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Found 751 results
  1. Content Article
    A dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
  2. Content Article
    This quality standard from the National Institute of Health and Care Excellence (NICE), covers preventing and controlling infection in adults, young people and children receiving healthcare in primary, community and secondary care settings. It includes preventing healthcare-associated infections that develop because of treatment or from being in a healthcare setting. It describes high-quality care in priority areas for improvement.
  3. Content Article
    Regardless of a patient's health literacy level, it is important that staff ensure that patients understand the information they have been given. The teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way for clinicians to confirm they have explained things in a manner their patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler).
  4. Content Article
    This book explains the role of communication in mental health, emergency medicine, intensive care and a wide range of other health service and community care contexts. It emphasises the ways in which patients and clinicians communicate, and how clinicians communicate with one another. The case studies explain why and how communication is critical to good care and healing. Each chapter analyses real-life practice situations, encourages the learner to ask probing questions about these situations, and sets out the principal components and strategies of good communication. 
  5. Content Article
    The objective of this Australian paper, published in the International Journal for Quality in Health Care, was to develop, implement and evaluate a system-wide 'challenge' with the aim of improving safety and quality.
  6. Content Article
    The ‘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.
  7. Content Article
    The framework for safe, reliable, and effective care, set out by the Institute for Healthcare Improvement, provides clarity and direction to health care organisations on the key strategic, clinical, and operational components involved in achieving safe and reliable operational excellence, a 'system of safety', not just a collection of stand-alone safety improvement projects.
  8. Content Article
    The Health Foundation commissioned the London School of Hygiene and Tropical Medicine to survey over 2,300 GPs and 1,400 practice managers across the UK, alongside qualitative interviews.  The research shows that most GPs and practice managers see quality improvement as a core aspect of their work, with 99% reporting undertaking QI activities, and many working collaboratively with neighbouring practices to improve services.  However, there are many issues making it difficult to deliver improvement, including high patient demand and staff shortages; demands of other NHS agencies, lack of protected time and level of improvement capability.  
  9. Content Article
    Conquer the most essential adaptation to the knowledge economy The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth offers practical guidance for teams and organisations who are serious about success in the modern economy. With so much riding on innovation, creativity, and spark, it is essential to attract and retain quality talent--but what good does this talent do if no one is able to speak their mind? The traditional culture of "fitting in" and "going along" spells doom in the knowledge economy. Success requires a continuous influx of new ideas, new challenges, and critical thought, and the interpersonal climate must not suppress, silence, ridicule or intimidate. Not every idea is good, and yes there are stupid questions and yes dissent can slow things down, but talking through these things is an essential part of the creative process. People must be allowed to voice half-finished thoughts, ask questions from left field, and brainstorm out loud; it creates a culture in which a minor flub or momentary lapse is no big deal, and where actual mistakes are owned and corrected, and where the next left-field idea could be the next big thing. This book explores this culture of psychological safety, and provides a blueprint for bringing it to life. The road is sometimes bumpy, but succinct and informative scenario-based explanations provide a clear path forward to constant learning and healthy innovation. Explore the link between psychological safety and high performance Create a culture where it's "safe" to express ideas, ask questions, and admit mistakes Nurture the level of engagement and candour required in today's knowledge economy Follow a step-by-step framework for establishing psychological safety in your team or organisation Shed the "yes-men" approach and step into real performance. Fertilise creativity, clarify goals, achieve accountability, redefine leadership, and much more. The Fearless Organisation helps you bring about this most critical transformation.
  10. Content Article
    Published by the American Association of Medical Colleges (AAMC), Quality improvement and patient safety competencies across the learning continuum is designed for: faculty medical education curricula developers residents medical school administration Designated Institutional Officials (DIOs) clinical leaders at teaching hospitals  and others interested in undergraduate, graduate, and continuing medical education.
  11. Content Article
    Medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human factors, electronic health records, and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
  12. Content Article
    Paul Batalden has defined quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. Quality improvement (QI) goes beyond traditional management, target setting and policy making. QI methodology is best applied when tackling complex adaptive problems – where the problem isn’t completely understood and where the answer isn’t known – for example, how to reduce frequency of violence on inpatient mental health wards. QI utilises the subject matter expertise of people closest to the issue – staff and service users – to identify potential solutions and test them. East London NHS Foundation Trust (ELFT) is a provider of mental health and community services, to a population of approximately 1.5 million people, mainly across East London, Bedfordshire and Luton.
  13. Content Article
    In this article, Human Factors Consultant, Jayne Higgs, talks about systems thinking. She highlights the different components that contribute to systems thinking (including human factors) and argues that this approach can aid a move away from a narrow-perspective blame culture.
  14. Content Article
    When 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.
  15. Content Article
    Eighteen years after the advent of the National Patient Safety Agency (NPSA) why is investigating in such a parlous state? Ed Marsden, Managing Director of independent investigative consultants Verita, discusses why making improvements to patient safety comes second place to sorting out problems with the investigative process.
  16. Content Article
    Published on the Johns Hopkins University website, this commentary from Saralyn Cruickshank focuses on the newly released book Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. Written by Robert Wears and Kathleen Sutcliffe, the book argues that the patient safety movement has evolved but not, in all cases, for the better.
  17. Content Article
    Mark Lomax, CEO at Patient Experience Platform, talks about the value of disruptive healthcare innovations and how to identify the 'disruption killers' and the champions within an organisation.
  18. Content Article
    Improvement is now becoming a way of life and a way of being. How do we hold onto and strengthen our approach to QI projects? Have a read of Amar’s latest QI Essentials Blog.  Amar Shah is a consultant forensic psychiatrist and Chief Quality Officer at East London NHS Foundation Trust.
  19. Content Article
    AQuA are an NHS health and care quality improvement organisation at the forefront of transforming the safety and quality of healthcare. They are based in the North West and work with over 70 member organisations. They also undertake a number of consultancy based projects across the UK with both health and care organisations.
  20. Content Article
    Designed for faculty, medical education curricula developers, residents, medical school administration, Designated Institutional Officials (DIOs), clinical leaders at teaching hospitals, and others interested in undergraduate, graduate and continuing medical education. There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the Association of American Medical Colleges (AAMC) has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of health care services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally. 
  21. Content Article
    A new study published in the December 2019 issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement project by researchers at Penn Medicine, Philadelphia, USA, to reduce the risk of single-patient insulin pens.  Insulin pens are widely used in hospitals because they have multiple safety advantages compared to insulin vials, including a product name and barcode and a dial mechanism for less error-prone dosing. Despite these features, accidental sharing of pens still occurs, putting patients at risk for exposure to HIV, hepatitis B virus or hepatitis C virus.
  22. Content Article
    A 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.
  23. Content Article
    This report from the Parliamentary Health Service Ombudsman (PHSO) explains the findings of their research, highlights the issues they have identified and sets out the action they believe needs to be taken to improve the quality of NHS investigations.
  24. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) use clinical advice as a key source of evidence to inform their thinking in around three quarters of their health investigations. It is crucial that they commission and use clinical advice correctly. It is also important that those involved in a complaint understand and have confidence in the way it has informed decisions. To meet a commitment they made in their new strategy for 2018-21, the PHSO carried out a major review of the way they use clinical advice when they investigate NHS complaints. 
  25. Content Article
    Dr Helen Higham, Co-Director of the Patient Safety Academy, presented at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference on how we can effectively learn from serious incidents.
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