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Showing results for tags 'Quality improvement'.
Found 757 results
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Content ArticleThis blog from Eli Quisenberry, Director of the Kaizen Promotion Office at the Virginia Mason Medical Centre, discusses what makes up 'standard work' and how this contributes to patient safety. Eli partners with leaders, staff and teams across the medical centre, applying the Virginia Mason Production System principles as they work to transform healthcare and achieve the organisation’s vision as the quality leader.
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Content ArticleProfessor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University, delivers the James Reason lecture at the 2018 HSJ Patient Safety Congress on work force and safety and discusses the complexity of demand.
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Content ArticleIn an interesting paper by Brazil and colleagues in the July edition of BMJ Quality and Safety, the authors explore the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields.
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Content ArticleIn association with the United Kingdom’s Foreign and Commonwealth Office and the Department of Health and Social Care (DHSC), the Wilton Park High Level Forum on Patient Safety convened experts from around the world to discuss priorities in patient safety at a global level. The two-day concentrated discussion covered the articulation of the burden of harm, possibilities to drive action towards improvement and the various roles different stakeholders play in fostering a culture of continuous improvement for safer care.
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SHIFT to Safety - Canadian Patient Safety Institute
Claire Cox posted an article in Healthcare Excellence Canada
Established by Health Canada in 2003, the Canadian Patient Safety Institute (CPSI) works with governments, health organisations, leaders and healthcare providers to inspire extraordinary improvement in patient safety and quality. SHIFT to Safety is a major shift to empower staff with the tools and information they need to keep patients safe, at any level. -
Content ArticleThis is a summary of the Care Quality Commission (CQC) report into social care in the UK. This report is written to target all audiences.
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Patient Safety/Quality Assurance Report - NHS Rotherham CCG 2018
Claire Cox posted an article in Health
This is the annual safety and quality assurance report from Rotherham Clinical Commissioning Group. -
Content ArticleIn this podcast by the University of Oxford, Ms Sarah Kessler (producer of the feature-length documentary ‘The Checklist Effect’ and past Lead for Lifebox) discusses and shows clips from ‘The Checklist Effect’, the award-winning documentary inspired by the WHO Surgical Safety Checklist. Professor Shafi Ahmed (Consultant Laparoscopic Colorectal Surgeon at the Royal London Hospital and Associate Dean at Barts and the London Medical School) talks about his passion around innovation, technology, global health and education, and how they marry together.
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NHS Resolution: Annual report and accounts 2020/21
Patient Safety Learning posted an article in NHS Resolution
This performance summary provides an overview of the work of NHS Resolution, including their purpose, key risks to achieving their objectives and a summary of activities they have undertaken over the past year. It sets out the activity to meet the four strategic aims outlined in their business plan for 2020/21. -
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LPZ – improving quality and safety in care homes
Patient Safety Learning posted an article in Older people
The East Midlands Patient Safety Collaborative (EMPSC) piloted an audit tool to measure the prevalence of common care problems found in nursing and residential homes. The audit tool was first rolled out to 26 care homes across Nottinghamshire and Derbyshire in 2015, extending to 30 care homes across the East Midlands in 2016, 31 in 2017 and 39 in 2018. The tool is called the International Prevalence Measurement of Care Problems in Care Homes (Landelijke Prevalentiemeting Zorgkwaliteit, or LPZ for short, in Dutch). LPZ was developed in the Netherlands to provide a reliable mechanism for measuring the prevalence of common care problems within care homes and provide consistent recording of data to drive, or measure, the impact of quality improvement initiatives in the sector. -
Content ArticleDr Sara Ryan is a senior researcher and autism specialist at Oxford University's Nuffield department of primary health sciences. Her son, Connor Sparrowhawk, died in a residential unit, aged 18.
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How to make a complaint to your GP or hospital
Claire Cox posted an article in Complaints
This guide from the Patients Association describes how to make a complaint to your GP or hospital. -
Content ArticleThis is the sixth annual report produced for the Maternal, Newborn and Infant Clinical Outcome Review Programme, run by the MBRRACE-UK collaboration. The authors analysed 2.3 million pregnancies from 2015-2017 in the UK and Ireland. During that three-year period, 209 women in the UK and Ireland died during their pregnancies or up to six weeks afterwards from pregnancy-related causes. This is equivalent to just over 9 women per 100,000. The leading cause of maternal deaths in the UK is still cardiovascular disease, including heart attacks, heart failure and heart rhythm problems, and there has been no reduction in maternal deaths from heart-related causes for more than 15 years. The full report can be found through the link below, or you can read the lay summary here.
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Content ArticleA ‘critical incident' is one that challenges your own assumptions or makes you think differently’. They provide the following helpful prompts to guide reflection on critical incidents. Here is a simple example of critical incident reflection produced by Birmingham City University.
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Content ArticleOn 20 March 2018 NHS Improvement launched an engagement programme to seek views from a wide range of stakeholders about how and when patient safety incidents should be investigated. Often those affected by incidents are not appropriately supported or involved in the investigation process; the quality of investigation reports is generally poor; and improvements to prevent the recurrence of harm are not effectively implemented. To obtain views on the problems with the current approach to the investigation of Serious Incidents, the issues driving these problems, and how such issues might be resolved, NHSI ran an online survey, national workshops and a live twitter chat, and held discussions with many individuals including patients, families, NHS staff, regulators and others. This document summarises the feedback received.
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Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
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Content ArticleThe Public Involvement in Research Standards produced here aim to provide people with clear, concise benchmarks for effective public involvement alongside indicators against which improvement can be monitored. They are intended to encourage approaches and behaviours which will support this: flexibility; partnership and collaboration; a learning culture; the sharing of good practice; effective communications. The standards are the work of a Public Involvement Standards Development Partnership which brings together representatives including public contributors from the Chief Scientist Office (Scotland), Health and Care Research Wales, the Public Health Agency (Northern Ireland) and the National Institute for Health Research (England).
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Content ArticleDr George Findlay, Medical Director at Western Sussex Hospital NHS Foundation Trust, talks on the theme of 'Becoming well-led' and how leadership can deliver quality improvement through engaging and empowering staff.
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Content ArticleThe Secretary of State asked NHS England and NHS Improvement to develop a new strategy for patient safety as a ‘golden thread’ running through healthcare. They consulted the UK on a set of ideas in December 2018. They received 527 contributions from organisations and individuals (staff, patients and carers). This strategy is the result of the consultation.
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Content ArticleThis joint project with East Berkshire CCG was highlighted within the AKI Programme within Oxford Patient Safety Collaborative. Fewer residents are suffering urinary tract infections (UTIs) following the introduction of a hydration programme in care homes. UTIs are closely associated with dehydration. This project was designed to encourage residents to drink more fluids with the aim that this would lead to fewer UTIs requiring medication or hospital admission. This approach involved introducing structured drinks rounds seven times a day, designed and delivered by care home staff. The initial focus was in four care homes which had higher than average UTI admission to hospital rates.
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Content ArticleThis ‘Erice Call for Change’ is a report from a group of experts, patients and patient representatives who met in Erice in September 2019 following previous similar meetings after the original Erice Declaration (1996). The aim of the meeting was to discuss the challenge of causal complexity and individual variation in modern healthcare. The group’s concern was the impact that new clinical decision-making tools, based on statistical correlations in large databases, could have on individual patient care if they replace other types of clinical investigation and knowledge. The group calls for a change in the approach to the care of the individual patient, and indicates some specific challenges to overcome for such changes to happen.
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Systems Approach Resources (NES)
PatientSafetyLearning Team posted an article in Improving systems of care
Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical and social), organisational structures and arrangement and external factors, such as the influence of national policy or regulation. The nature of these interactions often results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough). To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time. Therefore, to understand patient safety or staff wellbeing (and other emergent outcomes) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions. Follow the link below to the NHS Education Scotland (NES) website to find out more about systems thinking and access systems approach resources. -
Content ArticleEnhanced Significant Event Analysis (enhancedSEA) is a NHS Education for Scotland (NES) innovation which aims to guide healthcare teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.Follow the link below for:guidance on how to perform enhancedSEA the updated report format, new Guide Tools, a short e-learning module basic educational resources on human factors science and practice.Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.
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Content ArticleThe COVID-19 pandemic has required health systems to change much faster than normal. Many staff have experienced training in quality improvement and patient safety methods which can be used to support the design of new systems and to accelerate learning about new and adapted practices. This article, published in the International Journal for Quality in Health Care, sets out the principles of quality improvement and patient safety science, applying them in a selection of approaches, methods and tools, which may be useful in crisis situations such as the current pandemic. The article also makes reference to several resources which may be of use to those keen to advance their knowledge.
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Content ArticleNorth Tees and Hartlepool NHS Foundation Trust has achieved more than double its medicines savings target, delivering the best value for the North Tees and Hartlepool region and the wider NHS. The Trust’s Pharmacy and Medicines Optimisation team together in collaboration with the multidisciplinary medical and nursing teams, finance department and commissioners developed several work streams for medicines efficiencies and quality improvement initiatives. Getting best value for medicines is one of the core business priorities for the Pharmacy & Medicines Optimisation team, through significant collaboration with the multidisciplinary teams of senior medical, nursing, finance, and wider commissioning teams. The project has significantly benefited the organisation and the wider system, through exceeding the expectation of efficiency target, it has contributed directly to improving the quality of patient care and experience as well as ensuring the financial sustainability of the organisation.
