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Found 259 results
  1. Content Article
    Martin Hancock, Director of Talent Management at the NHS Leadership Academy, discusses how Regional Talent Boards came about and the core principles that underpin them.
  2. Content Article
    The Clinical Human Factors Group (CHFG) asks what good looks like and looks at the observed behaviours of organisations that apply human factors in their daily work.
  3. Content Article
    Video from the Clinical Human Factors Group highlighting the importance of embedding human factors within secondary care.
  4. Content Article
    The NHS England National Quality Board (NQB) has published a new framework that will promote improved quality criteria across all national health organisations for the first time. This publication provides a nationally agreed definition of quality and guide for clinical and managerial leaders wanting to improve quality. The approach has been agreed across NHS and social care organisations to provide more consistency and to enable the system to work together more effectively.
  5. Content Article
    This study from Petschonek et al. published in the Journal of Patient Safety sought to develop a survey that would measure individual perceptions of Just Culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability.
  6. Content Article
    This paper, by Michael West, Regina Eckhart, David Altman and Bill Pasmore, from the King's Fund, written in partnership with the Center of Collective Leadership, shows how collective leadership can be implemented to deliver a sustainable culture change in improving patient care.
  7. Content Article
    Blog from Datix on the importance of why a 'no blame and just culture' needs to be embedded in every aspect of healthcare.
  8. Content Article
    This resource supports organisations wishing to organise training exercises on how to use a 'just culture' guide. To help with the training, NHS Improvement have developed a series of case scenarios that facilitators can use to walk people through practical steps taken to achieve a just culture.
  9. Content Article
    Amy Shaw, Clinical Leader, Specialist Learning Disability Division from Mersey Care Foundation NHS Trust, UK talks about 'fostering a just culture' in her trust.
  10. Content Article
    A template used by St Joseph Health, in the USA, to guide you through a just culture scenario.
  11. Content Article
    Professor Sidney Dekker explains Just Culture and why you need it, what it is and how you get it.
  12. Content Article
    Restorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.
  13. Content Article
    This film documents the amazing transformation in one organisation — Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey towards a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organisation to a place where hurt doesn’t get met with more hurt, but with healing.
  14. Content Article
    Simon Fleming discusses in BMJ Opinion why he launched an anti-bullying campaign. Simon is a trainee orthopaedic surgeon and PhD Candidate at Barts and the London School of Medicine and Dentistry.
  15. Content Article
    NHS Improvement have recommended that healthcare professionals should use SBAR ( Situation, Background, Assessment, Recomendation), a communication tool that was first used by military personel in the US. SBAR helps to provide a structure for an interaction that helps both the giver of the information and the receiver of it. It helps the giver by ensuring they have formulated their thinking before trying to communicate it to someone else. The receiver knows what to expect and it helps to ensure the giver of information is not interrupted by the receiver with questions that will be answered later on in the conversation.
  16. Content Article
    Revised expectations of boards and board members in relation to Freedom to Speak Up plus supplementary resources and a self-review tool.
  17. Content Article
    Human factors understanding focuses on optimising human performance through better understanding the behaviour of individuals, their interactions, with each other and with their environment. Inhealth care, it underpins patient safety, offering an integrated approach to quality improvement and clinical excellence. In this episode, we are in conversation with Health Education England's deputy dean and physician Jo Szram, surgeon Peter Brennan, BA pilot Graham Shaw and Obs & Gynae trainee Ruth-Anna Macqueen to explore what human factors are, their importance in the health care setting and how knowledge of human factors can help both trainees and supervisors.
  18. Content Article
    The rapid transmission of COVID-19 has resulted in an international pandemic with the cumulative death rate expected to further escalate in the months to come. The majority of deaths to date (May 2020) have been highly concentrated in certain geographic areas, placing tremendous stress on local healthcare systems and associated workforces. Healthcare is a fundamentally human endeavor; its reliability and the capacity to provide it are tested under stressful conditions and the COVID-19 pandemic is proving to be an especially difficult test for healthcare systems. Consideration of the humanness of care in the broader context of patient safety can raise awareness of how human weaknesses impact individual clinicians and care teams in ways that could degrade patient safety and quality of care and increase risk for both patients with COVID-19 and the staffs that care for them. These weaknesses are exacerbated by fatigue and burnout, absence of team trust, lack of time, medical illness, and poor psychological safety, each of which can result in reduced performance and contribute to failures such as misdiagnoses and adverse events. This article published on AHRQ's PSNet explores these weaknesses.
  19. Content Article
    How people are treated following their involvement in a workplace accident can have far reaching implications for both the individual and the organisation. This paper, published by Science Direct, examines the impact the use of retributive justice mechanisms within the accident analysis process have on both the individual and the organisation. It analyses the perceptions of those involved in five accidents where retributive justice mechanisms were used. The study of these cases shows retributive justice mechanisms used as part of the accident analysis process negatively impacts three key areas; (1) the mental health of the individual; (2) organisational learning and; (3) organisational performance. The study also illustrates that the language used as part of the accident analysis has a significant impact upon the perception of the process and the willingness to participate.
  20. Content Article
    Cathe Gaskell, from The Results Company, presented at the recent Bevan Brittan Patient Safety Seminar on incivility in healthcare and the impact this has on patient safety. Attached are her presentation slides
  21. Content Article
    The Difficult Airway Society (DAS) has produced a difficult airway card for patients to carry in their wallet. This is to alert the anaesthetist that this patient has a 'difficult airway' before they find out the hard way.  This website also holds the database for patients with difficult airways. This is for clinicians to use to help assess risk in patients undergoing sedation or general anaesthetic.
  22. Content Article
    In this blog, Roi Ben-Yehuda, a trainer at LifeLabs Learning, discusses why learning from failure is so rare and difficult and gives his top tips on what we need to do to stop failing at failing.
  23. Content Article
    Workplace bullying (WPB) is a physical or emotional harm that may negatively affect healthcare services. The aim of this study, published in Human Resources for Health, was to determine to what extent healthcare practitioners in Saudi Arabia worry about WPB and whether it affects the quality of care and patient safety from their perception.
  24. Content Article
    Amandip Sidhu is a Learn Not Blame member and pharmacist. Tragically, Amandip lost his brother, a respected Consultant Cardiologist, to suicide. In this heartbreaking and powerful guest blog for Doctors Association UK (DAUK) and the Compassionate Culture campaign, Amandip reflects on the “just get on with it” attitude of the NHS, and how we must move to kinder NHS that treats it’s staff with much needed compassion.
  25. Content Article
    Is a focus on wellbeing a ‘nice thing to do’ in organisations, or are there more fundamental arguments? In this article in Hindsight, Suzanne Shale outlines ethical arguments for making wellbeing a priority.
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