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Showing results for tags 'Quality improvement'.
Found 757 results
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Content ArticleThe Scottish Patient Safety Programme (SPSP) is a national quality improvement programme that aims to improve the safety and reliability of care and reduce harm. Since the launch of SPSP in 2008, the programme has expanded to support improvements in safety across a wide range of care settings including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and medicines safety. Underpinned by the robust application of quality improvement methodology SPSP has brought about significant change in outcomes for people across Scotland.
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Content Article
WHO: Introducing the Patient Safety Friendly Hospital Initiative
Patient Safety Learning posted an article in WHO
The Patient Safety Friendly Hospital Initiative (PSFHI) aims to address the burden of unsafe care in the Eastern Mediterranean Region. It helps institutions in countries of the Region to launch comprehensive patient safety programmes, with assistance from the World Health Organization (WHO). -
Content ArticleThis report from the King's Fund looks at the reality of caring for acutely ill medical patients at the NHS front line and asks how care in hospitals can be improved. It comprises a series of essays by frontline clinicians, managers, quality improvement champions and patients, and provides vivid and frank detail about how clinical care is currently provided and how it could be improved. The essays are introduced and summarised by Chris Ham and Don Berwick and the report serves as the starting point of an ongoing appreciative inquiry into improving care processes, particularly for acutely ill medical patients.
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News Article
Hancock’s performance to be given a ‘CQC-style’ rating
Patient Safety Learning posted a news article in News
The parliamentary committee led by Jeremy Hunt will subject health ministers to a “CQC style ratings system”, as part of a new way of scrutinising the Department of Health and Social Care. The Health and Social Care Select Committee has set out plans for a new ratings system to “offer independent and objective evaluation of ministerial pledges”. This will mean the government is held to account by an evaluation process similar to that used across the NHS and social care system which gives not just an absolute score but key pointers as to how to improve that score next time round. “We hope it will focus attention on areas such as cancer, mental health and patient safety where a number of vital commitments have been made,” says Jeremy Hunt, committee chair and former health secretary. In his six year tenure as health secretary, Mr Hunt styled himself as a champion of patient safety, while his successor, Matt Hancock, has been criticised for appearing to jettison this agenda. Read full story (paywalled) Source: HSJ, 5 August 2020 -
News Article
‘Dr. Checklist’ Peter Pronovost gets chance to transform University Hospitals
Patient Safety Learning posted a news article in News
The ghosts of medical errors haunt Dr. Peter Pronovost. Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career. Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide. Now, he’s implementing his second act, at University Hospitals in the USA, as its Chief Transformation Officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment. The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States. “He’s a once-in-a-generation guy.” Read full story Source: Cleveland.com, 9 February 2020 -
Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Jono talks to us about why he is passionate about making sure patient voices are heard and valued in healthcare investigations and quality improvement. He also highlights the current workforce crisis, the need to look after NHS staff to ensure they can deliver compassionate, high quality care and the importance of being transparent with the public about the problems the NHS is currently facing. -
Content ArticleQuality and Outcomes Framework (QOF) might be back this month – but for practices the work never went away, practices managers have told Management in Practice. NHS England announced the resumption of the payments system last December after QOF was part-suspended in 2021/22 to free up time for Covid vaccinations. But while the QOF system was on hold, many practices have carried on with QOF targets throughout the pandemic, continuing to measure their performance against these indicators.. Now the programme has officially returned, despite concerns that the system does not take into account the significant impact of the pandemic on long-term conditions, and could financially penalise practices. Practice managers are, once again, having to get to grips with targets, and needing to organise appointments for patients most in need of a face-to-face review, while dealing with day-to-day work pressures and staff shortages. Here practice managers share their thoughts on the comeback of QOF, what it will mean for them and their practices, and whether its return is too much, too soon.
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Content ArticleIn this blog for The Health Foundation, the authors make five recommendations for strengthening NHS management and leadership: Support providers and systems to tackle variation in management practice Improve access to training and development opportunities Ensure training equips managers and leaders with the skills they need today Tackle the reporting burden and 'priority thickets' facing managers Ensure the role of managers and leaders is better understood and valued
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Content ArticlePatient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
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Content ArticleThis is the report of Professor Ben Goldacre’s review into how the efficient and safe use of health data for research and analysis can benefit patients and the healthcare sector. It sets out a practical vision of how the Department of Health and the NHS can curate, manage and analyse the huge volume of health data available in the UK, and then communicate and use that data to improve the quality, safety and efficiency of health services.
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Content ArticleHot debriefs are interactive, structured team conversations that take place immediately or very shortly after a clinical case. They are designed to help the whole team learn from the experience, reflect on what went well, identify team strengths or difficulties and to consider ways to improve future performance. In this blog, the authors describe how a multidisciplinary focus group at Edinburgh Emergency Medicine, alongside staff from the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF), developed “STOP5: STOP for 5 Minutes”, a new tool to facilitate hot debriefs.
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Content ArticleDeveloping an organisational approach to improvement in healthcare is a journey that can take several years. It requires corporate investment in infrastructure, staff capability and culture over the long-term. These resources from NHS Providers explain why organisation-wide improvement in healthcare matters, and how to get started.
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Content ArticleThis long read by the Health Foundation examines the challenges of discharging people from hospital, and looks at 'discharge to assess' (D2A) an approach to reducing the incidence of delayed discharge. It outlines priorities for policymakers and the NHS and suggests next steps for managing hospital discharge.
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Content ArticleThe focus on error detection and its management has not produced the expected gains in patient safety, primarily because these methods are not well suited to a complex adaptive system such as healthcare. Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic. One approach to focusing on success is positive deviance. While positive deviance can be used to describe the behaviour of an exemplary individual, the term can also be extended to describe the behaviours of successful teams and organisations. Originating in international public health projects, positive deviance has recently been embraced to improve quality and safety of healthcare delivered in organisations. The premise is that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalised. Lawton et al. explain more in this BMJ article.
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Content ArticleAn introduction to Appreciative Inquiry from NHS England and some team-based exercises for staff.
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Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Julie talks to us about how attitudes to patient safety have evolved since the 1990s, the role of the World Health Organization in improving quality and safety, and the need to learn lessons from infection prevention and control approaches that were adopted during the Covid-19 pandemic. -
Content ArticleTraditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10-20% of errors are ever reported and, of those, 90-95% cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm. The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using “triggers” (or clues) to identify possible adverse events. Many hospitals have used this tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. The recommended time limitation for review and the random selection of records are designed to produce a sampling approach that is sufficient for the design of safety work in the hospital.
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Content Article
The 'So What' of maternity data (August 2022)
Patient-Safety-Learning posted an article in Maternity
This report from the Healthcare Quality Improvement Partnership (HQIP) aims to explore how the multiple national data sets and national audits are used in maternity services across the UK. Based on data from a survey of over 100 people working in a variety of roles across maternity services and a series of in-depth interviews with a diverse group of clinicians and methodologists working in this area, the report explores what data is being reviewed and how it might influence quality improvement, as well as the burden of data. -
Content ArticleThis interactive timeline from The King's Fund sets out reviews and other significant developments concerning NHS and social care leadership in England between 2008 and 2022.
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Content ArticleTraining was recognised as a “bridge to quality” 20 years ago and quality improvement is now integrated into appraisal for doctors in training and outcomes for undergraduate medical education. In the UK, expectations for training of doctors in their first two years after graduation are set by the UK Foundation Year curriculum, which states that FY2 doctors are required to contribute significantly to at least one quality improvement project and report their work in their e-portfolio. Two systematic reviews found that teaching quality improvement and patient safety to trainees frequently resulted in changes in clinical processes. However, there are concerns that trainees in the UK are on short rotations, have limited time or support, and may perceive that they lack authority to persuade colleagues that problems need tackling. This article describes an approach which applies evidence about successful quality improvement training to a curriculum on healthcare improvement for doctors in their first two years of training, drawing on the authors’ experiences. The article recommends principles to help integrate quality improvement into medical training.
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Content ArticleIn a world where there is increasing demand for the performance of health providers to be measured, there is a need for a more strategic vision of the role that performance measurement can play in securing health system improvement. This book presents the opportunities and challenges associated with performance measurement, in a framework that is clear and easy to understand. It examines the various levels at which health system performance is undertaken, the technical instruments and tools available, and the implications using these may have for those who govern the health system. Technical material is presented in an accessible way and is illustrated with examples from all over the world. This book is practical guide for policy makers, regulators, patient groups and researchers.
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Content ArticleThis book focuses on the consumer’s perspective and emphasises how advocacy can influence change in healthcare quality at multiple social levels. This introductory volume synthesises patient advocacy from a multi-level approach and is an ideal text for graduate and professional students in schools of public health, nursing and social work.
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Content ArticleThis edition to the Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
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Content ArticleThis updated edition includes the latest findings on patient safety by two of the foremost authorities on medical mistakes. Two physician-professors investigate (and re-investigate) the errors endemic to modern medical care and suggest ways to prevent hospitals and doctors from inadvertently killing their patients. Emerging from these compelling stories and insights is a powerful case for change - by policymakers, hospitals, doctors, nurses, and even patients and their families. The authors underscore the depth and breadth of dangers in medical care. They also suggest basic safety procedures and hard-nosed remedies that could make erratic systems fail-safe and save countless lives.
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Content ArticleMedication errors are common at the hospital discharge transition but there’s a lot we can do to improve this. The Royal College of Physicians have developed resource focusing on medication safety at hospital discharge that takes teams through the quality improvement process step-by-step. The project was developed in close consultation with a multidisciplinary task and finish group and with input from across health and social care, including patient and carer representatives. This enabled a better understanding of problems that cross sector boundaries, such as medication safety at the hospital discharge transition, and ensured the problem was approached from multiple perspectives. The guide and accompanying improvement tool templates are available to download below.
