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Content ArticleThe World Health Organization (WHO) has published a new edition of this guidance on health technology assessment (HTA) for medical devices. Health technology assessment (HTA) is described as ‘a well-recognised and methodologically robust evidence-based priority-setting process used to provide information on the safety, efficacy, quality, appropriateness, and cost-effectiveness of health technologies’. This document ‘is intended to provide guidance to policy-makers, particularly those in low- and middle-income countries that are currently developing HTA capacity.’ The document describes ‘general concepts of HTA and points to best-practice resources to enable low- and middle-income countries to make consistent, transparent and informed decision-making on the adoption and use of medical devices to ensure clinical needs are met whilst delivering value to patients, healthcare providers, and the broader health system.’
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News Article
NHSE vows to end ‘bombardment’ of trusts
Patient Safety Learning posted a news article in News
NHS England has vowed to “reduce duplication and prevent providers from being bombarded with conflicting instructions”, including by removing integrated care boards’ performance management role. A new draft NHS Performance Assessment Framework, published today, promises to “streamline oversight” by “providing consistent and co-ordinated oversight to reduce duplication and prevent providers from being bombarded with conflicting instructions”. The document attempts to set out how integrated care boards and trusts will be regulated by NHS England, starting from July. It confirms that NHSE, not ICBs, will be responsible for provider performance management – a move announced late last year but met with anger from many ICBs. The new paper says: “Discussions about performance will be led by colleagues at NHS England, who are experienced in addressing delivery challenges.” The proposal that NHSE performance management will be carried out “with and through” ICBs — included in earlier versions of the framework — has gone. In addition, trusts’ performance “segments” will no longer take into account wider system performance, nor a proposed judgement of their “capability”, as they will “solely [be] linked to delivery metrics”. ICBs will still have to “hold their partners to account using the system levers that bind them together, such as their joint system plans, partnership agreements, joint committees and collaboratives”, however. The framework is subject to consultation, and new NHSE CEO Sir Jim Mackey told its board today it was likely to be changed. There will “absolutely be some things we need to change and adjust”, he said. “This isn’t something that can be perfect at the first go.” Read full story (paywalled) Source: HSJ, 27 March 2025 -
Content ArticleThe NHS performance assessment framework (PAF) is a tool to measure and improve the performance of the NHS. NHS England has developed an updated Assessment Framework which will replace the current Oversight Framework, setting out how success and areas for improvement will be identified, and how organisations will be rated. This will apply to trusts who provide services, and to integrated care boards (ICB) who have the responsibility to assess population need and arrange services to meet those needs. Additionally, NHS England has developed a Strategic Commissioning Framework to support ICBs strengthen their capability to drive the 3 shifts set out by the government. This updated framework, to reflect the new government’s mandate to the NHS and the 3 shifts as part of the Health Mission, builds on the one which was developed following engagement with organisations such as the Local Government Association, Healthwatch, Association of Directors of Children’s Services, National Voices, Local Authority Chief Executives and think tanks and was subject to a public consultation in summer 2024. Extensive engagement with the NHS on the updated framework took place between December 2024 and January 2025.
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EventuntilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI’s Health Equity Warning Score (HEWS) and the Health Equity Assessment and Resource Toolkit (HEART). MNSI's health equity, diversity and inclusion leads developed this assessment tool to systematically identify, acknowledge, investigate and analyse factors affecting health equity which impact care and perinatal outcomes. Join this webinar to find out how you can put this tool into practice in your trust. Register for the webinar
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Content Article
Understanding your HSE culture (2018)
Patient Safety Learning posted an article in Culture
Understanding your HSE culture is one of the world's most widely used tool for measuring HSE culture. The tool measures organisational HSE culture against the Hearts and Minds/Hudson and Parker safety culture ladder. Understanding your HSE culture helps organisations explore their culture by providing descriptions of how companies behave at the 5 different levels of culture: Pathological: people don’t really care about HSE and are only driven by regulatory compliance and/or not getting caught. Reactive: safety is taken seriously, but only after things have gone wrong. Managers feel frustrated about how the workforce won’t do what they are told. Calculative: focus on systems and numbers. Lots of data is collected and analysed, lots of audits are performed and people begin to feel they know "how it works". The effectiveness of the gathered data is not always proven though. Proactive: moving away from managing HSE based on what has happened in the past to preventing what might go wrong in the future. The workforce start to be involved in practice and the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Generative: organisations set very high standards and attempt to exceed them. They use failure to improve, not to blame. Management knows what is really going on, because the workforce tells them. People are trying to be as informed as possible, because it prepares them for the unexpected. This state of "chronic unease" reflects a belief that despite all efforts, errors will occur and that even minor problems can quickly escalate into system-threatening failures. -
Content Article
Using the Hudson Ladder in the context of health culture
Patient Safety Learning posted an article in Culture
Is the Hudson Framework suitable for health culture? David Day, Head of SHE at nuclear specialist Nuvia UK, talks about why he has selected a particular cultural model as the basis to develop a health culture assessment tool. -
News Article
Teenager’s death linked to national IT system, review suggests
Patient_Safety_Learning posted a news article in News
The 999 assessment and triage system is being reviewed after the death of a young footballer, which may have highlighted a recurring flaw in the tool. Adam Ankers collapsed as he came off the pitch after playing for Wycombe Wanderers’ under-19s team in January. He was airlifted to the Harefield Hospital in London but was brain dead and a few days later his family agreed to his life support being turned off. The talented youngster was found to have an inherited heart condition, arrhythmogenic right ventricular cardiomyopathy. This and other inherited heart conditions are thought to be responsible for at least 600 sudden deaths a year in teenagers and young adults. But a serious incident investigation into Adam’s death by South Central Ambulance Service Foundation Trust, shared with HSJ by Adam’s dad, revealed there was a potential missed opportunity to start life support earlier because “agonal breathing” — which is indicative of a cardiac arrest — was not identified. Read full story (paywalled) Source: HSJ, 28 October 2024 -
Content Article
Top picks: Venous thromboembolism
Patient Safety Learning posted an article in High risk areas
Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post. -
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Content Article
Eating disorders training for health and care staff
Patient-Safety-Learning posted an article in Eating disorders
This series of training programmes was collaboratively developed by eating disorder charity Beat, Health Education England and NHSE. It was developed in response to the 2017 PHSO investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. It is designed to ensure that healthcare staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It includes sessions relevant for different healthcare professionals and includes: Medical students and foundation doctors programme Nursing workforce sessions GP and Primary care workforce sessions Medical Monitoring in eating disorders Understanding Eating Disorders Webinar resource for dietitians, oral health teams and community pharmacy teams -
Content ArticleAn estimated 90,000 people are living with dementia in Scotland, with that number expected to increase to 164,000 by 2036. These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. We also hear from Marion Ritchie, a carer who experienced pre-death grief while caring for her husband.
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Content ArticleThe Greater Manchester Major Trauma Network recognise that many older patients self-present to emergency departments and the ‘Meet Harry’ infographic was produced as an aide memoire to triage nurses and clinicians to assist in assessment. You can view the ‘Meet Harry’ infographic by clicking on the image or download it from the attachment below.
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Content ArticleHealthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study from Simpson et al. was undertaken to provide a snapshot as to how the NHS is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally. An online survey was sent to 234 NHS hospital trusts, with a response rate of 35%. Respondents who completed the online survey, on behalf of their representative organisations, were senior clinical governance leaders. The findings demonstrate that the majority of organisations, that responded, were actively measuring culture. Significantly, a wide variety of tools were in use, with variable levels of satisfaction and success. The majority of tools had a focus on patient safety, not on understanding the determining factors which impact upon healthcare OC. This paper reports the tools currently used by the respondents. It highlights that there are deficits in these tools that need to be addressed, so that organisations can interpret their own culture in a standardised, evidence-based way.
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Content ArticleThe number of older people having surgery is increasing. However, older patients are more likely to have complications after surgery than younger patients as they often have multiple health conditions and age-related problems such as frailty and a decline in mental ability. These factors increase the risk of surgery and can hinder recovery. Surgical pre-assessment usually focuses on the patient’s physical fitness for surgery, not the broader range of health-related factors that are important to consider in older patients. The Perioperative care for Older People undergoing Surgery (POPS) model was developed to provide a holistic assessment of an older person’s medical, physiological and functional condition prior to surgery. The assessment is then used to inform interventions that can reduce the risk of complications. The POPS model is increasingly being implemented across the English and Welsh NHS, but there are often challenges in introducing these new ways of providing care that need to be better understood. This independent study, led by THIS Institute Fellow Professor Justin Waring, outlines the key activities and strategies that are needed for the POPS model to be successfully implemented and become part of routine practice in a hospital.
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Content Article
Patient-led assessments of the care environment (PLACE)
Patient Safety Learning posted an article in Environmental
PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The 2023 programme is planned for launch in early September 2023. Good environments matter. Every NHS patient should be cared for with compassion and dignity in a clean, safe environment. Where standards fall short, they should be able to draw it to the attention of managers and hold the service to account. PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The assessments involve local people (known as patient assessors) going into hospitals as part of teams to assess how the environment supports the provision of clinical care, assessing such things as privacy and dignity, food, cleanliness and general building maintenance and, more recently, the extent to which the environment is able to support the care of those with dementia or with a disability. Recruitment and training of patient assessors is the responsibility of those organisations undertaking assessments. The assessments take place every year, and results are published to help drive improvements in the care environment. The results show how hospitals are performing both nationally and in relation to other hospitals providing similar services. -
Content ArticleThe Acute Frailty Network (AFN) was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. In July 2023, Street et al published a paper in BMJ Quality and Safety analysing the impact of the AFN which concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not. This article outlines the position of the British Geriatrics Society (BGS) on the paper, addressing why it thinks that focusing on older people’s healthcare is more important than ever. It highlights the importance of ensuring that the paper's findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble efforts to identify and overcome the barriers to delivering CGA in acute settings.
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News Article
Met wins battle with NHS over not attending mental health calls
Patient Safety Learning posted a news article in News
The Metropolitan police has won its battle to stop attending most of the mental health calls it receives after a tense behind-the-scenes row with the health service, the Guardian has learned. From 31 October the Met will start implementing a scheme that aims to stop officers being diverted from crime fighting to do work health staff are better trained for. In May, the Guardian revealed that the Met commissioner, Sir Mark Rowley, had written to health and social care leaders setting a deadline of 31 August – leading to furious reaction from health chiefs who wrote to the commissioner protesting that it would put vulnerable people at risk. The agreement means Rowley will push his deadline for the start of the changes back by two months, before a phased introduction. Health services will not publicly criticise the police decision, and will race to put measures in place to pick up the work. The scheme is called Right Care Right Person (RCRP), and has been agreed nationally by government departments and national police and health bodies. The letter sent on Thursday says: “In practice, this means that police call handlers will receive a new prompt relating to welfare checks or when a patient goes absent from health partner inpatient care. The prompt will ask call handlers to check that a police response is required or whether the person’s needs may be better met by a health or care professional.” Read full story Source: The Guardian, 17 August 2023 -
Content ArticleThe Dermatitis Family Impact (DFI) questionnaire is a disease‐specific measure to assess the impact of atopic eczema on the quality of life (QoL) of the parents and family members of affected children. The authors set out to review the published literature and to collate data on the clinical and psychometric aspects of the DFI questionnaire from its development in 1998–2012, in order to create a single source of reference for users of the DFI.
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Content ArticleRecording of a recent Care Quality Commission (CQC) webinar. Hear from Mandy Williams, Interim Director of integration, inequalities and improvement as she updates on CQC's approach to assessing integrated care systems. During the Q&A session, Mandy is also joined by Helen Rawlings, Deputy Director of Integration, Inequalities and Improvement, Matt Tait, Head of Acute Policy and Dominique Black, Strategy Manager who answers attendees questions from the live chat.
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Content ArticleThis guidance outlines the Care Quality Commission's (CQC's) approach to assessing integrated care systems (ICSs). It includes information on how these assessments will be carried out. The guidance focuses on: Themes and quality statements Evidence categories How we will assess integrated care systems Reporting and sharing information Intervention and escalation
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News Article
Thousands of children unsure of gender identity ‘let down by NHS’, report finds
Patient Safety Learning posted a news article in News
Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found. The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said. Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress. But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” Read full story Source: The Guardian, 10 April 2024 -
News Article
NHS faces ‘avalanche’ of demand for autism and ADHD services, thinktank warns
Patient Safety Learning posted a news article in News
The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned. There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust. The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services. Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand. “We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.” Read full story Source: The Guardian, 4 April 2024 -
News Article
USA: Care quality, safety 'worse than expected' during Covid-19 pandemic
Patient Safety Learning posted a news article in News
A new CMS report reveals disparities in care quality and patient safety within US hospitals before and during the pandemic, finding "a large proportion of measures had worse than expected performance." CMS released its 2024 National Impact Assessment Feb. 28, which is released every three years and evaluates the measures used in 26 CMS quality and value-based incentive payment programs. This edition of the report compares quality measure scores pre-COVID-19 with hospitals' results in 2020 and 2021, the initial years of the COVID-19 public health emergency. Here are eight findings from the 72-page assessment: 1. During 2020 and 2021, a large proportion of measures had worse than expected performance, including significant worsening of key patient safety metrics. 2. Half or more of the performance measures in five priorities had worse results in 2021 than expected from the 2016–2019 baseline. Priorities with the highest proportions of worse-than-expected results in 2021 were wellness and prevention (69%), behavioural health (55%), safety (54%), chronic conditions (52%), and seamless care coordination (50%). 3. Specific to safety, standardised infection ratios worsened significantly in hospitals for central line–associated bloodstream infections (94% worse), MRSA (55% worse) and CAUTI (34% worse). Before the Covid-19 PHE (2015–2019), 34,455 fewer healthcare-associated infections (HAIs) were reported in acute care settings. 4. More than 35% of measures in two priorities had better results in 2021 than expected from 2016–2019 baseline trends. Those priorities are seamless care coordination (50%) and affordability and efficiency (38%). 5. Specific to affordability and efficiency, emergency department visits for home health patients fared 1.4 percentage points better, and acute care hospitalization in the first 60 days of home health in 2021 was 1.5 percentage points better. 6. Accountable entities with the highest proportions of worse than expected results in 2021 were clinicians (64%), accountable care organizations (54%), and acute care facilities (54%). 7. Wellness and prevention had the highest percentage of measures showing health equity disparities; notable examples include pneumococcal and influenza vaccinations among racial and ethnic groups. 8. Comparison racial and ethnic groups fared worse than the White reference group on 40 of 45 (88.9%) affordability and efficiency measures and 32 of 41 (78%) chronic conditions measures. For example, disparities were recorded for Black or African American patients in 32, or 71%, of the affordability and efficiency measures, mostly related to readmissions. Read full story Source: Becker Hospital Review, 29 February 2024 -
EventuntilThis upcoming webinar from the Care Quality Commission will focus on quality statements and evidence categories. It will talk through where these two elements fit in the wider new regulatory approach and what guidance is available to help you understand them. The webinar will focus on example quality statements to explore how CQC will use evidence categories to identify specific sources of evidence to use in their assessments. Alongside the provider guidance, this webinar will give you the information you need to understand the evidence that CQC use to assess each of their new quality statements. This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them and other stakeholders to hear the latest updates about CQC's new regulatory approach. The webinar will be led by Dave James, Head of Policy – Adult Social Care and Amanda Hutchinson, Head of Regulatory Change. Register
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Event
CQC: Local authority assessments webinar
Patient Safety Learning posted an event in Community Calendar
untilThe Health and Care Act 2022 gives the Care Quality Commission (CQC) new powers that allow them to provide a meaningful and independent assessment of care at a local authority level. This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them, other stakeholders, local authorities, and stakeholders that represent the public to hear about CQC's approach to assessing local authorities and what it means for you. Register
