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Found 147 results
  1. Content Article
    The aims of ADAPt: To make it easier to monitor the quality and safety of services by including private healthcare data within healthcare reporting systems. To help staff keep accurate and complete records when a patient journey spans both private and public providers. To ensure transparency for patients by publishing comparable performance measures relating to quality of care and patient safety for both privately funded and NHS funded healthcare. To identify where the burden of data collection and reporting by NHS and private care providers can be reduced. Find out via the link below.
  2. Content Article
    PDSA is a very structured four-step cycle which requires effort and discipline. It incorporates careful and detailed consideration of the following: Plan: A plan of what is to be tested including questions to be answered, predictions and answers to the questions and a plan for collection of data to answer the questions. Do: Carry out the test of change according to the plan, recording observations including unexpected outcomes/observations. Study: A comparison of the data against the predictions made in the plan and study the results. Act: Make a decision about the next course of action. Whilst the PDSA cycle originates from industry, it has been incorporated into the Model for Improvement It can be used to test ideas in the real or simulated context.
  3. Content Article
    Practical guidance on the application of human factors in the investigation process is presented. Nine principles for incorporating human factors into learning investigations are identified: 1. Be prepared to accept a broad range of types and standards of evidence. 2. Seek opportunities for learning beyond actual loss events. 3. Avoid searching for blame. 4. Adopt a systems approach. 5. Identify and understand both the situational and contextual factors associated with the event. 6. Recognise the potential for difference between the way work is imagined and the way work is actually done. 7. Accept that learning means changing. 8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement. 9. Do not confuse recommendations with solutions.
  4. News Article
    In many ways it is wrong to talk about the NHS restarting non-coronavirus care. A lot of it never stopped — births, for instance, cannot be delayed because of a pandemic. However, exactly what that care looks like is likely to be very different from what came before. There are more video and telephone consultations and staff treat patients from behind masks and visors. That is likely to be the case for some time, experts have told The Times. Read full story (paywalled) Source: The Times, 6 June 2020
  5. Content Article
    The authors conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. They found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organisational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of “preventable causes”, the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the “big picture” of causes of accidents as a basis for further remedial actions.
  6. Content Article
    Healthcare safety is complex every day – yet the emergence of the novel coronavirus has made holes in the Swiss cheese of the system more apparent. UK psychologist James Reason’s now famous “Swiss Cheese Model” serves as a metaphor for this month’s Letter from America. As more details on the coronavirus emerge, and time enables reflection on what has transpired, deeper analyses will no doubt materialise. Knowledge is developing in real time, helping us see gaps in our safety barriers and providing valuable insight to the challenge of reducing harm. The Swiss Cheese model illustrates how latent weaknesses in the protective barriers that systems build exist and become more apparent after failures occur – if we look for them. COVID-19 is just such a test; it is amplifying the holes in today’s healthcare system. A recent New Yorker essay highlights the known weaknesses in healthcare visible long before COVID-19 – racial inequities, bureaucratic inefficiencies, drug shortages, under resourced public health initiatives and fiscal prioritisation to the detriment of preparedness. Others are more specific to the pandemic: lack of access to personal protective equipment and medical devices, supply chain disruptions, hording behaviours, misinformation and patients not seeking chronic, emergency or preventive care. The essay suggests that we should not seek to return to this “normal”, but to learn, revise and improve. Holes in processes to keep patients and workers safe are also expanding as the cheese melts. Healthcare worker illness, psychological strain and suicide are revealing fractures across US healthcare delivery that undermine the ability of clinicians to provide care as they work to keep patients and themselves safe. The US National Academies of Medicine has outlined an approach to protect clinicians’ wellbeing. Through a focus on organisational and national priorities, it aims to help sideline the negative after-effects that first responders to the COVID-19 crisis may experience through a call for funding, epidemiology and real-time support for providers. Efforts to diagnose COVID-19 are thick slices of cheese with a myriad of holes that affect both clinical and policy responses. As summarised in a recent commentary, the system response is a fundamental challenge: measurement is a mess, data are inconclusive, testing processes are inconsistent and results in some cases unreliable. While this state of affairs is rapidly changing, foundational concerns are likely to remain. Economic support for organisations and States rests on the data that are apt to be skewed, ineffective and counterproductive. The international disease codes used to document COVID-19 cases are being imprecisely applied. The authors of the commentary provide suggestions to impove the use of the diagnostic codes and thus the quality of the data collected. Actions in this area are needed to inform the research so we can understand what has happened and fund and design public health initiatives and reopening strategies that enable containment, testing and equitable treatment. As time passes, suggestions for improvement informed by national and local experience appear. Communities are painfully aware of the situation COVID-19 places them in. Experts there are contextually situated to address local challenges such as population instability due to unemployment, homelessness and food insecurity. A Health Affairs blog calls for strengthening the community-based workforce to assist in propping up vulnerable populations after disaster of any kind strikes, including COVID-19. Community health workers, volunteers and nonprofit organisations are highlighted as important players in testing and contact tracing strategy implementation, psychological support provision and establishment of the infrastructure communities need to face their specific challenges. It will take resources, tenacity and courage to facilitate and sustain community level COVID-19 response. Watching media coverage can be overwhelming but can also illustrate the complexity of addressing the disruptive tendencies of the coronavirus pandemic. Newspapers and healthcare media services can provide insight into the system-level complexity of the pandemic. These services are flagging and providing access to articles from the press or literature to provide a well-rounded collection of materials to track what is happening. It’s one way to remain keep abreast of the issues: who from racial, ethnic and socioeconomic groups are impacted, what programmes and industries are being altered, where specifically in the US the virus touches, when the threat emerged to affect a particular segment of the population or workforce and why the connections between them all are important to consider. This is highlighted in a recent commentary in the Lancet, which illustrated some of the interacting components in a society responding to the threat of COVID. Tools such as these can assist in keeping us informed to combat weaknesses in failure barriers that emerge due to bias from listening to one outlet or seeking only one point of view. No matter what slice of the COVID-19 Swiss cheese sits on the plate in front of us – its holes are apparent. Experts are calling for coordinated system-wide action to prevent further loss of life and economic hardships. Other challenges are likely to emerge the longer COVID-19 influences lives. We all need to learn from the lack of success during the current response manifestation and use those insights to inform actions to prepare for the next virus wave. It will help to navigate future choppy, uncharted waters. To prepare for the 'new normal', courage to see value in failure is paramount. We should also proactively apply learnings based on what went well to better prepare organisations, systems and governments to close holes in the global approach before the next wave.
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