concluded with a Q&A panel with the presenters and Gillian Lewis Head of Patient Safety Strategy Delivery, NHS England.
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Content ArticleJudy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.
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EventThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England TBC Further information
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EventThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Transition webinars focus on the different phases of the PSIRF preparation guide and feature presentations from NHS organisations currently transitioning to PSIRF. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England TBC Further information