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Showing results for tags 'Quality improvement'.
Found 754 results
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Content ArticleAmiri et al. analysed the role of nurse staffing in improving patient safety due to reducing surgical complications in member countries of Organization for Economic Co-operation and Development (OECD). They found that a higher proportion of nurses is associated with higher patient safety resulting from lower surgical complications and adverse clinical outcomes in OECD countries.
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Content Article
Seize the opportunity (British Journal of Diabetes, 2016)
PatientSafetyLearning Team posted an article in Diabetes
In this article, published by the British Journal of Diabetes, authors argue: "For most, if not all, health economies it is possible to deliver care for all people with diabetes in a more effective and cost-effective way. To do this requires excellent clinical leadership, clear governance, respect for culture and relationships that already exist, service user and carer involvement at the centre, financial and contacting mechanisms that help rather than hinder innovation (even though there is unlikely to be any additional money), joined-up IT systems and a workforce that is committed to improvement and that understands its role. Consultant diabetologists have told us they are up for the challenge. The time has come to go and ruffle a few feathers, take some calculated risks and achieve something of which we can be proud." -
Content ArticleCOVID-19 placed unprecedented pressure on the health and care system. Improvement, which offers systematic approaches that can help adapt to change, would be expected to be a useful asset in the response to the pandemic. Q members, a community of over 4,000 people skilled in improvement, were asked about the role of improvement tools, methods, approaches and mindsets in supporting change during COVID-19. This paper summarises their responses and shares key findings and recommendations for action.
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Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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Content Article
Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. -
Content ArticleThe Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
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Content ArticleThe U.S. Military Health System cares for over 9 million patients and encompasses 63 hospitals and 413 clinics worldwide. Military medicine balances the simultaneous tasks of caring for those patients wounded in military engagements, treating large numbers of families of service men and women, and training the next generation of health care providers and ancillary staff. Similar to civilian health care delivery in the United States, military medicine has also seen increased scrutiny in the areas of cost and quality. To determine the scope of complication rates, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were analysed. The goal of this article from Maturo et al. was to describe the NSQIP surgical outcome data for the U.S. Military's largest medical center from 2009 to 2014 and compare national averages in the areas of mortality, morbidity, cardiac occurrences, pneumonia, unplanned intubation, ventilator use greater than 48 hours, infections, readmissions, and return to operating room.
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Content ArticleTraditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these two methods might not overlap. This is a retrospective observational study from Anderson et al. of all hospitalisations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event identified by surgery faculty and residents for review by departmental M&M conference or administrative data. The authors analysed the degree to which these two processes captured PSI-defined events and reasons for exclusion by each process. The study found that surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.
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Content ArticleUseful information on websites, guides and frameworks related to quality improvement.
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Content ArticleThe Perioperative Warming Quality Improvement Resource summarises the evidence for temperature monitoring, pre, intra and post-operative warming, plus intravenous and irrigation fluids. See also the Perioperative Warming Decision Guide to help support what pre, intra and post-op actions need to be taken to prevent inadvertant perioperative hypothermia.
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Content ArticleThe Surgical Skin Preparation Quality Improvement Resource summarises the evidence for patient washing, hair removal, skin disinfection and the use of incise drapes.
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Content ArticleLearn about the latest scientific evidence around theatre ventilation, movement in and out of theatres and the cleaning processes.
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Content ArticleThe OneTogether Quality Improvement Resources are intended to provide practical information for implementing best practice for each of the elements of care across the surgical pathway. These resources can be used as stand‑alone documents, but are recommended to be used in conjunction with the OneTogether Assessment Toolkit. The OneTogether Assessment Toolkit is designed to measure adherence to best practice to prevent surgical site infection (SSI). Following completion of the OneTogether Assessment, healthcare professionals will be able to identify areas of low compliance and develop a prioritised action plan for improvement. The Quality Improvement Resources summarise the evidence underpinning recommended practice and provide a competency assessment checklist. The information they contain is drawn from evidence-based guidelines or expert recommendations from professional bodies
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Content Article
Global Tracheostomy Collaborative
Patient Safety Learning posted an article in Suggest a useful website
The Global Tracheostomy Collaborative has created a community where a multidisciplinary team of healthcare professionals, patients and families are empowered to learn and continuously improve the outcomes of patients with tracheostomies. -
Content Article
UK National Tracheostomy Safety Project
Patient Safety Learning posted an article in Suggest a useful website
The goal of the UK National Tracheostomy Project is to improve the safety and quality of care for patients with tracheostomies and laryngectomies through education. The project has collaborated with key stakeholders in tracheostomy care to develop freely accessible resources, supported by online learning developed with the Department of Health. -
Content ArticleThe safety huddle has become an important way for hospitals to surface safety concerns affecting patients and the workforce. The best huddles are multidisciplinary, highly structured, brief (15 minutes or less), take place early in the morning and focus on incidents from the day before and risks to safety in the day ahead. Is the safety huddle effective? Have organisations grown lax with the process over time? Some participants have observed that, over time, safety huddles tend to become "just another meeting" or "another box to check off." Dr. James Reinertsen, who has spent decades coaching clinical leaders and staff about safety, says too many huddles allow department leads to report "no safety issues today." That's impossible, says Reinertsen. Every department has safety risks; it's a matter of being proactive and looking for them. In this podcast, Ronette Wiley shares the story of the turnaround with the safety huddle and the tools they use at Bassett Medical Center in upstate New York, USA, and Dr Helen Mackie educates us about the safety huddle at Hairmyres Hospital in Scotland where issues are flagged daily in a rigorous process known as The Onion.
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Content ArticleAn organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again. At the recent Future of Hospitals event from Health Plus Care Online, Helen Hughes, Patient Safety Learning's CEO, speaks with Dr Duncan Bootland, Medical Director at Air Ambulance Kent Surrey Sussex (AAKSS), who was recently rated as outstanding by the Care Quality Commission across all five of its inspection key lines of enquiry. In this recording of the session, Helen and Duncan talk about the safety culture synergy of healthcare and aviation and how behaviour impacts on safety, considering the values-based approach being championed by AAKSS.
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Content ArticleIn this blog, Patient Safety Learning outlines the key points included in its response to the Care Quality Commission’s (CQC) consultation on their new strategy from 2021, identifying the opportunities this presents for the health and social care regulator to help improve patient safety.
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Content ArticleThe purpose of this guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) is to urge all maternity units to consider the use of the Maternity Dashboard to plan and improve their maternity services. It serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground. This may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure a woman-centred, high-quality, safe maternity care.
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Content ArticleEvidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. Alidina et al. explored the factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings. They found that performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. The authors conclude that future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.
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Content ArticleThis survey tool from the Australian Commission on Safety and Quality in Health Care provides Australian health service organisations with a set of 14 principles supported by a variety of risk reduction strategies. The tool is intended for use in hospitals by all clinicians involved in the medication management pathway, including those with governance responsibilities within the health service. The survey tool is also intended to be applied within pharmacy and ward storage environments.
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Content Article
NHS Patient Safety Strategy: February 2021 update
Patient Safety Learning posted an article in NHS Improvement
The NHS patient safety strategy was published in 2019. While the principles and high-level objectives of the strategy remain unchanged, NHS England and Improvement recognised the need for some shift in scope. They have updated their tables of deliverables to include the extra work they will be doing, including the new commitment to address patient safety inequalities and to reflect the disruption and uncertainty arising from the pandemic. -
Content ArticleFor World Patient Safety Day, Natasha Swinscoe, Patient safety national lead for the AHSN Network and CEO, West of England AHSN, highlights the difference the AHSNs and Patient Safety Collaboratives have made in safe maternal and newborn care.
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Content ArticleThere is widespread consensus that learning is crucial for the performance of health systems and the achievement of broader health goals. However, this consensus is not matched by shared knowledge and understanding of how health systems learn, or of how to improve health systems learning across different contexts. The report is aimed at an audience of diverse stakeholders invested in strengthening health systems, and aims to achieve two things. First, to move towards a shared language and frameworks to discuss the problems and solutions of learning, as they apply to health systems. Second, the report seeks to advance action on learning – by providing stakeholders with clarity on steps that they can undertake to advance learning for health systems. This report is intended to be a starting point for gaining a shared understanding of learning health systems as an actionable agenda. The hope is that it will spur useful conversations and fuel the movement for better informed, more analytical and more self-reliant health systems – especially in the context of low- and middle-income countries.
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Content ArticleAs part of a Patient Safety in Surgery Webinar Series held by Massachusetts General Hospital’s COMPASS (Center for Outcomes and Patient Safety in Surgery), Vivian Lee, president of Verily Health Platforms, shares strategies for leading quality improvement and change to work toward a healthcare system that provides better care, more efficiently and at a lower cost.
