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Showing results for tags 'Speaking up'.
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Content ArticleThis document outlines the standard operating procedure (SOP) adopted by University Hospitals Bristol NHS Foundation Trust, relating to parental involvement in escalation of clinical care for acutely ill children. It aims to clarify the process of empowering parents to escalate concerns if they are worried about the clinical condition and care being delivered to their child, or themselves if they are a patient. It also aims to ensure accurate and appropriate information is provided to parents on admission (elective and acute) regarding how they should escalate concerns about the care their child is receiving.
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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. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer. -
Content ArticleThis framework produced by the Royal College of Paediatrics and Child Health (RCPCH) aims to improve how healthcare organisations recognise and respond to children at risk of deterioration. A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning. The framework covers: Patient safety culture Partnership with families Recognising deterioration Responding to deterioriation Open and consistent learning Education and training
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Content ArticleThe aim of this study in Australian Critical Care was to develop an evidence-based paediatric early warning system for infants and children, that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care. The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was an important and new component of the system.
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Content ArticleThis document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events. Staffing Overcrowding Inflow Outflow Acuity
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Content ArticleThere are over 850 Freedom to Speak Up guardians in NHS primary and secondary care and independent sector organisations, national bodies and elsewhere who work to ensure workers can speak up about any issues which have an impact on their ability to do their job. For Speak Up month, the National Guardian Office find out more about the people behind the role in the 'Stuck in a lift' interviews.
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News ArticleThe troubled agency that supplies blood to the NHS has a ’very serious problem’ with racism, a staff survey has revealed. Six hundred staff at NHS Blood and Transplant were surveyed and the results have been summarised in an internal memo, seen by HSJ. It said 55% of respondents felt the problem of racism at NHSBT is “extremely or very serious”, while half had little confidence in the organisation’s recent efforts to tackle racial inequality. When contacted for comment, a NHSBT spokeswoman said the results were “difficult to read” and added that “we are deeply sorry to those who have experienced negative behaviour”. The issues over race and leadership come at perhaps the most operationally challenging period in NHSBT’s history. It is struggling to find enough staff for its donation clinics, which meant it issued its first-ever “amber alert” over blood supplies recently. Read full story (paywalled) Source: HSJ, 21 October 2022
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News Article
'No-one joined the dots' - grandad who exposed an NHS scandal
Patient Safety Learning posted a news article in News
More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022 -
News Article
Leadership review launched at ‘outstanding’ trust
Patient Safety Learning posted a news article in News
The Care Quality Commission has launched a review of leadership at an “outstanding”-rated specialist trust, after receiving multiple concerns from whistleblowers. The regulator is understood to have made an unannounced visit to The Christie Foundation Trust within the last week to inspect its medical services. The review will also cover the trust’s overall leadership. HSJ understands the review is, at least, partly in response to the regulator receiving a number of concerns from whistleblowers about the trust’s leadership culture and behaviour of senior staff. It comes after the trust came under scrutiny from NHS England last year, with independent reviews finding there had been multiple failings around the handling of a major research project. The reviews also criticised the trust’s reaction to staff who had raised concerns, but failed to answer a key accusation that was made about the detriment suffered by whistleblowers. Read full story (paywalled) Source: HSJ, 19 October 2022 -
Content ArticleThe journalist Merope Mills voices her anger at her daughter Martha's preventable death in this Woman's Hour programme.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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News Article
Number of NHSE whistleblowers tripled in 2021-22
Patient Safety Learning posted a news article in News
The number of concerns reported by NHS England staff through the freedom to speak up process almost tripled last year, the organisation’s latest board papers have revealed. There were 152 cases received by the internal freedom to speak up guardians in 2021-22 compared to 56 in 2020-21. This year 54 cases were received in quarter three alone. The most common concerns are related to allegations of bullying and harassment. These accounted for nearly 40% of the total. People and team management concerns accounted for a third of FTSU cases. Within the latter, there were sub-themes of breakdown in relationships, failure to offer role models and sanctioning or ignoring poor culture. This week’s report also set out the NHSE FTSU guardian’s next steps. These include appointing a lead guardian, finalising a strategy and continuing to engage with Health Education England and NHS Digital staff as they are brought into NHSE next year. Read full story (paywalled) Source: HSJ, 7 October 2022 -
Content ArticleIn this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
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Content ArticleThis information sheet produced by South Australia Health's Safety and Quality Unit describes how patients and staff can work together to make sure that if clinical deterioration occurs, it will be acted upon in a timely and effective manner. The information also applies to carers, family members, friends or the patient’s appointed responsible person. It includes information relating to deterioration during an emergency department visit or hospital stay, and at and after discharge.
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News Article
CQC triggers two reviews into whistleblowing concerns
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has commissioned an independent review into handling of a high-profile whistleblower case, and a wider internal review of how it responds when it is given “information of concern”. The independent review will be led by Zoë Leventhal KC of Matrix Chambers and will consider how the regulator handled “protected disclosures” from University Hospitals of Morecambe Bay Foundation Trust surgeon Shyam Kumar, alongside “a sample of other information of concern shared with us”. Mr Kumar won a tribunal against the CQC earlier this month, which found he was unfairly dismissed as a special advisor on hospital inspections after raising serious patient safety concerns. Between 2015 and his dismissal in 2019 Mr Kumar wrote to senior colleagues at the CQC with a number of concerns within his trust around bullying, patient harm and the quality of CQC hospital inspections. The tribunal drew particular attention to the two whistleblowing disclosures made by Mr Kumar about the CQC itself, which it found “clearly had a material influence on the decision to dismiss”. The CQC said in an announcement today that the independent review would aim to determine whether it took “appropriate action” in response to the information disclosed in Mr Kumar’s case and others. It will include consideration of whether the ethnicity of the people raising concerns impacted on decision making or outcome and is expected to conclude by the end of the year. Read full story (paywalled) Source: HSJ, 28 September 2022 -
EventuntilJoin Kayleigh Barnett, Senior Improvement Advisor at Aqua who will share her experience in using Appreciative Inquiry methods to create additional value for learners in a quality improvement (QI) programme aimed at aspiring senior leaders. Appreciative Inquiry is increasingly used as the basis for building a structured learning process and this session will present a case study, and provide practical ideas for you to consider. Ensuring that Appreciative Inquiry processes are included in any part of an organisation can also contribute to psychological safety. Psychological safety is the belief that you won’t be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. Kayleigh has worked at Aqua for six years and is the Delivery Lead for Appreciative Inquiry. She is an accredited Appreciative Inquiry Practitioner from the International Academy of Appreciative Inquiry. Her other areas of work are quality improvement and human factors. The case study she will present has also been featured in the September edition of the Appreciative Inquiry Practitioner journal. Register
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Content ArticleThe Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
News Article
Coffey warned of ‘significant risk’ posed by CQC restructuring
Patient Safety Learning posted a news article in News
Staff at the Care Quality Commission (CQC) have been left ‘in fear of speaking out’ against structural changes to the organisation which they believe ‘pose a significant risk’ to the CQC’s ability to regulate health services, trade unions have told the health and social care secretary. A letter signed by senior officers of Unison, Royal College of Nursing, Unite, Prospect and the Public and Commercial Services union has called on Therese Coffey to urge the CQC to pause its organisational change and enter into “meaningful discussions” with the unions. The unions have raised concerns that organisational changes to the CQC have been drawn up by consultants with no frontline experience in health and social care, or in regulation, and that staff have had limited input into the changes. They allege that staff raising concerns about the changes have been dismissed as being “disruptive” or “negative”, and significant numbers of experienced staff have recently left the regulator. The CQC said in response to the letter that the changes it was proposing were needed to enable the regulator to “work more effectively across the health and care system”, and that it has engaged with trade unions throughout the process. Read full story (paywalled) Source: HSJ. 23 September 2022 -
Content ArticleRepeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
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Content ArticleFrom April 2023 the new Health Services Safety Investigations Body will require doctors to be candid about errors that have led to patient harm. But can medics trust that material given in this “safe space” won’t be used against them?
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Content Article
In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.- Posted
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Content ArticleEverybody makes mistakes at work but what if you're a doctor and you ruin a patient's life - or even end it? Doctor-turned-writer Jed Mercurio recalls a catalogue of errors from his years as a medical student.
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Content ArticleThis presentation provides an insight into a real life crowdfunded NHS whistleblowing case. This comes from the perspective of both a frontline NHS clinician and crowdfunder. The tactics used against Dr Day, his response to them and the effect that such a public protracted fight has had on NHS culture and ‘confidence in the system’. Potential changes are then discussed Chris is a Locum Emergency Medicine doctor working at the moment in East London. Chris is also a Claimant in a high profile whistleblowing case that has been ongoing for nearly 9 years. The case re-established statutory whistleblowing protection (in the Court of Appeal) for junior doctors in England. The case has had further media attention last month when Chris’ NHS opponents admitted to destroying evidence whilst a 16 day court hearing was in progress.
