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Showing results for tags 'Quality improvement'.
Found 757 results
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Content ArticleMaking Healthcare Safer III report is the third in a series of reports from the Agency for Healthcare Research and Quality (AHRQ), which reviews research supporting patient safety practices in place to reduce patient harms. This supplement from Shoemaker-Hunt et al. presents the reviews for eight of the patient safety practices from the Making Healthcare Safer III report: The use of rapid response teams to reduce failure-to-rescue events. The use of patient monitoring systems to improve sepsis recognition and outcomes. Environmental cleaning and decontamination to prevent Clostridioides difficile infection in healthcare settings. Chlorhexidine bathing strategies for multidrug-resistant organisms Using deprescribing practices and STOPP criteria to reduce harm and preventable adverse drug events in older adults The effect of opioid stewardship interventions on key outcomes System-level patient safety practices that aim to reduce medication errors associated with infusion pumps Improving team performance and patient safety on the job through team training and performance support tools.
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Content ArticleDr Steve Barker is joined by Ronald Weinstein, Director/Founder, Arizona Telemedicine Program, and Jeffrey Dunn, Founder/CEO, Redivus Health, to discuss the future of telemedicine within the patient safety and quality improvement space. Telemedicine has become a significant area of investment in recent years and the panelists predict that, in the future, user experience, consolidation, customisation based on relevance to the user, robotics, and health literacy will become top priorities.
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Content ArticleWhen it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges. This resource has been designed by the Canadian Patient Safety Institute to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.
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Content ArticleAs caseloads soar and new challenges related to the coronavirus keep emerging, efficiently sharing key information is crucial. Use the tips below to learn (or review) five ways to make safety huddles more effective.
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Content ArticleThe highly publicised crashes of two Boeing 737 Max aircraft quickly triggered pointed questions about the company’s commitment to safety versus profits. As we near the twentieth anniversary of the landmark Institute of Medicine (IOM) report on medical error, To Err is Human, that same level of scrutiny should apply to hospitals. Cost-benefit analysis is both a legitimate and crucial management function. But the criteria used in those calculations can range from appropriate to appalling. It’s long past time to examine how the “business case for safety” can sometimes represent a serious threat to patients’ lives. Michael L. Millenson discusses the dangers in the "business case" for patient safety in his blog in Health Affairs.
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Content Article
Nadine’s story: Informed consent (the Montgomery case)
Claire Cox posted an article in Consent and privacy
In this short film, Nadine Montgomery presents her story that led to the landmark ruling on consent (Montgomery v Lanarkshire Health Board, 2015) -
Content Article
Supporting patients who are resistant to mouth care
Claire Cox posted an article in By health and care staff
Mouth Care Matters have launched a video – Supporting Patients in Hospital Who Are Resistant to Mouth Care. As part of their work with trusts in England, care resistant behaviour was the number one barrier to providing mouth care. They have developed a video is to explain why a patient may be resistant towards mouth care, and some ways that may help manage this. This video is aimed at all healthcare professionals. Covering techniques, use of distraction and products, we hope after watching this video you will have picked up many new tips towards delivering better care, to a patient who may at first be resistant to mouth care. -
Content ArticleThis article from Delaveris et al. outlines one health system's experience implementing a bundle to reduce sepsis-related mortality and the observed connection between adherence to the bundle and improved sepsis care.
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Content ArticleThis article from Perlin et al. discusses how a 173-hospital system used technology as a strategy to reduce sepsis-related mortality system-wide by real-time dissemination of basic laboratory and clinical data to alert teams to patients exhibiting signs of sepsis risk.
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Content ArticleAuthors of this article, previous argued that inadequately managed pain in children should be considered an adverse event, a harmful patient outcome. They argued that inadequately managed pain meets the definition of an adverse event and further hypothesised that treating pain as an adverse event may improve care by raising health care administrators and quality improvement experts’ awareness of this issue. In this article, published in the Journal of Child Care Health five years on, they reflect on the progress made in both moving this proposition forward and testing out the concept. They then move on to look at what still needs to be done to ensure that children’s pain is managed effectively.
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Content ArticleIn this edition of the Nursing and Midwifery Council's (NMC) public newsletter, we hear from Sarah Seddon, who was a witness in a fitness to practise investigation following the tragic loss of her baby. She shares how this process felt and how she is using her personal experience to help the NMC work in a more person-centred way.
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Content ArticleThis report from the Parliamentary and Health Service Ombudsman, follows an invitation from the House of Commons Select Committee on Public Administration and Constitutional Affairs to explore the state of local complaints handling across the NHS and UK Government departments. It draws upon significant evidence taken from interviews carried out with a wide range of individuals and organisations who have first-hand experience of how the NHS and UK Government departments approach complaints. It also incorporates a review of a wide range of other research reports and over 300 of our own investigation reports documenting complainant experience. The report highlights three areas that need to change: There is no consistent way in which staff are expected to handle and resolve complaints. Staff do not get consistent access to training to support them in their complex role - complaint handling should be recognised as a professional skill. Public bodies too often see complaints negatively, not as a learning opportunity that can be used to improve their service.
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Content ArticleThe Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
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Content Article
The Obs Pod, by obstetrician Florence Wilcock
PatientSafetyLearning Team posted an article in Maternity
This series of podcasts, supported by the Maternity Experience (#MatExp), is produced by Florence Wilcock. She explores different topics within maternity, aiming to ignite positive change and action. -
Content Article
NHS Education for Scotland: SBAR
Patient Safety Learning posted an article in Quality Improvement
SBAR is an easy to use, structured communication format that enables information to be transferred accurately between individuals. SBAR stands for 'Situation, Background, Assessment, Recommendation' and was originally developed in the milatary context to create a reliable consistent process to facilitate concise, clear, focused communication. SBAR communication is normally very focused and relatively brief. Most SBARs are around one page of A4, two at most. The aim is to convey the critical information in an understandable way, clearly and succinctly. The SBAR tool has also been widely used by healthcare teams as a focused way of transferring information about a person's condition. -
Content Article
NHS Education for Scotland: Stakeholder analysis
Patient Safety Learning posted an article in Quality Improvement
Stakeholder analysis is a way of identifying, prioritising and understanding your stakeholders. It is an interest/influence grid with four quadrants. It enables you to plot or map stakeholders based on their level of interest (high/low) and level of influence (high/low). Where you plot a stakeholder guides the actions you should take for involving and communicating with them. -
Content Article
NHS Education for Scotland: Charts and graphs
Patient Safety Learning posted an article in Quality Improvement
Charts are useful for collecting and charting data over time, you can find trends or patterns in the process. NHS Education for Scotland has provided resources and guidance on a number of different charts you could use for quality improvement. -
Content Article
NHS Education for Scotland: Prioritisation matrix
Patient Safety Learning posted an article in Quality Improvement
The Prioritisation Matrix is a structured visual tool to help you decide which improvement ideas to test first and how to focus your activity and energy. It works best in a collaborative environment and can help to build buy-in and communicate why you have chosen to test certain ideas before others. They come in many different forms, but the simplest and easiest to use is the 2 x 2 matrix. The axis of the matrix are usually labelled to enable you categorize the priority of each change idea. Usually the horizontal axis is labelled with a concept such as “effort” or “willingness to adopt”. The vertical axis is usually “impact” or “value”. -
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NHS Education for Scotland: Force field analysis
Patient Safety Learning posted an article in Quality Improvement
Force Field Analysis was created by Kurt Lewin in the 1940s. He used it in his work as a social Psychologist. In the modern world, it is used for making and communicating decisions about whether to go ahead with a change or not. It frames problems in terms of factors or pressures that support the status quo (restraining forces) and those pressures that support change in the desired direction (driving forces). The driving forces must be strengthened or the resisting forces weakened for the change to take effect. A factor can be people, resources, attitudes, traditions, regulations, values, needs, desires, etc. As a tool for managing change, Force Field Analysis helps identify those factors that must be addressed and monitored if change is to be successful. It can be difficult for teams to make decisions about testing new ideas especially when there are a variety of opinions. Force Field Analysis provides a structured approach to decision making which helps teams to consider the forces that are driving the change and those that resist the change. -
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NHS Education for Scotland: Measurement plan
Patient Safety Learning posted an article in Quality Improvement
A measurement plan sets out details for each measure proposed for an improvement project. -
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NHS Education for Scotland: Capacity calculator
Patient Safety Learning posted an article in Quality Improvement
This is a simple tool that helps you to understand the time you have available for your main work activity, e.g. seeing patients or managing a service. It is an excel spreadsheet that calculates this for you if you enter the time spent on various activities. When analysing and planning capacity, it’s important to look at time available for people to do the work required. This means understanding how much time people can actually spend on the required tasks. The tool provides a helpful way to understand this for individuals and teams and therefore can help plan work and improve productivity. -
Content ArticleCause and effect is a diagram-based technique that helps you identify all of the likely causes of the problems you're facing.
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Content Article
NHS Education for Scotland: Process mapping
Patient Safety Learning posted an article in Quality Improvement
A process map is a planning and management tool that visually describes the flow of work. Using process mapping software, process maps show a series of events that produce an end result. -
Content Article
NHS Education for Scotland: Model for improvement
Patient Safety Learning posted an article in Quality Improvement
The Model for Improvement is a simple yet powerful tool for accelerating improvement. The model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement. -
Content Article
NHS Education for Scotland: Pareto Chart
Patient Safety Learning posted an article in Quality Improvement
A Pareto chart is a type of bar chart in which the factors that contribute to an overall effect are arranged in order from most frequent to least. This ordering helps identify the "vital few" — the factors that warrant the most attention. It also includes a line showing the cumulative % (so you can see easily for example that the top three causes account for 80% of incidents). According to the "Pareto Principle," in any group of things that contribute to a common effect, relatively few account for the majority of the effect.
