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Showing results for tags 'Process redesign'.
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Content ArticleIn The Silo Effect, the author uses an anthropological lens to explore how individuals, teams and whole organisations often work in silos of thought, process and product. With examples drawn from a range of fascinating areas - the New York Fire Department and Facebook to the Bank of England and Sony - these narratives illustrate not just how foolishly people can behave when they are mastered by silos but also how the brightest institutions and individuals can master them.
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- Perception / understanding
- Flawed processes
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Content Article
Why do we need to talk about patient data?
Claire Cox posted an article in Actions in response to data
This short video, by Understanding Patient Data, shows people talking about why it's important to use patient data, and why we need to better explain the benefits and safeguards. -
Content ArticleIn this blog published in the New York Times, Theresa Brown explains why American healthcare has become one giant workaround. "The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait." These 'work arounds ' pose a significant patient safety risk. What work around problems do you have in your department? Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.
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- Resources / Organisational management
- Decision making
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Content ArticleToo often, women are struggling to get the right information they need about their health, to book routine appointments and to get their basic health needs met. Health services miss opportunities to ask the right questions, prevent illness and ensure the best outcomes for girls and women. This report from the Royal College of Obstetricians and Gynaecologists (RCOG) follows a survey of over 3000 women in the UK and identifies simple and cost-effective solutions to prevent girls and women falling through the cracks of our health systems. A strategic approach is required across the life course to prevent predictable morbidity and mortality and to address the determinants of health specific to women’s health.
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- Obstetrics and gynaecology/ Maternity
- Process redesign
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News Article
RCOG launches 'Better for Women' report
Patient Safety Learning posted a news article in News
UK women face widespread barriers to essential healthcare services. A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course – in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life. Read full report- Posted
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- Obstetrics and gynaecology/ Maternity
- Process redesign
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Content ArticleThe ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: increase time nurses spend in direct patient care improve safety and reliability of care improve experience for staff and patients make changes to physical environments to improve efficiency. The objective of this paper, published in BMJ Quality & Safety, was to explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale quality improvement intervention.
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- Quality improvement
- Patient safety strategy
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Content ArticleHomeLink Healthcare (HLHC) has been providing clinical care in the home with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUHT) since January 2019, to release in-patient bed capacity and improve patient choice. The two organisations have co-created the service, NNUH at Home, creating additional capacity and promoting improvements in patient flow from hospital to home. A key feature of NNUH at Home is that it compliments and integrates with existing services, rather than replicating those already in place.
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- Care home
- Hospital ward
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Content ArticleThis initiative at Chase Farm Hopsital, from the Royal Free NHS Foundation Trust, was started to mitigate wrong implant never events. Instead of just the one person going into the stock room to collect the implant and equipment, two people go and both check. This poster is a gentle reminder to check with a colleague before sending to theatre. What do other Trusts do to mitigate this type of never event?
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- Packaging/ labelling/ signage
- Safety process
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Content ArticleA whole-system approach to nasogastric tubes led by nurses is improving patient safety at Lancashire Teaching Hospitals NHS Foundation Trust. This initiative won the patient safety improvement category in the 2018 Nursing Times Awards.
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- Medical device / equipment
- Training
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Content Article
The architecture of safety: hospital design (2007)
Patient Safety Learning posted an article in Design for safety
This paper reviews recent research literature reporting the effects of hospital design on patient safety.- Posted
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- Process redesign
- Workspace design
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Content ArticleThe direction of hospital design is taking a turn for the practical as a surge of institutions are updating their infrastructure and responding to demands for more outpatient facilities. Beyond aesthetics, hospitals are seeking architectural updates that improve safety, patient and staff satisfaction, and friendliness to the environment. Infection control, lighting conditions, noise level, air quality, and patient room design are just some of the factors that are considered.
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- Workspace design
- Process redesign
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(and 3 more)
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Content ArticleIn his book, Atul Gawande discusses how today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. However, he notes that avoidable failures are common and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently. The checklist manifesto shows how the simplest of ideas could transform how we operate in almost any field.
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- Decision making
- Ergonomics
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Content ArticleThis is a comprehensive collection of proven quality, service improvement and redesign tools, theories and techniques that can be applied to a wide variety of situations. You can search the collection alphabetically for a specific tool or browse groups of tools using one of four categories.
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- Root cause anaylsis
- Quality improvement
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Content ArticleThis thought paper from Carl Macrae and Charles Vincent explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this. Many safety critical industries depend on the work of an independent, national safety investigator to investigate the most serious risks that span the system and to develop safety recommendations that target any and all organisations that need to work together to address those risks–from front-line providers to regulators. This paper defines the fundamental principles, the practical challenges and the considerable opportunities that any healthcare system must grapple with in the development of a national safety investigator that supports system-wide learning.
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- Investigation
- Background
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Content ArticleThe Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
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- End of life care
- Medicine - Palliative
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Content Article
HQCA: Patient Experience Awards 2019
Patient Safety Learning posted an article in Implementation of improvements
For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience.- Posted
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- Patient
- Obstetrics and gynaecology/ Maternity
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Content ArticleWhen a serious incident occurs, it is vital that the investigation process is thorough and can withstand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process. Experienced investigator, Chris Brougham, who previously worked at the National Patient Safety Agency, shares her thoughts on what a high quality investigation actually looks like and how you can go about achieving that.
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- Process redesign
- Investigation
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Content ArticleThe National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
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- protocols and procedures
- Process redesign
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Content ArticleThe National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.
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- Patient death
- Process redesign
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Content ArticleEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
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- Safety process
- Safety management
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Content Article
NHS Improvement: Elective care pathway analyser (updated 10 April 2019)
Claire Cox posted an article in Processes
NHS Improvement has devised an elective care pathway analyser tool which will support critical review of any clinical pathway (including administrative and process steps) across all types of elective pathway, including referral to treatment (RTT), diagnostics and cancer, and help identify high impact interventions.- Posted
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- Innovation
- Process redesign
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Content ArticleThe Model Hospital is a digital information service designed to help NHS providers improve their productivity and efficiency. It is an easy to navigate, free tool that can be used by anyone in the NHS, from board to ward.
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- Hospital ward
- Tests / investigations
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Content ArticleThere are 15 Academic Health Science Networks (AHSNs) across England, established by NHS England in 2013 to spread innovation at pace and scale – improving health and generating economic growth. Each AHSN works across a distinct geography serving a different population in each region.
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- Communication
- Organisational culture
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Content Article"It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
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- Accident and Emergency
- Ambulance
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(and 30 more)
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- Accident and Emergency
- Ambulance
- Care home
- Community care facility
- HDU / ICU
- Prison
- Operating theatre / recovery
- Mental health unit
- Hospital ward
- AHP
- Anaesthetist
- Care home staff
- Carer
- Doctor
- Nurse
- Paramedic
- Surgeon
- Social care staff
- Radiologist
- Physiotherapist
- Pharmacist
- Health and safety
- Fatigue / exhaustion
- Resilience
- Motivation
- Organisational culture
- Workforce management
- Process redesign
- Time management
- Case report
- Link analysis
- Workload analysis
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Content ArticleAbout 40% of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm. This step-by-step guide can help you increase the reliability of the testing process in your office.
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- Information processing
- System safety
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