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Showing results for tags 'Process redesign'.
Found 121 results
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Content ArticlePresentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.
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News Article
Wall Street Journal: How the Swiss Cheese Model can help us beat COVID-19
Clive Flashman posted a news article in News
No single solution will stop the virus’s spread, but combining different layers of public measures and personal actions can make a big difference. It’s important to understand that a vaccine, on its own, won’t be enough to rapidly extinguish a pandemic as pernicious as Covid-19. The pandemic cannot be stopped through just one intervention, because even vaccines are imperfect. Once introduced into the human population, viruses continue to circulate among us for a long time. Furthermore, it’s likely to be as long as a year before a Covid-19 vaccine is in wide-spread use, given inevitable difficulties with manufacturing, distribution and public acceptance. Controlling Covid-19 will take a good deal more than a vaccine. For at least another year, the world will have to rely on a multipronged approach, one that goes beyond simplistic bromides and all-or-nothing responses. Individuals, work-places and governments will need to consider a diverse and sometimes disruptive range of interventions. It helps to think of these in terms of layers of defence, with each layer providing a barrier that isn’t fully impervious, like slices of Swiss cheese in a stack. The ‘Swiss cheese model’ is a classic way to conceptualize dealing with a hazard that involves a mixture of human, technological and natural elements. This article can be read in full on the WSJ website, but is paywalled. The illustration showing the swiss cheese pandemic model is hyperlinked to this hub Learn post. -
Content ArticleIn 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
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Community Post
Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear
Patient Safety Learning posted a topic in Medication including labelling
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See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
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Content ArticleThis handbook provides tools for designing a structure for a management system, as well as the tools for documenting processes within it. The starting point is based on current safety research. The book is designed for medical professionals, managers, project members, politicians, public officials, and executives-all who work with patient safety matters. The content shows a new way to healthcare management, presenting an alternative approach together with concrete advice on how healthcare executives and practitioners can begin to think and act differently in order to provide safe healthcare.
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Content ArticleIn this blog, Patient Safety Learning look at why complaints are important to improving patient safety and sets out its response to the Parliamentary and Health Service Ombudsman (PHSO) consultation on a new Complaint Standards Framework for the NHS.
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Content ArticleAn educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleNeil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
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EventuntilThe Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
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Content ArticleStewart Munro, Managing Director of Pentland Medical Ltd, highlights some of the current procurement problems within the NHS and explains why this needs to change if we want to improve patient and staff safety.
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Content Article
Out-patient Parenteral Antibiotic Therapy (OPAT) is now a routine part of care in the UK following demonstration that it is safe and effective for patients and OPAT is now being actively promoted as part of the UK government’s stewardship initiatives. NHS North Tees and Hartlepool share their experience of redesigning their OPAT services. See the attachment below for details on the project. -
Community Post
Responding to COVID: How do we coordinate new guidance quickly and safely?
Margot posted a topic in Coronavirus (COVID-19)
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Healthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-Covid guidance obsolete. Different Trusts are doing different things. What’s the solution?- Posted
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Content Article
Whole system flow: From front door to front door
Claire Cox posted an article in Processes
The Whole System Flow programme has been accepted for presentation at the International Conference of Integrated Care in San Sebastien in April 2019. This poster provides an overview of the programme’s structure and outputs. We will be opening applications in April for the next group of systems to work with on a system pathway that they choose. -
Content ArticleThe response to COVID-19 has created an outstanding amount of change to the NHS and we must learn from this, says Samantha Machen, Improvement Facilitator at Central London Community Healthcare NHS Trust and PhD Improvement Fellow at the Health Foundation.
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News Article
Swann reveals future of Northern Ireland health service post COVID-19
Patient Safety Learning posted a news article in News
Northern Ireland faces a massive challenge rebuilding health and social care in the wake of the first COVID-19 wave, Health Minister Robin Swann has said. Speaking at the Northern Ireland Assembly on Tuesday, Mr Swann said that the rebuilding process can secure better ways of delivering services but will require innovation, sustained investment and society-wide support. He said that services will not be able to resume as before and that rebuilding will be significantly constrained by the continuing threat from COVID-19 and the need to protect the public and staff from the virus. “Our health and social care system was in very serious difficulties long before Coronavirus reached these shores. The virus has taken the situation to a whole new level. The Health and Social Care system has had its own lockdown – services were scaled back substantially to keep people safe and to focus resources on caring for those with COVID-19." The Health Minister said that despite the pressures, there are opportunities to make improvements. “I have seen so many examples of excellence, innovation and commitment as our health and social care staff rose to the challenges created by COVID-19. Decisions were taken at pace, services were re-configured, mountains were moved. Staff have worked across traditional boundaries time and time again. I cannot thank them enough. We must build on that spirit in the months and years ahead. Innovations like telephone triage and video consultations will be embedded in primary and secondary care.” Mr Swann added that the health system can't go back to the way it was and that it must be improved. Read full story Source: Belfast Telegraph, 9 June 2020 -
Content ArticleAs the number of COVID-19 hospital admissions gradually declines, policy attention is turning to how the NHS can restart some more routine activities. But doing this while living alongside COVID-19 will involve major practical challenges that will need to be overcome. This new discussion paper by Nigel Edwards looks at the realities the health and care systems will now begin to face.
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Content ArticleThe CARe QI handbook is based on research in a range of healthcare organisations and settings, including acute care, primary care, care homes, oral health and community settings. It was designed to provide practical tools to apply ideas from resilient healthcare to quality improvement.
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News Article
‘Fundamental’ changes to London’s NHS in wake of COVID-19
Patient Safety Learning posted a news article in News
The NHS in London is planning to “fundamentally shift the way we deliver health and care” in the wake of coronavirus, according to documents obtained by HSJ. The plans from NHS England and Improvement’s London office say leaders should: Plan for elective waiting times to be measured at integrated care system level, rather than trust level. Accept “a different kind of risk appetite than the one we are used to”. Expect decisions from the centre on the location of cancer, paediatric, renal, cardiac, and neurosurgical services. Plan for a permanent increase in critical care capacity. Transform to a “provider system able to be commissioned and funded on a population health basis”. Work towards “a radical shift away from hospital care”. Expect “governance and regulatory landscape implications” plus “streamlined decision-making”. The document, titled Journey to a New Health and Care System, says there are three “likely” phases, with the final new system in place “from November 2021”. The preceding two phases are “action programmes” over the next 12 to 15 months which will be about reconfiguring services to deal with “immediate covid, non-covid and elective need”, and “transition” when the move to new configurations is evaluated and “public consent” sought. Read full story Source: HSJ, 11 May 2020- Posted
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Content ArticleUsing human factors science increases the likelihood of obtaining well-designed and easy to use products to deliver safe patient care. Poor designs, by contrast, can cause unintended harm to patients. This guide, developed by the Clinical Human Factors Group, is to help staff working in procurement or with medical devices and equipment, to use human factors to specify and select the best and safest products to use in healthcare. This is important because conformity with regulations and standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products.
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Content ArticleI had been away from the hospital for a week and I was reluctant to go back in, fearful of what I would face, but I am amazed at how much has been achieved in 7 days.
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News Article
London begins major COVID-19 reconfiguration
Patient Safety Learning posted a news article in News
St Bartholomew’s Hospital is to be the emergency electives centre for the London region as part of a major reorganisation to cope with the coronavirus outbreak. Senior sources told HSJ the London tertiary hospital, which is run by Barts Health Trust, will be a “clean” site providing emergency elective care as part of the capital’s covid-19 plan. It is understood the specialist Royal Brompton and Harefield Foundation Trust will also be taking some emergency cardiac patients. The news follows NHS England chief executive Sir Simon Stevens telling MPs on Tuesday that all systems were working out how best to optimise resources and some hospitals could be used to exclusively treat coronavirus patients in the coming months. Read full story (paywalled) Source: HSJ, 18 March 2020 -
Content ArticleA short video to show you how to have a video consultation with your GP surgery after receiving an invitation via text message.
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News Article
‘Inherently risky’ children’s cancer service to be overhauled
Patient Safety Learning posted a news article in News
Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders. Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change. The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience. Read full story (paywalled) Source: HSJ, 31 January 2020 -
Content ArticleThis study covers the world outlook for patient engagement solutions across more than 190 countries. For each year reported, estimates are given for the latent demand, or potential industry earnings (P.I.E.), for the country in question (in millions of U.S. dollars), the percent share the country is of the region, and of the globe. These comparative benchmarks allow the reader to quickly gauge a country vis-à-vis others.
