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Found 224 results
  1. Content Article
    This document includes: a brief history of the checklist application in practice types of checklist pros and cons of the checklist.
  2. Content Article
    AAR is a deceptively simple process for learning from any every day or exceptional 'action', which takes the individual expectations and experiences of the same event to build a shared mental model of what happened and use this as the basis for learning and action planning. To be successful it is essential that AARs are led by a trained AAR 'Conductor' who uses a defined four-question process and a universal set of AAR 'ground rules' to create a safe learning environment. The other vital component, which is often missing, is the organisational context in which the AARs take place. This needs to be set up to support the AAR approach to learning with leaders championing the process and the practice and believing in the value of organisational learning. “The After Action Review has democratised the Army. It has instilled a discipline of relentlessly questioning everything we do. Above all, it has re-socialised many generations of officers to move away from a command and control style of leadership to one that takes advantage of distributed intelligence.” Pascale, Millemann and Gioja, 20001 We can learn much from the military’s use of AAR. The problems created by its hierarchical structure are similar to ours in medicine, especially the fear of the consequences of speaking out and voicing a different opinion to your superiors. Research confirms that junior staff are often reluctant to question the direction or decisions of their seniors, even when they feared patients were at risk of harm.2 Fear of the consequences also limits open and honest reporting of incidents, restricting the potential gains of learning at the system-wide level and at the local level. Yet consistent and widespread use of AAR in battlefield and training environments has reduced the fear of blame and retribution and increased effective communication through the ranks and transformed the speed and value gained from learning. It has done this in part because every AAR creates a safe environment for learning due to the actions of the AAR Conductor and the organisational commitment to using AAR. Professor Amy Edmondson has spent over 20 years researching the components of effective 'work groups' and summarises what increases team performance as "psychological safety". It can be defined as "being able to show and employ one's self without fear of negative consequences of self-image, status or career".3 High levels of psychological safety in clinical teams have numerous benefits for safe and effective care.4 My experience has taught me that with repeated and regular use of AAR, the psychological safety experienced during them, shapes and influences behaviour positively outside of them. Another reason AAR works to improve patient safety is the quality of the learning and changes in behaviour coming out of them. Here the research is also very clear. A meta-analysis of research into AARs5 demonstrated that the learning coming out of AARs can improve team and individual performance as much as 25% when compared to control groups. This analysis of research in a wide variety of settings showed that participants learnt so effectively through the AARs, that they were able to perform and deliver up to 25% more effectively afterwards. This is because the participants in the AAR are fully involved in their own learning so instead of being talked at, they are being asked to make sense of the shared picture of the event that has been generated in the AAR. The responsibility for learning and change in an AAR, therefore, rests with the participants and is directly relevant to them. In a clinical setting this means that improvements in safety and behaviour can start the minute the AAR ends. Contrast this with an investigation, where the learning is owned by the investigator and the organisation that employs him or her, and the responsibility for change rests far away from those involved in the action. The quality of the shared mental model that is created in the best AARs directly supports learning about patient safety matters as the individual participants access other people’s experiences to gain an overview of an issue. The skilled facilitation by the AAR Conductors is a vital part of this, as once a safe learning environment is established, cognitive biases and prejudices are reduced and clearer thinking is possible. Patient safety learning is also greatly enhanced through AAR because of both its 'learn as you do' approach and the fit with effective adult learning theory models. AARs do not require clinical staff to leave the ward for days at a time for traditional teaching about patient safety. Instead AAR practice makes it possible for learning about patient safety to become an everyday habit and, therefore, more effective. Since the AAR process allows individuals to learn for themselves what happened and what got in the way or enhanced safe, effective care, it is mapped onto the individuals own knowledge base and makes a more lasting impact. The last feature of the issues highlighted in the NHS Long Term Plan concerning patient safety was the workforce. My experience of facilitating hundreds of AARs in clinical settings has highlighted its potential to reduce the stress levels of staff as the supportive no-blame environment encourages greater clarity and less personal blame. Lower stress levels will have an indirect but valuable effect on staffing levels as sickness absence may be reduced and retention boosted. This is just a summary of some of the features of the AAR approach which I know will enhance patient safety. Other AAR Conductors will have more insights to share, and the academic researchers in the US and Israel universities many more. I would love to discuss AARs further with you, contact me at: judy.walker@its-leadership.co.uk References Pascale RT, Millemann M, Gioja L. Surfing the Edge of Chaos: The Laws of Nature and the New Laws of Business. Three Rivers Press; 2000. Crowe S, Clarke N, Brugha R. ‘You do not cross them’: Hierarchy and emotion in doctors' narratives of power relations in specialist training. Social Science & Medicine 2017; 186: 70–77. Kahn WA. (1990-12-01). Psychological Conditions of Personal Engagement and Disengagement at Work". Academy of Management Journal 1990; 33(4): 692–24. doi:10.2307/256287. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines : Team Learning and New Technology Implementation in Hospitals. Harvard University Administrative Science Quarterly 2001; 46: 685–716. Tannenbaum SI, Cerasoli CP; the Group for Organizational Effectiveness. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors 2013; 55(No. 1): 231–245.
  3. Content Article
    Key messages Most opportunities to raise safety concerns may arise in routine clinical work. Informal strategies for raising concerns are multiple and often effective. Use of strategies varies within and between professional groups and hierarchies. Increased focus on effective use of informal strategies of social control is needed.
  4. Content Article
    This web page includes videos and facts on the evidence behind the theatre cap challenge.
  5. Content Article
    This briefing is aimed at staff in operating theatres and is recommended to be conducted at the beginning of the day before the theatre cases start.
  6. Content Article
    Our Critical Care Outreach Team (CCOT) work regular shifts within the CCU and our new high dependency unit (HDU). I believe we are not alone, but at times there is an element of divide across the teams and we wanted to limit the ‘them and us’ culture. Even when we are not working within the units, we need effective teamwork to maintain best practice and, ultimately, patient’s safety. Unlike some trusts, our outreach, CCU and HDU are all managed as one big team. With this in mind, we brainstormed ideas for the reasons behind this ‘divide' and decided a regular newsletter might help us. The initial benefits would be: To keep CCU/HDU staff up to date with our current projects - this was a problem identified during recruitment into the outreach team as CCU staff suggested that they had limited opportunity to become involved in the work of the outreach team. Having the CCU staff become more involved and aware of the ‘extra’ work we do has helped to improve our working relationships; various nurses are now more involved with some of our projects, and others are looking to help with the view of progressing into a future outreach role. To explain our role as it not always widely understood by some colleagues on CCU. To offer our support to any individual wanting to work on a QI, but was not sure how to proceed. To highlight our achievements and hard work and to introduce staff to some of our ‘behind the scenes’ work. To involve all staff - we regularly asked staff for suggested content that they would find most useful. The success of the newsletter quickly led us to adapt it to all hospital staff of any discipline or grade: The above benefits were similar, but now pertinent to a larger audience, including healthcare assistants, students, physios, occupational therapists, speech and language therapists, doctors and management. Some of our team are relatively new and it is a good tool to introduce them, using photographs to help improve our visibility and approachability within the hospital. We wanted an ‘educational hot topic’ to be a regular feature to help maintain high quality care and standards amongst staff. We asked readers what topics they wanted to engage with. We now have a number of ‘guest writers’ for this section, from various specialties, to help share their knowledge and expertise. It is encouraging to hear how healthcare assistants, students and associate practitioners have found our newsletter content so educational and helped them to provide better care to the patients (and feel more engaged with the care they are providing). Every time a new edition of the newsletter is sent out, I have received personal feedback of how useful and interesting it has been. Staff have often personally thanked me on the wards and in the corridor. There is a lot of effort and time that goes into these newsletters, but I feel it is definitely worthwhile. I am a great believer in valuing staff and this has really helped me to keep going, despite the difficulties encountered. The newsletter is now jointly written with our Hospital Out of Hours (HOOH) team. Although we are two separate teams, our lead, Rhona, is shared. We all work very closely, supporting each other and preach many of the same messaged, so this just made sense. Challenges and lessons learnt: Team engagement – not all team members wish to be involved in the newsletter and feel there is little extra time to engage with this extra workload. The time spent writing and editing is significant and cannot be done within my working hours, so much of this work has been in my own unpaid time. I have to rely on some sections being written by other professionals. It is difficult to quickly replace sections if deadlines are missed or not already within a requested word limit. I initially edited the newsletter in Word, but found formatting was very difficult. I discovered Publisher and taught myself to use this. I am sure I can learn much more, but have so far found this much easier to work with. We wanted to send to ‘All email users’ within the hospital, but were told this was not possible. Instead, I use various groups of staff set up on our work email system. My first Ward newsletter was only sent out to CCU staff and Ward Managers. This was not always shared with other staff; inboxes were frequently full and therefore emails could not be received; and this method missed vital teams such as physiotherapists, speech and language, doctors, students. Following my distribution issues, I have since compiled a ‘mailing list’ which I add to regularly (this includes professionals in other trusts who enjoy our newsletter too). The hospital librarian team and individual keen students have personally asked to be added to this list which is encouraging. Perhaps we could all share our newsletters and stories within our trusts and on the hub and support each other in this patient safety initiative. I’d love to hear from others on ideas for newsletters and how they have overcome some of the challenges I describe above. CCOT Newsletter to WARDS FEB 2019 Edition 1.pdf CCOT Newsletter for ITU Staff Edition 1. Feb 2019.pdf Joint CCOT and HOOH Newsletter 2nd Edition June 2019.pdf
  7. Content Article
    The presentation requires sound to be on; BSL facilities are available for D/deaf viewers.
  8. Content Article
    What will I learn? The IHI White Paper 'Framework for Improving Joy in Work' Video by Don Berwick MD, IHI President Emeritus and Senior Fellow, 'How does joy in work advance healthcare quality and safety?' Video by Stephen Swensen, MD, IHI Senior Fellow, 'How to build Joy into work' Video by Derek Feeley, IHI President and CEO, 'How will we know when there is joy in the healthcare workforce?' Video by Trissa Torres, MD, IHI Senior Vice President 'Impediments to joy in work'
  9. Content Article
    What will I learn? Strategies for intervening: Interrupt the behaviour. Affirm and support the target. Use humour to call out behavior. De-escalate and calm the aggressor if other interventions fail. Let bystanders know there is a clear limit.
  10. Content Article
    This study confirmed that the most influential factors in the decision to use assistive devices for patient transfers are time constraints and difficult patient-handling situations. These factors lead to infrequent use of assistive devices, especially mechanical devices that are difficult to retrieve or not readily available.
  11. Content Article
    What will I learn? An overview of the NHS Innovation Accelerator (NIA) Support available: the role of the AHSNs An innovator’s journey: ORCHA Lessons and insights from the NIA
  12. Content Article
    This document explains how patients are informed, involved and consulted in the development, improvement and delivery of health and care services.
  13. Content Article
    This blog highlights solutions to the problem of poor culture of speaking up and bullying within healthcare. Dr Blair Bigham and Dr Amitha Kalaichandran propose three solutions to enable a culture without fear. Measure culture within the organisation. Hire talented leaders. Embrace diversity and inclusion and reject hierarchy.
  14. Content Article
    This guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents. Key challenges include: fear equity and fairness bullying and harassment.
  15. Content Article
    Never Events are serious incidents that are considered to be wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers. However, Never Events continue to happen despite the hard work and efforts of frontline staff: there were 468 incidents provisionally classified as Never Events between 1 April 2017 and 31 March 2018. The CQC examined the underlying issues in NHS trusts that contribute to the occurrence of Never Events and the learning that can be applied to wider safety issues. What makes it easier, and what makes it harder, for the different people and organisations in the system to prevent Never Events and deliver safe care more widely? Findings in this report have led to the conclusion that this continual recurrence means that if healthcare staff are to give patient safety the priority it requires, the culture of the NHS needs to change to one that is orientated around safety. Recommendations NHS Improvement should work in partnership with Health Education England and others to make sure that the entire NHS workforce has a common understanding of patient safety and the skills and behaviours and leadership culture necessary to make it a priority. NHS Improvement and Health Education England should also develop accessible, specialist training in patient safety that staff can study as part of their clinical education or as a separate discipline. The National Patient Safety Strategy must support the NHS to have safety as a top priority. Driven by the National Director of Patient Safety at NHS Improvement, it should set out a clear vision on patient safety, clarifying the roles and responsibilities of key players, including patients, with clear milestones for deliverables. It should ensure that an effective safety culture is embedded at every level, from senior leadership to the frontline. Leaders with a responsibility for patient safety must have the appropriate training, expertise and support to drive safety improvement in trusts. Their role is to make sure that the trust reviews its safety culture on an ongoing basis, so that it meets the highest possible standards and is centred on learning and improvement. They should have an active role in feeding this insight back to NHS Improvement so that other NHS organisations can learn from it, as is the case in other industries. NHS Improvement should work with professional regulators, royal colleges, frontline staff and patient groups to develop a framework for identifying where clinical processes and other elements, such as equipment and governance processes, can and should be standardised. The National Patient Safety Alert Committee (NaPSAC) should oversee a standardised patient safety alert system that aligns the processes and outputs of all bodies and teams that issue alerts, and make sure that they set out clear and effective actions that providers must take on safety-critical issues. NHS Improvement should work with professional regulators and royal colleges to review the Never Events framework, focusing on leadership and safety culture, and exploring the barriers to preventing errors such as human behaviours. CQC will use the findings of this report to improve the way we assess and regulate safety, to ensure that the entire NHS workforce has a common understanding of leadership and just culture, and the skills and behaviours necessary to make safety a priority.
  16. Content Article
    Key learning points Duty of Candour is a legal requirement. Duty of Candour applies when someone is harmed by a procedure or accident Your duty is to (1) put the patient first; (2) keep the patient informed; and (3) don't wait for a complaint or a question. You must (1) let the patient know what happened; (2) provide support; (3) explain the next steps; (4) apologise; (5) write to confirm; and (6) keep the patient informed.
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