Jump to content

Search the hub

Showing results for tags 'Action plan'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous


  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Learning news archive
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous


  • News

Find results in...

Find results that contain...

Date Created

  • Start

Last updated

  • Start

Filter by number of...


  • Start



First name

Last name


Join a private group (if appropriate)

About me



Found 23 results
  1. Event
    This free webinar from the Patient Safety Movement Foundation in the US is at 7.30am PST (3.30pm GMT). It takes a significant amount of work to implement a performance improvement initiative. However, typical approaches to sustainment are insufficient and lead to drift. Panellists will propose actionable recommendations to set up effective models for sustainment and systems to identify early indicators of drift. Moderator: Chrissie Nadzam Blackburn, MHA, Principal Advisor, Patient and Family Engagement, University Hospitals Health System, Cleveland, Ohio Panellists: Kristen Miller DrPH, MSPH, MSL, CPPS, Senior Scientific Director, MedStar Health National Center for Human Factors in Healthcare Joyce Alumno, President & CEO, HealthCore, President, Health Retirement & Tourism (HeaRT) Alliance of the Philippines Cristine Lacerna DNP, MPH, RN, CIC, CPH, Regional Director, Infection Prevention & Control and HEROES Program, Kaiser Permanente Sign up for the webinar
  2. Community Post
    I have been thinking recently about the challenges which is posed towards larger trusts with regards to patient safety. Particularly with getting information disseminated to all staff and being reliant on endless emails. I have recently done some work with our Action Card App which has posed its own challenges particularly with physically getting around the Departments, spreading the word, and assisting people on the app itself. What really helped us iare screen savers, twitter and having those key conversations with stakeholders within the trust. I was wondering what everyone elses perspectives were?
  3. News Article
    A leading public health expert has launched a devastating critique of the government’s handling of the coronavirus outbreak in the UK, saying it is too little too late, lacks transparency and fails to mobilise the public. Prof John Ashton, a former regional director of public health for north-west England, lambasted a lack of preparation and openness from the government and contrasted Britain’s response to that of Hong Kong. “Right at the beginning of February, they [Hong Kong] adopted a total approach to this, which is what we should have done five weeks ago ourselves. They took a decision to work to three principles – of responding promptly, staying alert, working in an open and transparent manner,” he told the Guardian. “Our lot haven’t been working openly and transparently. They’ve been doing it in a (non) smoke-filled room and just dribbling out stuff. The chief medical officer only appeared in public after about two weeks. Then they have had a succession of people bobbing up and disappearing. Public Health England’s been almost invisible." Read full story Source: The Guardian, 12 March 2020
  4. Content Article
    Last Friday I joined the Patient Safety Management Network where the topic of discussion was AARs – what was already known, what wasn’t, how people are implementing AARs, the benefits they’re seeing and what more is needed to help people share their experiences and useful ‘how to’ resources. Here I’ll briefly summarise this valuable discussion and the insights shared by members of the Network, which included both Patient Safety Managers and Assistant Directors of Patient Safety and Quality, with a wide range of professional backgrounds and knowledge in the topic. This is ahead of Judy Walker, a subject matter expert in the AAR approach, joining the Patient Safety Management Network meeting on Friday 19 November to share her expertise and participate in discussion with the group. AARs and patient safety Current NHS guidance on the new Patient Safety Incident Response Framework states: “An organisation’s Patient Safety Incident Response Plan should set out its approach to the different types of patient safety incident identified from the local situational analysis, acknowledging that this will include ‘do not investigate’ or ‘no response required’. An organisation must have systems to ensure the approach and tools it uses in its response to a patient safety incident achieve useful learning/insight and outline the circumstances where they are indicated – in its PSIRP.”[1] In listing techniques for responding to patient safety incidents, the guidance includes AAR as one approach to this, describing this as: “ A structured, facilitated discussion on an incident or event to identify a group’s strengths, weaknesses and areas for improvement by understanding the expectations and perspectives of all those involved and capturing learning to share more widely.”[1] This slightly differs from the World Health Organization (WHO), who define this as: “...a qualitative, structured review of the actions taken in response to an event, as a means of identifying and documenting best practices, gaps and lessons. The review seeks to identify immediate and longer-term corrective actions for future responses. An AAR can focus on a single, specific function or on a broad set of functions, covering one or more sectors involved in the response.”[2] What do Patient Safety Managers know about AARs? Knowledge and experience of AARs varied widely among the Patient Safety Managers at the meeting. Some are leading their organisation's approach to implementing AARs and are seeing strong impact in improving patient safety, with clinicians welcoming and embracing this learning and collaborative review approach. Others spoke about how they are developing their ideas and will be adopting AAR at an organisational and ward/service delivery level, while for some this was something that was coming further down the line and they wanted to find out more. The group shared their experiences, templates, successes and uncertainties. This is exactly what the Patient Safety Management Network is about: collaboration, shared learning, peer support and responding to requests for help. There was a real ‘buzz’ in the discussion, amazing for a online Teams call! So, in summary here are some of the issues discussed as well as suggestions, ideas and questions: Are people doing AARs? One Patient Safety Manager said that her organisation expects clinical staff to be doing AARs but without a structured implementation plan and training. Its therefore not surprising that staff are left puzzled at what to do in practice. The risk is that without guidance, AARs are being completed as if they were Serious Investigation forms, providing more of a description of events rather than informing learning or action. Another Network member said that they have been using AARs in reviews of delayed cancer care and that this had been working really well. They noted that AARs facilitated by the Patient Safety Managers and really embraced by clinical teams helped to capture good practice too. AARs can help to support learning from the ‘shop floor’, empowering frontline clinicians to support improvement locally as well as wider organisational learning. People are often hung up on timelines when they undertake investigations and are not looking at the ‘bigger picture;’ AARs can really help. There were concerns shared from a Network member from a major Acute Trust about them not yet implementing AARs and not having plans in place to do so. There were also some concerns about the practicalities of dong AARs at scale, for example doing AARs for each patient fall in a month. What support is needed to help use AARs to improve patient safety? Coaching skills, training and support to make sure we get the most out of AARs. Models of good practice to ensure that they are not introducing cognitive bias and the value that independent convenors can bring to this, such as an independent medic from a different clinical area providing professional challenge. Information on convenor roles (the ‘facilitator’ in undertaking AARs). Guidance on how to engage with families and manage their expectations: - before an AAR (to explain what's going to happen) - involvement of patients/families in an AAR - with the outcome and in the context of Duty of Candour, will an AAR be enough? What benefits are being seen from the use of AARs? Quicker learning and focus on action. Examples of learning from good practice. A move away from long reports that focus on descriptive detail to shorter reports that focus on learning and action. Multi-disciplinary learning and open engagement and discussion across teams. Moving away from a ‘policing model’ of investigations; focus on human working in complex environments with processes and systems, and not so hung up on timelines. Self-discovered learning by engaging in AARs; change that is owned by staff; also getting ward engagement in problem-based learning. A way to focus on Trust-wide implementation; the whole system being designed to keep patients safe. Questions of policy and governance How best to engage patients and families in AARs? To provide support, to source their views, to manage expectations (‘it’s not an investigation’). What are Clinical Commissioning Groups (CCGs) expecting from the new Patient Safety Incident Response Framework and AAR? Do CCGs want to see the detail of every investigation, AAR or thematic review and/or ‘the bigger picture’ issues emerging from these? Discussion suggested that CCGs/Integrated Care Systems (ICS) would want to see Trust-wide action plans not just those focused on individual units/Directorates. Should AARs be done on every incident or specific selection of events? For example one hospital is planning to do an AAR on every fall, whether this results in serious harm or not, while another has 200 falls a month and doesn’t have the capacity to do an AAR on every incident. What will organisation leaders expect to see from AARs? How will they be assured of the quality of the review when reports are shorter? This might be particularly of concern for AARs into deaths by suicide, where panels are used to receiving very detailed reports. Context of incidents is hugely important. Discussion was that AARs should focus on the incident but with the analysis highlighting context, causal factors and what action is needed. The need for ‘protected’ time to complete AARs. Value of appreciative inquiry and learning from what works well. Otherwise, it’s as if we’re “learning about sharks just from shark attacks”. Patient Safety Managers will have to ‘let go’ and support AARs wherever incidents take place, rather than controlling the process. Very different solutions for ward-based activity compared to theatres. The measure of success will be when there are fewer falls, for instance. How will the learning from AARs be shared within and between organisations? What is your experience of AARs? Share your resources with us During the course of this discussion many members of the Patient Safety Management Network volunteered to share their templates, presentations, training resources and guides related to AARs. These will shortly be added to the Network’s community on the hub. Do you have AAR resources and good practice to share? Included at the end of this blog is some related reading on this topic and we’d welcome further additions to the hub. If you’re a Patient Safety Manager interested in joining the Patient Safety Manager Network, you can do so by signing up to the hub today. If you are already a member of the hub, please email claire@patientsafetylearning.org. References NHS England and NHS Improvement. Patient Safety Incindent Response Framework 2020: An introductory framework for implementation by nationally appointed early adopters. March 2020. WHO. After Action Review. Last Accessed 9 November 2021. Related reading Salem-Schatz S, Ordin D, Mittman B. Guide to the After Action Review. Center for Evidence-Based Management, December 2010. CloserStill Media. Learn faster and better together: The power of After Acton Review (webinar recording). 4 June 2021. Judy Walker. How can After Action Review (AAR) improve patient safety? the hub, 23 August 2019. Judy Walker. Why isn’t After Action Review used more widely in the NHS. the hub, 1 February 2021. NHS England and NHS Improvement. After Action Review. August 2021. United States Army Combined Arms Center. The Leader’s Guide to After-Action Reviews (AAR). December 2013. WHO. After Action Review (AAR) resources. 11 November 2019.
  5. Event
    WHO Patient Safety Flagship invites you to participate in a virtual event for the launching of the “Global Patient Safety Action Plan 2021-2030”. This global action plan aspires for “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.” The event marks the achievement of an important and historic milestone, and prominent health leaders and patient safety champions will take you through the global patient safety journey. Speakers include: Dr Tedros Adhanom Ghebreyesus, Director-General, WHO Mr Jeremy Hunt, Chairperson, Health and Social Care Select Committee, UK Sir Liam Donaldson, WHO Patient Safety Envoy Dr Neelam Dhingra, Unit Head, WHO Patient Safety Flagship Further information and registration
  6. Content Article
    What are PFD reports? There is a statutory duty for coroners to issue a PFD report to any person or organisation where, in the coroner’s opinion, action should be taken to prevent future deaths. These reports are made publicly available on the Coroners Tribunals and Judiciary website with the organisations involved having a duty to respond within 56 days. When serious incidents occur in healthcare that result in the death of a patient, PFD reports play a key role in identifying what went wrong and the actions needed to prevent this reoccurring. These crucial insights may often be applicable beyond the organisation in which this took place and provide a point of wider system learning. Implementing actions and sharing learning While these reports provide a wealth of information, the key challenge is ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning while we recognise the important role these reports have to play, we have some concerns about how they are currently acted on. Implementing actions When actions are requested by the coroner, it is not clear under the current system whether there is a structured process, either at a national or individual organisation level, for monitoring the actions implemented in response to the PFD report. There is also an open question about who is held accountable if the actions requested are not fully implemented, or if the response taken is ineffective. It is difficult to assess how healthcare providers go about this as there appears to be no specific system of monitoring this at a national level. Sharing learning As noted earlier, often the learnings from PFD reports may be applicable beyond the organisation involved. However, at present there appears to be no clear system of sharing these outcomes more widely. Although these reports are published online, they are not in an easily searchable or shareable format and it is difficult to draw out common themes, actions and responses. Furthermore, it is not clear whether NHS England and NHS Improvement undertake any central trend analysis or review to draw out common themes that may be applicable to all organisations, in the same way that the Healthcare Safety Investigation Branch does when it publishes its investigation reports. What do we want to see? We have recently written to the Chief Coroner, Judge Mark Lucraft QC, to raise these issues. We have also drawn this to the attention of Dr Alan Fletcher, the National Medical Examiner. As the new National Medical Examiner system is currently being rolled out across England and Wales, their role in ‘ensuring proper scrutiny of all non-coronial deaths’ will be complementary to the current PFD system. We feel it is important that coroners and medical examiners take a consistent approach to reporting and sharing learnings as widely as possible. When we receive responses, we will take this up directly with NHS England and NHS Improvement, and other national bodies with responsibility for patient safety, along with our ideas of actions that we feel could help to address the current gaps in the system: Implementing actions 1) Analyse reports – Sustainability and transformation partnerships (STPs)/Integrated Care Systems (ICSs) to carry out annual thematic reviews of all PFD reports, Serious Incident (SI) reports and associated safety action plans. These plans can inform future commissioning, safety action plans and Care Quality Commission oversight. 2) National oversight – put in place a clear system of national oversight. Shared learning 3) Increase transparency – make all PFD reports, SI reports and their associated safety action plans available in the public domain. 4) Improve accessibility – create a central repository for all PFD reports, SI reports and associated safety action plans in one database searchable by actions and themes. 5) Standards – put in place patient safety standards for each STP and ICS, with requirements on individual trusts, primary care networks and service providers to share learning from these reports. 6) Publish an annual report – on PFD reports and SI reports including themes for learning and action.
  7. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!
  8. Content Article
    Objective Reduce incidence of falls and harm. Embed falls prevention into everyday practice. Engage clinical staff to identify patients at risk and implement harm prevention strategies. Process for target wards: Present data for the past 12 months for falls by severity, as baseline metric. Present serious falls and actions undertaken. Falls Risk Assessment audit as baseline metric. Falls Link Worker ensures a display board is refreshed with falls prevention displays and audit result. Ward team set own targets for improvement weekly. Teaching sessions delivered. These may be ward sessions or in the Quality Improvement and Innovation (QII) hub. Weekly audits continue. Evaluation: Meeting with the team to discuss programme results, falls incidences, post fall assessment themes and audit results. Link worker provides evidence of training undertaken and plan for those who have not received training. Improvement plan agreed to be delivered by the link worker.
  9. Content Article
    The strategy was developed over two years and involved input from a wide range of people, including service users, carers, front-line HSC staff, commissioners, departmental policy officials and professionals & Trade Unions. It has also been the subject of public consultation and was formally launched in November 2011. Its purpose is to create a strategic framework and plan of action that will protect and improve quality and, therefore, patient safety across all three dimensions within health and social care over the next 10 years. It recognises that this will be a period of major challenges, including financial constraints, as well as opportunities and demands from various quarters. It will be subject to review every 3 years to ensure that it remains fit for purpose.
  10. Content Article
    This document is a demonstration of Virgin Care’s commitment to providing the best quality community healthcare services to citizens in North Kent. Quality Accounts are an opportunity for an organisation to take stock of what has been achieved and to look ahead at what is planned for the coming year.