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This national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.

This blog, written by Human Factors expert Stephen Rice and published by Forbes, looks at what healthcare can learn from the success of the aviation industry when it comes to safety.

For senior managers and safety professionals within organisations wishing to develop performance indicators to give improved assurance of control over major hazard risks. Although primarily addressed to major hazard operators, the generic model for establishing a performance measurement system, as given in this guide, can equally apply to other enterprises requiring similar levels of assurance. Offering a six-stage process to adopt in order to implement a programme of performance monitoring for process safety risks.

Health and social care faces a conflict between safe and appropriate staffing and the (government) directive to be cost efficient. In a time of clinical and support staff shortages, increasing demand for services and financial austerity, there is a need for a consistent approach to workforce analysis, benchmarking and planning across the health and social care to enable informed decision-making across finance, HR and nursing management to put the patient and their safety at the centre of all we do. 'Establishment Genie' is an online workforce planning, safe staffing and benchmarking tool. It has been co-developed and tested with more than 300 teams across acute, community, residential care, hospice and independent providers of care. This has been supported by input from NHSE, NHS Professionals, The Florence Nightingale Foundation, Safe Staffing Alliance, Royal College of Nursing, Health Education England, Queen’s Nursing Institute and academic nurse staffing experts. Case study examples The following case studies show how trusts have been using the tool. Roles and responsibilities of staff have been reviewed and new workforce plans have been co-designed with staff at the frontline to deliver new ways of working that put the patient at the centre of care – whatever the setting. The Hillingdon Hospitals - Safety Supervision and Savings.pdfThe Hillingdon Hospitals - Ward Reconfiguration for Safety.pdf GIG Cymru NHS Wales - Residential Nursing homes Case Study.pdfChelsea and Westminister Hospital Case Study - Empowering Staff.pdf GIG Cymru NHS Wales - District Nursing Principles Case Study (1).pdfBerkshire Health Community Nursing Case Study.pdf Organisational benefits Integrated care levels, costs and common language enables clinical and corporate leads to collaborate and meet the requirements of a next-generation health and social care workforce: Precise staffing profiles and options appraisal support CIP development and budgeting. Gap analysis compared to budget and standards for exact hours and WTE requirement for each band. Uplift for leave is specific to each role and expected joiners, avoiding blanket uplifts that may not fit the needs of the unit. Governance and control underpinned by agreed, costed roster templates, with ready reckoners to keep within range. Improved recruitment and retention with evidence of staffing levels and support. Outcomes track quality, with benchmarking to assure. Clinical benefits Professional judgement in workforce planning is supported by this NICE-endorsed tool: Planning care levels and WTE for expansion, efficiency, reconfiguration and new service models. Evaluating alternative shift models to reorganise, invest or save. Modelling skill-mix and impact of new roles. Understanding and validating variation. Challenging peaks and troughs in cover to improve safety, release capacity and release cost savings. Benchmarking and triangulation of patient care levels, with outcomes for correlation. Mapping other staff group input across each setting. Background on 'Establishment Genie' Creative Lighthouse was founded in response to frustration at the focus on financially led decisions in health and social care management that did not consider the safety and care of patients or staff. We set out to build a platform that would allow all management groups in the healthcare sector to collaborate on safe staffing and financial governance. Creative Lighthouse self-funded the development of a unique workforce-planning tool under the brand name ’Establishment Genie’, endorsed by the National Institute of Health and Care Excellence (NICE) in 2017. In April 2017, the Creative Lighthouse team were awarded a grant from Innovate UK to continue to develop the tool to include all settings of care in the knowledge that patient safety and workforce planning is not only the responsibility of acute services, but of all providers and commissioners of care. This is a critical aspect of enabling the improvement of quality and patient outcomes in a cost effective way, whilst providing data driven analytics to support professional judgment. About the author I am a healthcare professional with over 15 years’ experience working in and consulting to public and private health and social care organisations. I have worked with a variety of health and care sector clients in the delivery of complex change, from transformational change and organisational design process to programme leadership and execution. I am passionate about the safe staffing agenda, recognising that in order for any organisation to ensure appropriate care and evidence for professional judgement, there must be consistency in approach and a way of linking staffing levels to quality outcomes that can then be benchmarked within and across organisations. This passion resulted in the birth of ‘Establishment Genie’.

Reducing the burden of harm and instilling better practice requires both systems thinking and committed local ownership. Comparisons of health systems across the world can help visualise best practice, opportunities for learning and potential for diffusion of innovations. Most importantly, depicting the global state of patient safety showcases exemplar safety systems and facilitates exploration of their characteristics and enablers.   This report seeks to stimulate ambitious visions and bold action to significantly reduce harm and improve the lives of millions of patients and their families.  Global burden of unsafe care The clinical burden of unsafe care The economic burden of unsafe care The broader impact of unsafe care Reducing the burden. How are countries around the world doing? The importance of measurement and comparisons International variation in safety and quality Opportunities for learning. Future outlook Healthcare means safe care Threats and opportunities from innovation Ambitious capacity building.

While a recognised and accepted investigation process, barriers exist to the effective use of root cause analysis and implementation of improvements identified to generate sustainable action. This article lists tools identified by a literature review that sought to highlight incident review alternatives to RCAs, with particular focus on low-harm or no-harm events that should be examined to minimise their potential for contributing to patient harm.

The phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.

‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. Anniversaries are special. They acknowledge events from personal to the historic. I just celebrated an anniversary that met both those criteria: 25 years of marriage. I did so in a place marking the centennial of its designation as a national park – a true American wonder – the Grand Canyon. It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff need to keep safety in mind. Just as clinicians, patients and families do while they are in the hospital. They need to get informed, prioritise activities and trust judgment to manage risk. Distributing good, freely available information The Grand Canyon Visitor’s centres and trail heads provide a cornucopia of maps, pamphlets and booklets highlighting options for activities. Making information and data available is key to keeping a visitor to the Canyon free from harm. Similar to trail maps noting loose rocks, unmaintained walkways and mudslide potential, the US Pennsylvania Patient Safety Authority (PSA) models the important mission of transparency by sharing what they learn about threats to safety. The organisation has been collecting and analysing adverse event and other data for 15 years. The Authority disseminates it not only to generate action within their state, but throughout healthcare. Their new open access journal, Patient Safety, continues down a trail established by the PSA newsletter. This work will help all of us progress by providing insights to manage both unseen and known obstacles to safety. Prioritising action Grand Canyon National Park offers a wide array of choices for visitors. If you only have a day or two in the region, prioritising what hike to take and when to go takes some planning. Just as in safety where the options, tools and improvement goals can become overwhelming. It is crucial to have a method to sort things out. In both instances there is so much to do! Recently the US Veterans Administration (VA) health system published a paper on the process they use to prioritise efforts in their system. They summarised an approach that rests on a foundation of learning practices that could be helpful for all of us to consider in moving forward. Trusting your gut My husband in his college days hiked down the Canyon to the Colorado river and back up three separate times. Those treks gave him experience that enabled him to know when “worry” was worth listening to as we ventured down a rugged, steep, trail during our visit. We went down and came back up into the Canyon safely. A recent study from the US, published in JAMIA Open, looked at the accuracy of nursing judgement as a barometer for patient deterioration. The “Worry Factor” proved to be a darn good signal – over 75% of deterioration situations were correctly identified by nurses ahead of time. Then there are the others Do you ever wonder “what the ???” when you see people doing something in a park – there are signs everywhere NOT to do ... but they do it anyway? Scampering up rocks behind the safety railing, feeding squirrels, trudging down a rocky trail in flip flops! Safety messages are posted all over the park in an effort to keep Grand Canyon visitors safe. Of course, humans being human, don’t always follow the advice due to arrogance, language issues or a myriad of factors – the distraction caused by the beauty and awe of the place being one of them. Same goes for healthcare. Unintended consequences of process and environment complexity can derail efforts to keep patients safe. Bureaucracy can undermine efforts to keep large systems resourced to provide high quality care delivery, as we heard in a recent examination of the US Indian Health Service. Despite efforts to monitor opioid prescribing practices of physicians, the behaviours are notoriously persistent. Transparency and accountability for failure, while heralded as core attributes of safe care, are not always available to patients. Patient safety and life are both grand adventures that we can navigate through the effective use of information, prioritisation and sound judgment. I hope you all have as good a partner in your journeys as I have had in mine.

Charts comparing COVID-19 deaths across countries are appearing daily in our newsfeeds. Done well, these international comparisons can help us to understand how different national strategies and policies have affected the spread and severity of COVID-19 outbreaks. But sometimes what is presented in these neat charts is not quite as straightforward as it seems, and can draw misleading conclusions. Excess deaths is a better measure than COVID-19 deaths of the pandemic’s total mortality. It measures the additional deaths in a given time period compared to the number usually expected, and does not depend on how COVID-19 deaths are recorded. This report, written by Holly Krelle, Claudia Barclay and Charles Tallack, summarises some of the ways of comparing countries to help use make sense of data on deaths.

Professor Anne Marie Rafferty, Royal College of Nursing (RCN) President, has been involved in two decades of vital nursing workforce research. She explains in this interview for the RCN how the evidence could help us achieve safe staffing. The growing global evidence that Anne Marie and academic colleagues have gathered shows we need more nurses, with the right skills and support, if we want to reduce patient mortality and improve nurses’ wellbeing. The RCN has used this research to create the aims of its safe staffing campaign and to tell all four UK governments what nurses and patients need now.

The involvement of patients in their care is a top priority for the NHS, highlighted in the NHS Constitution and the NHS Five Year Forward View. Healthcare providers are encouraged to develop different relationships with patients and communities to help empower them and engage them in their care. This same approach applies to patient safety in healthcare, where greater engagement of patients is seen as one of the building blocks for improvement. . The framework outlined in this document provides a structure for thinking about engaging patients in patient safety and gives examples of how this can be achieved. It is mindful of the criticisms of approaches to patient engagement in patient safety and is a first step towards adopting a theoretical approach to this context. Some factors which influence engaging with patients in patient safety which were identified from this work are also presented. The framework describes three levels of patient engagement in patient safety across three levels of the NHS healthcare system. It also presents real-world examples of patient engagement in patient safety and applies these to the framework. For the purposes of the framework: Patient safety is defined as freedom from healthcare associated preventable harm. Patient engagement is the encouragement of patients, carers and families to work with healthcare professionals, healthcare service providers, commissioners and policy makers to improve health and healthcare. Descriptors of three levels of patient engagement are presented in the framework. Patients may be someone receiving care and giving ‘real-time’ feedback, patients who have previously received care or treatment, patients who have experienced harm, or members of the public.

I’d like to introduce my ‘Letter from America’, a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. “One small step for man ... “ 50 years on – we all recognise this phrase that accompanied one of the most famous descents in history: Neil Armstrong’s emergence from the lunar module toward his first step on the moon. The Apollo 11 moon landing represents an unparalleled accomplishment. Its characteristics resonate with patient safety professionals who look to space for inspiration. The Apollo programme experienced both triumphant achievement and catastrophic failure. The effort learned from mistakes, embraced teamwork, and considered human factors as part of its domain. Its workforce remained focused on a single goal. The effort embodied commitment, complicatedness and complexity. The 50th anniversary of these victories provides compelling parallels for error reduction efforts active today in healthcare in the US: Organisational learning systems NASA (National Aeronautics and Space Administration) is a learning system. Learning systems are developed and nurtured through common goals, leadership commitment and resource sustainability. They thrive through action generated by the application of data, evidence and knowledge. Likewise, the US Agency for Healthcare Research and Quality (AHRQ) has partnered with the US-based hospital and healthcare accreditation organisation, The Joint Commission, to disseminate analysed evidence compiled by the Evidence-based Practice Center (EPC) programme. These organisations are working together to transfer what is known into an actionable form through a series of articles to enhance the use of better practice and learning on the frontline. This programme and the article series are introduced in a recent commentary on the project. Coordinated action The Keystone Center represents the culmination of the work of patient safety’s own Neil Armstrong – Dr Peter Pronovost, known for his otherworldly (at the time) commitment to the checklist intervention. The Keystone Center initially coordinated and collected data to guide the implementation of the checklist concept in 70 intensive care units across the state of Michigan. Now the Center serves as the state’s mission control for hospital patient safety and quality. Leaders there raise awareness of success through the Speak-Up! award programme that acknowledges frontline healthcare staff for voicing their concerns and making care safer. The Center enables sharing of concerns that result in cost savings due to harm avoidance. A push in the right direction The Apollo programme applied technical sophistication, engineering and know-how to land a man on the moon and return safely to Earth within a decade. No small feat! Despite that imperative, both the module and the space programme needed a little boost now and again to get out of Earth’s orbit to complete its momentous undertaking. Patient safety has a similar call motivating its work – zero preventable harm. Some aim for ‘zero harm’ but is this achievable? Healthcare is very complex with multiple machine/human/machine interfaces. Clinicians, leadership and organisations still need a boost to design and use technology and data to support the workforce to improve care at the bedside. The mission-driven, Boston-based Betsy Lehman Center builds on a strong desire to prevent failures similar to those that took the life of its namesake – Betsy Lehman – the Boston Globe reporter who died in 1994 due to medication errors. The Center is a state agency that serves as mission control for its constituents. To help healthcare in Massachusetts move its safety work beyond the comfort of the status quo, they have recently convened a consortium to propel existing programmes towards new and aspirational achievement. On the dark side of the moon Of course, the Apollo programme suffered setback and tragedy. While I want to highlight successes in my Letter from America, I will also share stories of struggle to foster learning from what doesn’t work. News and narrative will often remind us of why continued work on safety improvement is fundamental. Diagnostic error is prevalent. A recent analysis of closed US medical malpractice claims found that delayed or missed diagnoses in three primary clinical areas – vascular events (such as strokes), infections (like sepsis) and cancer – substantially resulted in disability or death. You can take that to your mission control to motivate data collection, teamwork and effort to focus on diagnostic improvement in practice. Transparency is messy. The revelation of Neil Armstrong’s reported death in 2012 due to substandard medical care is sad for all kinds of reasons. It underscores persistent cultural influences that reduce the sharing of information related to poor care. This minimises our opportunity to learn from failure and support patients, families and clinicians involved in error. Organisational resistance to transparency about mistakes and the messiness of openness are challenges... even when the incident involves a patient with less name recognition. The Apollo programme and the 1969 lunar landing remains inspirational to this day. It behooves all of us who dream of contributing to something we once felt was impossible to engender the right spirit, resources and commitment to help get it done. The learning required for such accomplishment takes time, a culture that supports discussion and recognition of success. If we embrace contribution, collaboration and community, our small steps have the potential to contribute to the “giant leap” forward – to help us take off, realise achievement and return our patients safely home.

Healthcare isn’t the only industry that’s working to protect people in dangerous environments. Each year at the Institute for Healthcare Improvement (IHI) National Forum, the IHI faculty leads excursions to organisations outside of healthcare to learn about how they do their work. Kathy Duncan, IHI Faculty, leads a trip to the Central Florida Zoo, which has one of North America’s largest collections of venomous snakes. In this video, Duncan goes behind the scenes to learn about the staff’s safety procedures for handling snakes when they need to be moved from their enclosures. Learning objectives At the end of this activity, you will be able to: List three principles of reliable systems. Explain how the Central Florida Zoo uses these three principles in protecting staff from venomous snakes. Discuss how the zoo’s safety system can be applied to health care.

Meet Patient Safety Learning's Chief Executive, Helen Hughes. In this video she discusses her passion for patient safety, some of Patient Safety Learning's six foundations for a patient-safe future, as detailed in our latest report, A Blueprint for Action, and she explains why she's excited about the hub. View video (16 minutes)

Professor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University, delivers the James Reason lecture at the 2018 HSJ Patient Safety Congress on work force and safety and discusses the complexity of demand. What will I learn? Professor Leary offers insights from her Winston Churchill Fellowship visiting organisations such as NASA to investigate approaches to safety cultures and systems: Understand what these high reliability organisations do to handle risk, encourage safety cultures, utilise data and workforce. Learn what approaches your organisation could adopt to improve patient safety and workforce issues across the board.

The report from The Leapfrog Group analyses eight high-risk procedures to determine which hospitals and surgeons perform enough of them to minimise the risk of patient harm or death, and whether hospitals actively monitor to assure that each surgery is necessary. The report finds that the vast majority of participating hospitals do not meet The Leapfrog Group’s minimum hospital or surgeon volume standards for safety nor do they have adequate policies in place to monitor for appropriateness. Rural hospitals are particularly challenged in meeting the standards. Leapfrog advises "given the variation in patient outcomes between higher-volume and lower-volume hospitals, the importance of patients using Leapfrog results to select a hospital for these high-risk procedures cannot be overstated." The Leapfrog Group is a US nonprofit organisation 'driving a movement for giant leaps forward in the quality and safety of American healthcare.' Their flagship Leapfrog Hospital Survey collects and transparently reports hospital performance to inform purchasers and giving consumers information to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog’s other main initiative, assigns letter grades to hospitals based on their record of patient safety. Safety In Numbers summarises findings from the 2018 Leapfrog Hospital Survey, submitted by over 2,000 hospitals nationwide. This is the first year Leapfrog reported the new surgical standard by hospital, assessing whether both hospitals and surgeons met volume standards, and whether hospitals monitored for surgical necessity. This Leapfrog report states that patients should be very careful before they choose a hospital for one of these high-risk procedures and should worry even more about hospitals that decline to report this information because 'candour and transparency is the necessary first step to improvement.'

This article in the International Journal of Environmental Research and Public Health proposes a new approach to hospital bed planning and international benchmarking. The number of hospital beds per 1000 people is commonly used to compare international bed numbers. The author, Rodney Jones, suggests that this method is flawed because it doesn't consider population age structure or the effect of nearness-to-death on hospital use. To remedy this problem, Jones suggests a new approach to bed modelling that plots beds per 1000 deaths against deaths per 1000 population. Lines of equivalence can be drawn on the plot to delineate countries with a higher or lower bed supply. This method is extended to attempt to define the optimum region for bed supply in an effective health care system. England is used as an example of a health system descending into operational chaos due to too few beds and manpower. The former Soviet bloc countries represent a health system overly dependent on hospital beds. Several countries also show evidence of overuse of hospital beds. The new method is used to define a potential range for bed supply and manpower where the most effective health systems currently reside. The role of poor policy in NHS England is used to show how the NHS has been led into a bed crisis. The method is also extended beyond international benchmarking to illustrate how it can be applied at a local or regional level in the process of long-term bed planning.

Produced by the Institute of Global Health Innovation at Imperial College London, and commissioned by the charity Patient Safety Watch, this report considers the current state of patient safety around the world, through analysis of publicly available data from the last two decades. It includes an interactive data dashboard, case studies of patient safety excellence and a ranking of patient safety in OECD countries. Based on its findings, the authors of the report set out three recommendations to improve the measurement of patient safety: Assessment: A more balanced and comprehensive set of global patient safety indicators is required to address the data gaps identified in this report, and to ensure comparable data is available for all countries. Consensus is required on the minimum set of indicators that all countries should report on. Adoption: A global repository of safety measurement and improvement interventions should be developed and made freely available to frontline teams of practitioners and researchers across the world. Activation: To ensure the faithful adoption of interventions, patients, families and carers must be given the agency to become active and equal partners in the delivery of safe care.