Search the hub
Showing results for tags 'Quality improvement'.
Found 754 results
-
Content ArticleThrough a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
-
Content ArticleHigh reliability organisations are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement. This evidence scan collates empirical evidence about the characteristics of high reliability organisations and how these organisations develop within and outside healthcare.
-
Content ArticleThis report published by the National Confidential Enquiry into Patient Outcome and Death, is a review of the care provided to patients aged 16 and over with a diagnosis of, and who underwent surgery for, Crohn’s disease. In summary, the report says that surgery for patients with drug resistant Crohn’s disease surgery should be considered earlier in the treatment pathway for patients, instead of surgery being perceived as a failure of medical care. Once a decision to perform surgery has been made it should be undertaken within a month to prevent patients on elective waiting lists deteriorating and requiring emergency surgery. Furthermore, closer working between all members of the multidisciplinary team would benefit patients, to reduce delays as well as providing all the holistic care that patients with Crohn’s disease need. Read the full list of recommendations and the report via the link below.
-
Content ArticleThe National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
-
Content ArticleThe Strengthening Medication Safety in Long-Term Care initiative, funded by the Ontario Ministry of Long-Term Care was established in partnership with the Institute for Safe Medication Practices (ISMP) Canada to address the medication safety-related recommendations in Justice Gillese’s Long-Term Care Homes Public Inquiry Report. The three-year initiative is designed to improve medication management processes, including those intended to deter and detect intentional and unintentional harm in long-term care homes across the province of Ontario. This bulletin provides an overview of the initiative and highlights selected examples of improvement projects completed in the first phase.
-
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jenny talks about the challenge of keeping up with and prioritising new guidance and the need to streamline recommendations to ensure they are implemented efficiently. She also discusses the importance of getting the basics, like staffing levels, right and how sea swimming has influenced how she sees patient safety. -
Content ArticleInconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. The Safer Tracheostomy Care in Adults bundle was a programme of 18 interventions implemented across 20 hospitals in England between August 2016 and January 2018. These interventions were designed to improve the quality and safety of care for patients who have had tracheostomies. This evaluation report outlines why the interventions were needed and assesses their impact, including an estimated reduction in total hospital length of stay per tracheostomy admission of 33.02 days, corresponding to a potential reduction of over £27,000 per admission.
-
Content Article“Breaking the Rules for Better Care” was developed and initiated by the US-based Institute for Healthcare Improvement (IHI) Leadership Alliance in 2016 as a way to identify health care “rules” that get in the way of the care experience. They recognised that as healthcare leaders they aim to provide positive experiences for patients, families, and staff. However, sometimes they may inadvertently create processes or policies that have an unintended impact on the people they work to serve and support. In 2017, 10 members of the IHI Health Improvement Alliance Europe (HIAE) conducted their own “Breaking the Rules for Better Care” week, amassing 500 proposed rules by means of feedback boxes in cafeterias, postcards, stickers, comment boards, and staff brainstorming sessions. One organisation even ran an underground “guerrilla campaign,” covering its hallways and doorways with red masking tape to illustrate “breaking the rules” in action. To view the existing system with a new lens, organisations from these two IHI networks have been asking: If you could break or change one rule in service of a better care experience for patients or staff, what would it be and why? This is a resource pack to help others undertake a similar "breaking the rules for better care" campaign.
-
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.
- Posted
- 4 comments
-
- (and 4 more)
-
Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
- Posted
- 2 comments
-
1
-
- (and 4 more)
-
Event
BHP Lecture Series - Professor Mary Dixon Woods
Sam posted an event in Community Calendar
untilThis lecture will briefly outline challenges in quality and safety in healthcare, will identify the patchy history of attempts to make improvements, will emphasise the need to build and evidence base for improvement, and will outline some of the challenges and opportunities in evidence generation. Mary Dixon-Woods is Director of THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge. Register -
Content Article
World Hospice and Palliative Care Day takes place on 14 October 2023. Patient safety in hospice and palliative care involves ensuring that every patient is able to access the services, support and pain relief that they need when they reach the end of life. It is also vital that families and carers are given relevant and timely support and information by healthcare services during their loved one’s hospice or palliative care, and following their death. -
Content Article
The evidence behind personalised care
Patient_Safety_Learning posted an article in Quality Improvement
Through personalised care, people have the opportunity to be actively involved in the decision-making process around their treatment options and care by speaking up on things that feel most important to them. There is increasing evidence to show that involving people in decisions about their healthcare leads to improvements in the quality of care, higher patient satisfaction and improved health outcomes, all of which lead to the more effective use of healthcare services. Find out more about the evidence for personalised care, including links to related research, on the Personalised Care Institute website via the link below. -
Content Article
Personalised Care Institute
Patient_Safety_Learning posted an article in Improving systems of care
The Personalised Care Institute (PCI) helps to empower patients with the knowledge, skills and confidence to feel more in control of their mental and physical health. They do this by educating and inspiring health and care professionals to deliver universal personalised care that takes into account an individual’s strengths, needs and expectations, in order to deliver the right care for them. They set the standards for evidence-based personalised care training, providing a robust quality-assurance and accreditation framework for training providers and commissioners along with a central learning hub for health and care professional learners. -
EventThis conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure patient feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Sessions will include learning from patients, improving patient experience, practical sessions focusing on delivering a patient experience based culture, measuring patient experience, using the NHS Improvement National Patient Experience Improvement Framework, demonstrating insight and responsiveness in real time, monitoring and improving staff experience, the role of human factors in improving quality, using patient experience to drive improvement, changing the way we think about patient experience, and learning from excellence in patient experience practice. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-insight or email aman@hc-uk.org.uk Follow on Twitter @HCUK_Clare #PatientExp hub members receive a 20% discount. Email info@pslhub.org
-
News ArticleTrust leaders have been asked to “self-assess” the quality of their “improvement culture” as part of an initiative launched by NHS England chief executive Amanda Pritchard in the spring to lead the service's new improvement drive. The call came from NHS Impact, led by former Modernisation Agency chief David Fillingham, who along with NHS Impact’s deputy chair – University Hospitals Coventry and Warwickshire Foundation Trust CEO Andy Hardy – has written to service leaders, setting out the first stage in the improvement drive. They have asked the boards and CEOs of trusts and integerated care boards to “engage directly” with a new self-assessment tool and maturity matrix created by NHS Impact. This is designed to gauge their progress on adopting the five practices that NHS IMPACT claim “form the DNA of an improvement culture”. Those five practices are: A shared purpose and vision which are widely spread and guide all improvement effort. Investment in people and in building an improvement focused culture. Leaders at every level who understand improvement and practise it in their daily work. The consistent use of an appropriate suite of improvement methods. The embedding of improvement into management processes so that it becomes the way in which we lead and run our organisations and systems. Read full story (paywalled) Source: HSJ, 29 September 2023 .
-
Content ArticleIncident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.
-
Content ArticleThe Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
-
Content ArticleThis blog from the Institute for Healthcare Improvement (IHI) looks at the importance of embedding quality control (QC) measures into everyday work. QC methods sustain improvements for the long-run and promote stable systems to produce reliable outcomes. When effectively used, they can internally monitor performance, assess progress towards goals and allow systems to direct improvement resources to where they are needed most.
-
Content ArticleOvercrowding in the emergency department (ED) is a global problem that causes patient harm and exhaustion for healthcare teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. This study in BMJ Open Quality looked at a quality improvement project that aimed to ensure that no patients were lying in bed awaiting care or referral outside a care area. Several plan–do–study–act (PDSA) cycles were tested and implemented to achieve and maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: No patients lying down outside of a care unit Forward movement Examination room always available Team huddle An organisation overcrowding plan The researchers found that the PDSA strategy based on these five measures removed in-house obstacles to the internal flow of patients and helped avoid them being outside the care area. These measures are easily replicable by other management teams.
-
Content ArticleDr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
-
Content ArticleThe NHS-Virginia Mason Improvement Partnership was a five-year programme where five NHS organisations implemented organisation-wide improvement. The evaluation, led by Dr Nicola Burgess of University of Warwick - Warwick Business School offers profound lessons on how to create a culture and system for continuous improvement. The six lessons from the evaluation are now available in a free eBook.
-
Content ArticleFamily-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. Brady et al. aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU).
-
Content ArticleThis state-of-the-nation report from the National Hip Fracture Database (NHFD) focuses on the period from 1 January to 31 December 2022. It shows that the number of people who died in the month following a hip fracture now stands at 6.2%; down from 10.9% in 2007, when the NHFD was set up. However, the report also finds that it took longer for patients to reach a ward where a hip fracture team can work together (where there is the best chance of recovery) in 2022. It also states that fewer patients received prompt surgery to repair their broken hip by the day after they presented to hospital. There was an improvement in how many people with hip fracture received bone strengthening medicines to avoid future fractures in 2022, but some hospitals continue to report that none of their patients receive such treatment.
-
Content ArticleThe Acute Frailty Network (AFN) was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. In July 2023, Street et al published a paper in BMJ Quality and Safety analysing the impact of the AFN which concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not. This article outlines the position of the British Geriatrics Society (BGS) on the paper, addressing why it thinks that focusing on older people’s healthcare is more important than ever. It highlights the importance of ensuring that the paper's findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble efforts to identify and overcome the barriers to delivering CGA in acute settings.
