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Found 293 results
  1. News Article
    NHS England has announced the first details of its ‘Leadership Competency Framework’, and revealed it will be launched this September. The LCF will underpin the annual appraisal of NHS board directors and, in turn, adherence to the revamped Fit and Proper Person Test. NHSE also revealed that leaders, including senior clinicians, who hold “significant roles” but are not board members may be subject to the FPPT in the near future. The new FPPT framework said the LCF would contain “six competency domains which should be incorporated into all senior leader job descriptions and recruitment processes”. Read full story Source: HSJ, 3 August 2023
  2. Content Article
    The Fit and Proper Person Test (FPPT) Framework has been developed by NHS England in response to recommendations made by Tom Kark KC in his 2019 review of the FPPT (the Kark Revew). This framework introduces a means of retaining information relating to testing the requirements of the FPPT for individual directors, a set of standard competencies for all board directors, a new way of completing references with additional content whenever a director leaves an NHS board, and extension of the applicability to some other organisations, including NHS England and the CQC. It will help prevent directors who have been involved in or enabled serious misconduct or mismanagement from joining a new NHS organisation.
  3. Content Article
    Authors conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. They used interrupted time series models to study and estimate the impact of removing the 4-hour access standard.
  4. Content Article
    This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
  5. Event
    This conference is for staff involved in managing concerns in NHS Scotland, including the promotion, delivery, and use of the Whistleblowing Standards. The Independent National Whistleblowing Office are supporting the event. It will explore the legislative requirements around whistleblowing and the benefits of effective management of concerns. The programme concludes with a focus on what a healthy speak up culture looks like and how that can be delivered. The day will be chaired by John Sturrock, KC, and include a keynote presentation from Rosemary Agnew, the Independent National Whistleblowing Officer. It also brings together expert speakers from NHS Scotland, Scottish Government, trade union and academia with expertise in speaking up, culture change, quality, safety and candour. The programme will consider the Whistleblowing Standards since their launch in April 2021, as they approach their anticipated 3-year review. It offers an opportunity to share good practice, support ongoing improvements and promote an effective Speak Up culture that works from the bedside to the boardroom. Programme Register
  6. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
  7. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.
  8. News Article
    The trust at the centre of a maternity scandal insists it has been providing immediate anaesthetic cover for obstetric emergencies, contrary to an NHS England report suggesting it had not and had been potentially breaching safety standards. Health Education England – now part of NHSE – visited William Harvey Hospital in March and was told senior doctors in training who were covering obstetrics could also be covering the cath lab – which deals with patients who have had a heart attack, and could receive trauma, paediatric emergency and cardiac arrest calls. This suggested the trust was in conflict with Royal College guidelines which state an anaesthetist should always be “immediately available” for obstetrics. East Kent Hospitals University Foundation Trust, which runs the hospital, originally told HSJ its rota had very recently been changed and that an anaesthetist with primary responsibility for maternity could leave any other work to attend to a maternity emergency immediately. However, it has since said it has been the case for a long time that an anaesthetist is available to return to maternity in case of an emergency. Read full story (paywalled) Source: HSJ, 17 June 2023
  9. News Article
    A trust at the centre of a maternity scandal has been failing to meet Royal College standards in one of its maternity units, HSJ can reveal. The duty anaesthetist for the maternity unit at the William Harvey Hospital in Ashford has also had to cover the hospital’s primary percutaneous coronary intervention suite. This could mean no anaesthetist is available to carry out an emergency Caesarean if they are needed to treat a heart attack patient. This goes against Royal College of Anaesthetists’ guidelines, which say a duty anaesthetist must be “immediately available for the obstetric unit 24/7”. The guidelines add that where the duty anaesthetist has other responsibilities – because, for example, they work at a smaller maternity unit where the workload does not justify them being there exclusively – then “these should be of a nature that would allow the activity to be immediately delayed or interrupted should obstetric work arise”. The William Harvey unit is East Kent Hospitals University Foundation Trust’s major birth centre. The trust has around 6,500 births a year – the majority at the WHH – and was heavily criticised for poor maternity care in a report by Bill Kirkup last year. Read full story Source: HSJ. 17 July 2023
  10. Content Article
    Organisations should uphold the patient safety incident response standards to ensure they meet the minimum expectations of the Patient Safety Incident Response Framework (PSIRF). The standards cover the following aspects of PSIRF: policy, planning and oversight competence and capacity engagement and involvement of those affected by patient safety incidents proportionate responses. This document provides the complete list of patient safety incident response standards, and where relevant refers to specific PSIRF documentation.
  11. Content Article
    The Professional Standards Authority (PSA) oversees the work of 10 statutory bodies that regulate health and social care professionals in the UK. In undertaking this oversight role, PSA strive to strike a proper balance between scrutiny on the one hand, and advice and support on the other. During 2022/23 they implemented changes to their performance review processes to ensure they continue to be proportionate and that they contribute to improvements in professional regulation. This year PSA have made further improvements to their performance reviews for the statutory regulators in health and social care and to their Accredited Registers programme. They published their Safer care for all report in September 2022.
  12. Content Article
    The Joint Commission's National Patient Safety Goals address patient care and safety to give healthcare organisations a framework for improvement. This article from the University of Southern California takes a look at the current National Patient Safety Goals, the role of healthcare administration in patient safety, strategies to implement safety goals in hospitals and evaluating the effectiveness of safety goals.
  13. Content Article
    This national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.
  14. Content Article
    The Professional Standards Authority (PSA) commissioned this research to help inform a consistent and appropriate approach by the regulators and registers towards the various types of discrimination in health and care. The research was undertaken to help PSA understand better the views of the public and service users on the following key questions: What constitutes discriminatory behaviour in the context of health and care? What impact discriminatory behaviour may have on both public safety and confidence? Through looking at these two areas, the research also drew out views from participants on how health and care professional regulators should respond to different types of discriminatory behaviour.
  15. News Article
    The Government is consulting on a draft code of practice which will ensure health and care staff, including GPs, receive training on learning disabilities and autism ‘appropriate to their role’. Since July last year, all CQC-registered health and social care providers including GP practices in England have been required to provide training for their staff in learning disability and autism, including how to interact with autistic people and people who have a learning disability. The legal requirement was introduced by the Health and Care Act 2022, but the Government has now launched a consultation on the Oliver McGowan Code of Practice, which outlines how providers can meet the new requirement. The BMA’s GP Committee last month said that the Act does not specify a training package or course for staff and that the CQC ‘cannot tell practices specifically how to meet their legal requirements in relation to training’. The Government’s draft code says that CQC-registered providers must ensure that all staff, regardless of role or level of seniority, have ‘the right attitude and skills to support people with a learning disability and autistic people’ and will need to demonstrate to the CQC how their training meets or exceeds the standards set out in the code. Read full story Source: Pulse, 29 June 2023
  16. Content Article
    Patient Safety Learning has developed a unique set of patient safety standards, resources and tools to help organisations not only establish clearly defined patient safety aims and goals, but also support their delivery and demonstrate achievement. This page provides an overview of our Standards with links to further information.
  17. Content Article
    The PIT stop (prosthesis/implant timeout) checklist is Birmingham Women's and Children's NHS Trust's visual and aid memoir. It was launched to limit 'human error' and thus preventing never events (wrong implant/prosthesis). The four steps cover the intra-operative stages when implants are required. It works by recording what is requested on a small, hand held white board, and works in harness with the NatSSIPs 8, specifically step 5 of the infographic that has been previously developed.
  18. Content Article
    This standard has been produced by NHS England to promote consistent delivery and quality of specialist orthodontic care provision to patients in England. It aims to ensure that resources invested by the NHS in specialist care are used in the most effective way, provide the best possible quality and quantity of care for patients and meet need rather than serve demand. The standard includes the following information: What is orthodontics? Complexity assessment Illustrative patient journey Assessing need Understanding current provision Model of care Clinical standard National key performance indicators Quality and outcome measures
  19. Content Article
    This paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
  20. Content Article
    Community pharmacies are offering an increased range of services to support care for people in the community. It is therefore essential that they are able to record and share vital information about a person’s care with GP practices and other services. Using digital standards, we can ensure that care professionals and citizens have timely access to relevant information, leading to better, safer and more personalised care in the community. This Community Pharmacy Standard developed by the Professional Record Standards Body (PRSB) defines the information that should be recorded in the community pharmacy and sent to the person’s GP, for all the services covered by the English Community Pharmacy Contractual Framework.
  21. Event
    until
    The aim of this webinar is to share, engage and discuss with clinicians, patient safety managers, patients and leaders the latest standards. There will be 2 sessions: 17.30: Session 1 – NatSSIPs 2: what it is and why it matters Welcome and introduction The CPOC perspective The Patient Safety Learning perspective Photo review of why NatSIPPs matters The patient perspective What is new in NatSIPPs 2? Resources to support Implementation: Checklists, infographics Q&A 18.30: Session 2 – NatSSIPs 2: implementation, practical insights and tips Our NatSIPPs 2 Workshop and how to consider a NatSSIPs gap analysis Team training for NatSIPPs 2 Q&A Register
  22. Event
    This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  23. News Article
    People concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes? That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps. But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry. The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies. A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public. Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences. Read full story Source: CNN, 30 May 2023 Related reading on the hub: Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative
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