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Showing results for tags 'Quality improvement'.
Found 757 results
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EventuntilThe final tweetchat in the 'Six lessons for leading improvement' campaign.
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Content ArticleGloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
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Content ArticleThe Regional Patient Safety Observatory of the Community of Madrid is an initiative aimed at increasing the quality of healthcare and the safety of professionals and patients in the healthcare environment. The Observatory is a consultative and advisory body of the Ministry of Health in matters of health risks and is functional in nature. Its objectives are: Promote and spread the culture of health risk management in the Community of Madrid. Obtain, analyse and disseminate regular and systematic information on health risks. Propose measures to prevent, eliminate or reduce health risks. It hosts the Patient Safety Brief Library, a tool for disseminating scientific knowledge developed by a group of experts within the framework of the Patient Safety Strategy 2027 of the Ministry of Health.
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Content ArticleThe International Alliance of Patients’ Organizations (IAPO) is an alliance of patient groups in official relationship with the WHO and is representing the interests of patients worldwide IAPO P4PS Observatory is a single-point global platform for gathering and analysing patients’ expertise and experience to feed evidence to the national, regional and global policies aimed at improving patient and quality of care for patients by the patients.
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Content ArticleDo you ever feel like you keep addressing the same healthcare issue over and over again, only to have it resurface? It can be frustrating to focus on individual symptoms or parts of the system and not see any lasting change. This is where systems thinking comes in - a holistic approach that allows you to see the bigger picture and understand how different parts of a system interact with each other. Find out more in this blog from Tara Thornton for the FutureNHS Community.
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Content ArticlePatients are vulnerable during emergency episodes outside the formal care sector, for example, care provided by paramedics responding to a stroke or heart attack at home. Yet much less is known about the safety of Emergency Medical Services (EMS) as compared with primary or secondary healthcare. This relative lack of information is important given there are aspects of EMS care that create unique patient safety challenges. This BMJ Editorial discusses how we can improve patient safety in the Emergency Medical Services.
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022.
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Content ArticleThe Armstrong Institute for Patient Safety and Quality provides an infrastructure that oversees, coordinates and supports patient safety and quality efforts across Johns Hopkins' integrated healthcare system. Their mission is to eliminate patient harm, achieve best patient outcomes at the lowest possible cost and share that knowledge through research and training The Armstrong Institute for Patient Safety and Quality leads regional, national and international projects that reduce preventable harm, improve patient and clinical outcomes, and decrease health care costs. They apply a scientific approach to improvement, employing robust measures and rigorous data-collection methods that can be broadly disseminated and sustained.
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Content ArticleNHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement. From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
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Content ArticleIn this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
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Content ArticleAcademic Health Science Networks (AHSNs) host England’s fifteen Patient Safety Collaboratives. They are experts in supporting quality improvement projects using methodology from the Institute of Healthcare Improvement model for improvement. This resource pack by The AHSN Network provides an overview of the different ways Patient Safety Collaboratives can support safety improvement projects and includes case studies and resources.
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Content ArticleThis paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
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Content ArticleThis review covers the impact the Eastern AHSN has delivered throughout the East of England and beyond in 2022/23, including an increased focus on fostering an innovation culture, tackling health inequalities, and supporting innovators to turn their ideas into positive health impact.
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Content ArticleThe AHSN Network comprises 15 AHSNs across England, established by NHS England in 2013 to improve health and generate economic growth in regionally distinct ways. In 2021, they launched their five-year strategy where they set out their ambition to support the NHS through an increased emphasis on health outcomes, their innovation pipeline, and by using knowledge and learning to build and embed greater momentum for NHS pathway transformation. Here is their latest progress report and achievements.
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The Child Health Clinical Outcome Review Programme has produced this review of the barriers and facilitators in transitioning children and young people with complex chronic health conditions into adult health services. Based on data on children and young people with one of 12 complex conditions identified from a sample period between 1st October 2019 and 31st March 2021, the report concludes that there is no clear pathway for the transition from healthcare services for children and young people to adult healthcare services. The report finds that the process of transition and subsequent transfer is often fragmented, both within and across specialties, and that adult services often sit only with primary care. It argues that developmentally appropriate healthcare should be everyone’s responsibility, with adequate resources needed to allow this to happen. The Inbetweeners also calls for services to: involve young people and parent/carers in transition planning and transition to adult services improve communication and coordination between all specialties be organised to enable young people to transfer to adult services effectively, and provide strong leadership at Board and specialty level at all stages of transition and transfer. The report’s recommendations highlight areas that are suitable for regular local clinical audit and quality improvement initiatives by those providing care to this group of patients. It suggests that the results of such work should be presented at quality or governance meetings, and action plans to improve care should be shared with executive boards. -
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Join the HQIP Service User Network (SUN)
Patient-Safety-Learning posted an article in Jobs and voluntary positions
HQIP hosts a Service User Network (SUN) for people who are interested in contributing to improving the quality of healthcare services. Anyone with lived experience as a patient or carer is invited to join. The SUN was established in 2009 and has had over 40 patient and carer advocates working in an advisory capacity to HQIP. There is no commitment once you sign up and all opportunities will be shared via a newsletter, To register your interest, complete this form. HQIP will then send you regular updates about projects that you could contribute to. -
Content ArticleThe publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
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Content ArticleIn this article for the BMJ, John R Drew, an improvement and culture consultant and Meghana Pandit, chief medical officer at Oxford University NHS Foundation Trust, argue that quality improvement (QI) should be a core tenet of how healthcare organisations are run. They highlight that some of the conditions and assumptions required for QI are at odds with prevailing management practices, with staff feeling more valued and respected while going through the QI process. They discuss the following subjects and questions: QI as the basis of management When do QI and good management coalesce? So is QI just good management? How can we help leaders get on this path?
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The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement. In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight. -
Content ArticlePatient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. Authors of this study, published in BMJ Quality & Safety, sought to understand the incidence and nature of patient-reported safety concerns in hospital.
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Content ArticleDoes your manufacturing facility experience an undesirable frequency of costly product losses? Are recurring operational issues impacting productivity and morale? Do people believe the causes of these production issues are ‘human error’? Do Quality Differently will show you: How to take a systems-based risk management approach to create more operational success. Practical examples to guide improvement in your operations. Ways to apply comprehensive approaches that reveal and address the combination of factors that influence performance outcomes.
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The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
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NHS Impact resources
Patient Safety Learning posted an article in NHS England
NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities. -
Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content ArticleThe NHS is at a critical juncture in its 75-year history. With finances as tight as they have ever been, and a workforce stretched to breaking point due in part to spiralling demand from an older and sicker population and a shrinking labour pool, it is clear that things cannot carry on as they are. The time has come to think and act differently – at every level of the health and social care system – and to do so at pace. This long read describes five guiding principles that should inform implementing the NHS Impact approach to improvement at provider, ICS and national level to maximise the chances of success in the current climate. We also present recommendations for provider organisation, system and national leaders on the steps needed to translate these principles into sustained improvements across ICSs.
