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Showing results for tags 'Transformation'.
Found 144 results
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Content Article'The state of care in NHS acute hospitals 2014 to 2016' presents findings from the Care Quality Commission (CQC's) programme of NHS acute comprehensive inspections. The report captures what has been learned from three years’ worth of inspections. It gives a baseline on quality that is unique in the world – and also shows that it is possible, even in challenging times, to deliver the transformational change that is needed if the NHS is to continue delivering high-quality care into the future.
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EventuntilThis virtual conference from The King's Fund will share practical ideas about transforming work and workplace cultures. It will explore how leadership and teamworking influences people’s work experiences, releasing their full potential to drive improved outcomes for patients and citizens. Discuss with other local health and care leaders how to create compassionate cultures with improved support for staff to make sure that the NHS and social care organisations are good employers and great places to work. Register
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EventIn today’s world of multidisciplinary care, good communication between professionals and with patients makes all the difference. The digital transformation the sector was already undergoing pre-pandemic to replace postal and fax systems with email has been dramatically accelerated by COVID-19. 94% of organisations are now sending more emails due to remote working and distanced service delivery. But more email means more risk to patient data. In fact, email data breaches happen every 12 working hours. With busy clinical and administrative staff focused on delivering high-quality care, it’s time for security solutions stepped up to eradicate the everyday mistakes they make, such as attaching the wrong file to an email or adding an incorrect recipient. Join this webinar to discuss the importance of human layer security within digital transformation to ensures patient data is kept secure, while also facilitating the email communications that are fundamental to multidisciplinary care. Presenters: Clive Flashman, Chief Digital Office, Patient Safety Learning; Dr Saif F Abed, Founding Partner & Director, Cybersecurity Advisory Services, The AbedGraham Group; Sudeep Venkatesh, Chief Product Officer, Egress Register
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Content ArticleThe Centre for Perioperative Care (CPOC) has started work on the UK’s first ever Green Paper on perioperative care.
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Content Article
The world turned upside down: Uncertainty and COVID-19
lzipperer posted an article in Letter from America
This month’s Letter from America explores uncertainties stemming from the COVID pandemic. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments and patient safety challenges in the United States. -
Content ArticleIn this article, published by the British Journal of Anaesthesia, the author looks at the impact a culture of blame can have upon NHS staff, including suicide, and offers recommendations for what should change.
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Content Article
Errors in medicine (June 2009)
PatientSafetyLearning Team posted an article in Research papers
The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down. -
Content ArticleA problem solving tool that captures everything you need on one piece of paper. Now that sounds pretty useful. In her latest blog, Sally Howard, Topic Lead for the hub, summarises 'A3', a problem solving tool that does exactly that. She draws on her own experience of using the tool to improve patient outcomes and provides both rich insight and practical examples to help others maximise it's potential.
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Content ArticleA study showed that when doctors tell heart patients they will die if they don't change their habits, only one in seven will be able to follow through successfully. Desire and motivation aren't enough: even when it's literally a matter of life or death, the ability to change remains maddeningly elusive. Given that the status quo is so potent, how can we change ourselves and our organisations? In Immunity to Change, authors Robert Kegan and Lisa Lahey show how our individual beliefs, along with the collective mind-sets in our organisations, combine to create a natural but powerful immunity to change. By revealing how this mechanism holds us back, Kegan and Lahey give us the keys to unlock our potential and finally move forward. And by pinpointing and uprooting our own immunities to change, we can bring our organisations forward with us. This persuasive and practical book, filled with hands-on diagnostics and compelling case studies, delivers the tools you need to overcome the forces of inertia and transform your life and your work.
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Content ArticleProf. Robert Kegan questions why there is a gap between a person's real intention to change and what the person actually does. He recalls an illustration in which heart doctors advise their patients to take their medications as prescribed or they would die. The follow up research shows that only 1/7 actually go on to take their medications. The other six have just as great a desire to stay alive and yet risk death by not following their doctor's advice.
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Content Article
Immunity to change, a blog by Sally Howard
Sally Howard posted an article in Culture
The New Year often encourages us to talk about change and to look ahead at what we want to achieve in the coming months as individuals, teams and organisations. In her latest blog, Sally Howard, topic leader for the hub, draws attention to the Immunity to change theory and outlines four key steps for realising our aspirations and making change happen. -
Content ArticleThis diagram, published by the Institute for Healthcare Improvement (IHI), is titled A driver diagram to systematically and proactively identify and eliminate non-value-added waste in the US health care system by 2025. Produced by the IHI's Leadership Alliance's Waste Working Group, it sets out a number of drivers for reducing waste in the healthcare system in America. The top driver listed focuses on safety and reducing harm.
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From Safety-I to Safety-II: A White Paper (2015)
PatientSafetyLearning Team posted an article in Organisational
This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II). -
Content ArticleThe current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
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Leading for improvement, a blog by Sally Howard
Sally Howard posted an article in Leadership for patient safety
Sally Howard, topic leader for the hub, shares her insight on the imminent NHS Improvement Framework after she attended a webinar with National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey. -
Content ArticlePublished on the Johns Hopkins University website, this commentary from Saralyn Cruickshank focuses on the newly released book Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. Written by Robert Wears and Kathleen Sutcliffe, the book argues that the patient safety movement has evolved but not, in all cases, for the better.
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Content ArticleLast year, the Canadian Patient Safety Institute (CPSI) launched a safety improvement project focused on the Measurement and Monitoring of Safety. The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.
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Content ArticleAthough considerable progress has been made with comparing human factors in a safety critical industry to human factors in healthcare, it is clear that the variabilities found in healthcare are far more complex than industrial situations. While comparing human factors in the operating room and intensive care unit with systems from the airline, maritime and off shore industries is appropriate, Geoff Cardwell in this article discusses why a generalised approach to apply human factors in the routine activities of hospitals is needed and the nuclear industry is more appropriate for this wider context, where the ALARA (As Low As Reasonably Achievable) principles is used for managing radiation exposure. This approach can be compared to minimising the exposure to infection and superbugs in hospitals as well as reducing process failure where human factors are involved.
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EAST: Four simple ways to apply behavioural insights (2015)
Patient Safety Learning posted an article in Techniques
If you want to encourage a behaviour in any setting, make it Easy, Attractive, Social and Timely (EAST). These four simple principles for applying behavioural insights are based on the Behavioural Insights Team’s own work and the wider academic literature. There is a large body of evidence on what influences behaviour, and we do not attempt to reflect all its complexity and nuances here. But we have found that policy makers and practitioners find it useful to have a simple, memorable framework to think about effective behavioural approaches. -
Content ArticleOn the 18 November 2019, Health Law from Browne Jacobson LLP hosted a Patient Safety Strategy Discussion Forum. This was focused on discussing the key proposals within the NHS Patient Safety Strategy, published in July 2019, and what they mean in practical terms. It also provided an opportunity for Trusts to share and hear about the work being done by others to implement the Strategy. The event was attended by a number of leading patient safety and quality experts and investigators from across the Midlands.
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WHO: Empowering patients (April 2012)
PatientSafetyLearning Team posted an article in WHO
Chronic diseases account for an estimated 86% of deaths and 77% of the disease burden in the WHO European Region, as measured by disability-adjusted life-years. These diseases, including cardiovascular diseases, cancer, diabetes, obesity and chronic respiratory diseases, are now the largest cause of death and disability worldwide. This development is bringing about a fundamental shift in health systems and health care and thus in the roles of patients. -
Content ArticleIn a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
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Content ArticleOur experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards.
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Content ArticlePresentation from Andrea McGuinness at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleOver the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy. The cost of compliance and bureaucracy can be mind-boggling – up to 10% of GDP, with every person working some 8 weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety.
