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Found 29 results
  1. News Article
    NHS England, the Care Quality Commission and other arm’s length bodies will be subject to an efficiency and performance review led by the Cabinet Office. The terms of a review into all government arm’s length bodies were set out this week, with minister Jacob Rees-Mogg insisting there is an “urgent need for public service reform”. The ‘public bodies review’ programme will consider whether ALBs “should be abolished or retained”, should continue to deliver all their functions, and whether they have an “effective relationship” with their relevant departments. Other ALBs include the National Institute for Health and Care Excellence, Health Education England, and the UK Health Security Agency. A guidance document says: “The outcome of this work should see powers returned to accountable ministers, greater efficiency and where appropriate, the state stepping back both financially and from people’s lives… Read full story (paywalled) Source: HSJ, 29 April 2022
  2. News Article
    Hospital staff may be carrying SARS-CoV-2, the coronavirus that causes COVID-19 disease, without realising they are infected, according to a study by researchers at the University of Cambridge. Patients admitted to NHS hospitals are now routinely screened for the SARS-CoV-2 virus, and isolated if necessary. But NHS workers, including patient-facing staff on the front line, such as doctors, nurses and physiotherapists, are tested and excluded from work only if they develop symptoms of the illness. Many of them, however, may show no symptoms at all even if infected, as a new study published in the journal eLife demonstrates. The implications of the new study, say senior authors Dr Mike Weekes and Professor Stephen Baker from the Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), are that hospitals need to be vigilant and introduce screening programmes across their workforces. “Test! Test! Test! And then test some more,” Dr Weekes explains. “All staff need to get tested regularly for COVID-19, regardless of whether they have any sort of symptoms – this will be vital to stop infection spreading within the hospital setting.” Read full story Source: University of Cambridge, 12 May 2020
  3. News Article
    Healthcare apps that triage patients should be put through a ‘fair test of clinical performance’ published by NHS England to ensure their safety, according to the Care Quality Commission (CQC). In addition, the Department of Health and Social Care should look into whether ‘safety-netting’ advice should be available to the public about how to use symptom checkers, said the CQC. The CQC made the recommendations as part of work to shape its approach to regulating healthcare apps. It found digital triage tools are currently not fully clinically validated or tested by product regulators and discovered ‘there is great variation in their clinical performance’. NHS England and other bodies should assess where people have been wrongly escalated, resulting in undue anxiety, as well as where tools have failed to address people’s ill health, said the CQC. Read full story Source: PULSE, 30 January 2020
  4. Content Article
    Numerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
  5. Content Article
    This paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
  6. Community Post
    Great blog in Learn from Martin on who should be in an investigation team - the expertise of the team, their roles and responsibilities. Do you agree?
  7. News Article
    As part of wide-reaching work being carried out to review the methods and processes the National Institute for Health and Care Excellence (NICE) uses to develop guidance, the organisation has launched a public consultation on proposals for changing how it selects the topics it will develop guidance on. Covering guidance on medicines, medical devices and diagnostics, the proposals clarify the criteria which would see a device or diagnostic selected for NICE guidance development. In particular, these include where costs and impacts are expected to be significantly cost-incurring or cost-saving – or there is uncertainty around the likely cost or the impact it would have on the healthcare system. With regard to medicines, the new proposals would confirm the commitment made in the 2019 Voluntary Scheme for Branded Medicines Pricing and Access that pledged NICE would appraise all new active substances and significant licence extensions for existing medicines, except where there was a clear rationale not to do so. Similarly, all new or significantly modified interventional procedures that would protect patient safety will be selected if they are available to the NHS or independent sector, or set to be used outside of formal research. This proposed approach would move away from the 15 criteria currently used to select topics for evaluation by NICE’s Centre for Health Technology Evaluation and provide a clearer and simpler process. Helen Knight, Programme Director for Technology Appraisals and Highly Specialised Technologies at NICE, said: “Topic selection plays an important role in the development of NICE guidance and is designed to ensure that the guidance we produce is on topics that support healthcare professionals and others to provide care of the best possible quality. “These proposals will ensure we can continue to meet these ambitions at a time of unprecedented change in the healthcare system.” The consultation on the proposals runs until 19 November. This will be followed by a separate public consultation on the case for change to its processes in February and March 2021. Read full story Source: NHE, 12 October 2020
  8. Content Article
    The Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
  9. Content Article
    The State of Care is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. The care that people received in 2019/20 was mostly of good quality. But while the quality of care was largely maintained compared with the previous year, there was generally no improvement overall. And in the space of a few short months since then, the pandemic has placed the severest of challenges on the whole health and care system in England.
  10. Content Article
    As trusts consider clearing the waiting list, there is an absence of objective approaches to prioritisation. There are 40 million variations of operative type and the NHS elective waiting list may reach more than 10 million. A coronavirus second wave may cause further delays and expansion of the waiting list. This blog from hub topic lead Richard Jones describes a proven approach to prioritising the waiting list built around individualised risk-adjustment for each patient and evolved from the core POSSUM methodology that is widely used for individual risk assessment pre-operatively.
  11. Content Article
    Mark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
  12. Content Article
    In my previous blogs I described the investigation process and where facts come from. We also pre-empted the content in this blog by saying that human factors (HF) is the scientific study of humans done by science types. It’s now time to talk ‘people’.
  13. Content Article
    Promoting patient and occupational safety are two key challenges for hospitals.  Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
  14. Content Article
    AQuA are an NHS health and care quality improvement organisation at the forefront of transforming the safety and quality of healthcare. They are based in the North West and work with over 70 member organisations. They also undertake a number of consultancy based projects across the UK with both health and care organisations.
  15. Content Article
    This report from the Parliamentary Health Service Ombudsman (PHSO) explains the findings of their research, highlights the issues they have identified and sets out the action they believe needs to be taken to improve the quality of NHS investigations.
  16. Content Article
    This thought paper from Carl Macrae and Charles Vincent explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this. Many safety critical industries depend on the work of an independent, national safety investigator to investigate the most serious risks that span the system and to develop safety recommendations that target any and all organisations that need to work together to address those risks–from front-line providers to regulators. This paper defines the fundamental principles, the practical challenges and the considerable opportunities that any healthcare system must grapple with in the development of a national safety investigator that supports system-wide learning.  
  17. Content Article
    This is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect.  This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
  18. Content Article
    The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America's health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions. This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report. This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety.
  19. Content Article
    Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. Borzecki and Rosen discuss what the 'best' measure for patient safety is in this Editorial published in BMJ Quality and Safety.
  20. Content Article
    State of Care is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
  21. Content Article
    The National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
  22. Content Article
    This is part two of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’ and concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types rather than by (deep breath) public speakers, non-technical skills (NTS) professionals, those who create team talks, medics who have been on a course about being nice and polite to other medics, and those that have married a human therefore they must be qualified to talk about humans – was also discussed. This and the next blog will introduce the concept of where facts or data comes from. Later blogs will deal with the who, how, when etc. The ‘who’ investigates (next blog) really is determined by where the facts come from. Later – if the cake lasts – we can chat about what to do with the data, and how to report it and save lives.
  23. Content Article
    After completing nearly 600 investigations and research projects in human factors, it might be worth sharing some observations of why we do incident (forensic) investigations. This will be a series of short blogs that will cover the investigation process, answer questions about humans and shine a light on the method of forensic investigations.  This will be undertaken alternating with the topic of human factors – the most misunderstood bit of science the healthcare sector deals with. In these posts I’ll cover what human is, the limits of human performance – covering the senses, fatigue – and why pilots and CRM is very dangerous to healthcare. Above all I want to get the idea that human factors is a science and it’s about understanding how human limits restrict how we deal with the built environment and complex systems.
  24. Content Article
    This paper, by the King's Fund, argues that the NHS in England cannot meet the healthcare needs of the population without a sustained and comprehensive commitment to quality improvement as its principal strategy.
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