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Found 78 results
  1. Content Article
    The workshops found five main risks to integration that appear to remain unresolved by current reforms. These are: Embedded culture and behaviours and inter-organisational power dynamics Organisational complexity, duplication, and overlapping focus Resource constraints Difficulties in defining, measuring and evaluating integration Integration fatigue. In response, this report offers some suggested approaches to mitigating those risks, which should be the focus of system leaders as partnerships take hold. These include: Ways of building integration into the day job Bringing clarity to the complexity of governance structures Better use of performance management, metrics and data Fostering culture change through greater mutual understanding Rebalancing capacity, including management capacity.
  2. Content Article
    During 2021-22, the impact of the Covid-19 pandemic continued to put intense pressure on healthcare services and required HIW to adapt its processes and approach to its work. This report outlines how HIW introduced new ways of working to ensure it discharged its statutory functions, whilst being as flexible and adaptable as possible to avoid putting undue pressure on health services. The report describes HIW's progress against its four strategic priorities: To maximise the impact of our work to support improvement in healthcare To take action when standards are not met To be more visible To develop our people and our organisation to do the best job possible It also details HIW's spending and performance against specific objectives for 2021-22.
  3. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  4. News Article
    The Independent Healthcare Providers Network (IHPN) have today launched a “refresh” of its Medical Practitioners Assurance Framework (MPAF), designed to further improve the safety and quality of care independent providers deliver to patients. Initially launched in October 2019, the MPAF – led by former National NHS Medical Director Sir Bruce Keogh – contains key principles to strengthen and build upon the medical governance systems already in place in the sector and sets out expected practice in a number of key areas. Care Quality Commission (CQC) now uses the framework’s principles in assessing how well-led an independent service is, with the framework a requirement of the NHS’ 2022/23 Standard Contract which all independent sector providers of NHS-funded care must adhere to. The MPAF was always designed to be a “live document” and today’s refresh strengthens the framework to ensure it remains in-keeping with current best practice in the health system. This includes taking into account recommendations from the Bishop of Norwich’s inquiry into Ian Paterson, as well as Baroness Cumberlege’s Independent Medicines and Medical Devices Safety Review (IMMDS). Key areas strengthened in the refresh include giving more prominence to expectations around patient consent, and the need to have greater transparency around conflict of interest declarations. New initiatives such as the Learn from Patient Safety Events (LFPSE) service are also reflected in the refreshed framework, as well as an IHPN Development Plan which sets how the network will support providers to continue to implement the MPAF. David Hare, Chief Executive of the Independent Healthcare Providers Network (IHPN) said: “IHPN are delighted to be launching today a new refresh of our Medical Practitioners Assurance Framework (MPAF), reflecting the independent health sector’s commitment to continuously improving the safety and quality of care they deliver to millions of patients every year. “Since the MPAF was launched in 2019, independent healthcare providers – with the support of CQC and NHS England – have really embraced the framework, using it to review and update their practices to further raise the bar in medical leadership in the sector. “With a continued focus amongst the entire healthcare system around improving patient safety and quality, this framework ensures providers adhere to the latest medical governance practices. “This will not only ensure greater consistency around how clinicians work across the independent sector and NHS, but also give confidence to patients that independent healthcare providers are committed to delivering the safest possible care”. Read press release Source: Independent Healthcare Providers Network, 26 September 2022
  5. Content Article
    Scope of the review The terms of reference outline that the review will consider cases from 1 April 2012 to a time anticipated to be three months before publication of the final report. Where the chair of the review believes the consideration of a case from 1 April 2006 to 31 March 2012 may add significantly to the review’s findings, it may be considered. Cases in the scope of the review will include clinical incidents where mothers and/or babies have suffered severe harm or death. The review will clearly and concisely set out to NUH an understanding of the elements of maternity care that have failed over the period of the review relating to: clinical care. governance and incident reporting and investigation and response to families. leadership and organisational culture including staff voices and staff wellbeing, including responses to staff whistleblowing. consideration of the commissioning and oversight of maternity services and any actions taken to improve the safety of maternity services by the then-primary care trust (PCT), clinical commissioning group (CCG) or other external bodies. Methodology The terms of reference sets out the review's methodology, including: approaches to engaging with families who joined the previous review. family support. staff support. Ways of working It also set out ways of working, including: resources. information sharing and governance. publication of findings.
  6. Content Article
    Providing the background for this review, the WHO introduces this report by highlighting that the pandemic has, and continues to, impact on every facet of healthcare systems across the world. It states that: “… the unanticipated surge of COVID-19 cases, the pandemic has created an unprecedented demand for care leading to a global strain on health systems, mot of which were not fully prepared to handle large-scale emergencies. The pandemic has emphasized the high risk of avoidable harm to patients, health workers, and the general public, and has identified a range of safety gaps across all core components of health systems at all levels. The impact of the pandemic is still unfolding and will have long-term ramifications.”[2] The report highlights that healthcare systems have faced a significant challenge in seeking to deliver safe care during the pandemic, including: Treating a significantly higher number of patients than normal as a result of Covid surges, while managing the subsequent disruption this has had on non-Covid care and treatment. The safety impact of staff shortages because of high numbers of Covid cases. Risks to infection control posed by the scarcity of key safety products such as Personal Protective Equipment (PPE). The significant toll on healthcare professionals, both in terms of their personal safety and general wellbeing, with heightened work-related stress and burnout. While it focused on the patient safety challenges that have been posed by the pandemic, it does however highlight some positive developments for patient safety relating to changes to care and treatment during this period: The focus on fighting Covid-19 has in some cases functioned as a stimulus to breaking down barriers between individuals and institutions delivering health and social care, encouraging more information sharing and collaborative working. We have seen the rapid development of new means to combat the virus, such as vaccines, diagnostics, and therapeutics. New positive healthcare innovations and changes to service delivery have emerged in response to pandemic, such as the communication tool CARDMEDIC.[3] There has been an increased public awareness of the importance of mental health and caring for healthcare professionals, which is fundamentally linked to ensuring patient safety.[4] Safety risks and avoidable harm “… COVID-19 has caused a “perfect storm” in the field of patient safety, and heightened the need to have further research in the area and identify and implement initiatives that ensure safer care, especially in the context of outbreaks and emergencies.”[2] The core of this WHO report is focused on six interlinked thematic areas where it seeks to summarise the main risks and harm implications of the pandemic for patient safety: 1. Health services Under this broad heading the report groups a wide range of different patient safety issues impacting on the delivery of healthcare services, including: Increased risks of healthcare-associated infections, including Covid-19 transmission in hospitals.[5] Safety incidents relating to medication use, including those exacerbated by redeploying staff members to areas they are less familiar with and the absence of family members and carers to provide input and knowledge of patients’ conditions. Diagnostic errors involving both patients with Covid-19 and non-Covid conditions, ranging from false negative test results to diagnosis errors because of system strain. Disruption to non-Covid care, treatment and diagnostic services. 2. Health and safety of health workers This theme covers a number of staff safety issues that impact on their ability to deliver safe care, such as exposure and risk of Covid infection, burnout from working in a highly pressured environment, and moral injury as a result of having to make increasingly difficult decisions about prioritising the case for seriously ill patients.[6] 3. Patients, families and communities, including inequities This heading groups together a larger number of issues that broadly concern patients, including: The pandemic both exposing and exacerbating existing health inequalities and gaps in health outcomes.[7] Impact of the pandemic on people living in long-term care settings. Patient safety issues here range from high numbers of potentially preventable deaths in care homes to the impact of prolonged periods of isolation with limited visits by friends and family members. Restrictions on visitation policies more broadly, concerning both the psychological consequences for patients and the safety consequences when family members and carers are not present to potentially help identify incidents and errors. The spread and impact of Long Covid.[8] 4. Leadership, governance and financing This theme considers the wider impact of the pandemic of healthcare systems, considering the safety roles play by organisational and national leaders, gaps that have been exposed in terms of system preparedness for a pandemic, and the financial impact of this on healthcare systems and their workforces in the long-term. 5. Communication and management of health information The report notes that the rapid spread of information has been one of the hallmarks of this pandemic, which has itself posed safety challenges. In particularly it cites the risk and harm from misinformation and disinformation about Covid-19, treatments and vaccines, and the limits of health data in countries where the healthcare system itself is under resourced. 6. Development and supply chain of medical products, vaccines and technologies The final theme is concerned with the safety implications related to products and resources needed to fight the pandemic. It highlights shortages and issues in the global and local supply chain related to essential safety related medical products, such as PPE and vaccines, as examples of this. Patient Safety Learning’s reflections We were pleased to be one of the international organisations who were able to contribute to the work of this review. The nature of this type of report however means inevitably there will always be gaps or areas that could potentially have been covered in more depth. Below we highlight three of note: Long Covid and its safety implications Millions of people across the world are living with Long Covid, a term created by patients to describe the prolonged, fluctuating symptoms following Covid-19. This WHO review does briefly refer to this under the heading ‘Post-Covid-19 condition’ however we believe this could be significantly expanded upon to include a range of safety issues encountered by people living with this condition, including: Inconsistent care and contradicting advice. Public health messaging not reflecting of the risks associated with Long Covid. How people living with Long Covid should be communicated and engaged with. Knowledge gaps among healthcare professionals on the nature of Long Covid and good practice in diagnosis and treatment. Patient safety reporting during the pandemic Another area this report also touches on, where we believe further research is needed, concerns the disruption of routine patient safety activities during the pandemic, in particular patient safety incident reporting. In our view, this area requires a much more detailed review as healthcare systems still have a limited understanding of the impact on avoidable harm. We cannot clearly say whether there has been an increase in avoidable harm in this period. At the height of Covid infections, many healthcare systems de-prioritised reporting of incidents of unsafe care, redirecting staff time to clinical care and other pandemic related activities. On paper this has resulted in a reduction in reports of unsafe care, most likely to be because of reductions in reporting.[9] Most of our existing estimates of levels of avoidable harm in health and social care still pre-date the pandemic. With less reporting and fewer investigations taking place during this period, we are less knowledgeable about the scale and causes of avoidable harm. Without this knowledge and insight, health systems are going to be compromised in their understanding and less able to respond to with appropriate and targeted action. Ongoing disruption and recovery of non-Covid care and treatment Understandably much of the focus of this review is on the impact of the Covid-19 pandemic on patient safety at the height of infection levels. In this context it does consider in some detail the safety implications of the disruption to non-Covid care, treatment and diagnostic services. We believe that in considering the implications of the Covid-19 pandemic on patient safety, there is a compelling case for further work being required looking at the long-term impact of the disruption it has caused to healthcare systems and its ongoing impact. This includes, but is not limited to: Safety challenges in prioritising and reducing backlogs in care and treatment. Long-term needs of patients who have significantly deteriorated while waiting for care and treatment. Managing these challenges in the face of global healthcare workforce shortages. Turning insights into action “Significant opportunities lie ahead for patient safety improvement in the context of the pandemic. Many instances of risks and avoidable harm identified in this rapid review are still ongoing and if unaddressed are likely to prevail again no matter what pathogen the next pandemic will involve.”[2] Towards the end of this review, WHO identify a number of potential opportunities and activities to build on lessons learned from the pandemic. Below we highlight several actions they identify which we believe all countries should be actively reviewing and considering how they can be applied to their healthcare systems: The report highlights numerous safety risks, varying from adequate infection and prevention control measures to overburdened workforces. There needs to be additional research and action in each of these areas on a country-by-country basis. More work is needed to identify best practices and lessons learned from this period, which can help to inform future interventions and contribute to building safer and more resilient health systems. Healthcare systems should seek to build on successful advances in areas such as digital innovation, increasing transparency, open and frequent bidirectional communication, data sharing, collaboration, and teamwork with the breakdown of traditional silos, and the rapid adoption of selected patient safety practices. There should be a concerted effort to develop protections for the health, safety and well-being of healthcare professionals. These should be aligned with patient safety, infection prevention and control, and other health workforce programmes. There is an opportunity to embed patient safety in design and development of health care systems, products and processes. Further work should be undertaken to employ multidisciplinary approaches to patient safety, which could yield lessons to inform the development and implementation of patient safety strategies and innovations for a safer healthcare systems. Health systems need to be better prepared for unexpected and emerging threats and seek to address current structural inequities. While the above points are taken from this report, they are not constituted as formal recommendations. The main thrust toward the end of this review is to point towards the recently developed WHO Global Patient Safety Action Plan 2021-2030 as providing a comprehensive framework to address the safety gaps identified in this report.[10] We believe there would be value in the WHO inviting all countries and healthcare systems to reflect on the findings of this review and formally consider the implications of Covid-19 on their health system. They could then report back on their assessment and the improve actions they aim to deliver, in the context of the Global Patient Safety Action Plan, enabling the WHO to collate and assess this to take forward learning and action in a collective global drive to reduce avoidable harm. References 1. Patient Safety Learning, Covid-19 – the ongoing impact of the pandemic on patient and staff safety, 14 December 2021. 2. WHO, Implications of the COVID-19 pandemic for patient safety: A rapid review, 5 August 2022. 3. Rachael Grimaldi, The story behind CARDMEDIC, Patient Safety Learning’s the hub, 28 May 2020. 4. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020. 5. Healthcare Safety Investigation Branch, COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation, 29 October 2020. 6. Suzanne Shale, Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it, 17 July 2020. 7. NHS Confederation, The unequal impact of COVID-19: investigating the effect on people with certain protected characteristics, 15 June 2022. 8. Patient Safety Learning, Long Covid: Information gaps and the safety implications, 7 June 2021. 9. Shawn Kepner and Rebecca Jones, 2020 Pennsylvania patient safety reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. Patient Saf. 2021; 3(2): 6-21. 10. WHO, Global Patient Safety Action Plan 2021-2030, 3 August 2021.
  7. Content Article
    Key points Corporate governance is the means by which boards lead and direct their organisations so that decision-making is effective, risk is managed and the right outcomes are delivered. In the NHS this means delivering safe, effective services in a caring and compassionate environment while collaborating through system and place-based partnerships and provider collaboratives to integrate care. Best practice is detailed in the following sections: Board leadership and purpose, Division of responsibilities, Composition, succession and evaluation, Audit, risk, and internal control, and Remuneration. Action required Trusts must comply with each of the provisions of the code or, where appropriate, explain in each case why the trust has departed from the code.
  8. Event
    This day will explore what clinical governance means for frontline clinicians. Based on experiential learning techniques, drawing on live case studies and shared experiences of the participants, it looks at the challenges that colleagues working in healthcare settings encounter as part of their journey into patient safety and overall clinical governance and what needs to happen to the system safer for the staff and the patients. Working in partnership, this day draws on expertise from the healthcare leaders and front line clinicians from BAPIO. It is grounded in principles of clinical governance which will be brought to life by the diverse experience and skills of the delivery team. The conference is open to anyone working in a health care setting who is involved in leadership role or providing care to patients. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/reinvigorating-clinical-governance or email kerry@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #ClinGov
  9. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published and which is being tested in early adopter sites. NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email kate@hc-uk.org.uk Follow on Twitter @HCUK_Clare #NHSSeriousIncidents hub members can receive a 20% discount. Email info@pslhub.org discount code.
  10. Event
    This Royal Society of Medicine meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths. The role of Medical Examiners and how they will impact on primary care. The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary. The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety. Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement. Book here
  11. Content Article
    This review was carried out in response to the very low numbers of investigations or reviews of deaths at Southern Health NHS Foundation Trust. Over a four-year period, fewer than 1% of deaths in Southern Health’s learning disability services and 0.3% of deaths in their mental health services for older people were investigated as a serious incident requiring investigation. Throughout this review, families and carers have told the CQC that they often have a poor experience of investigations and are not always treated with kindness, respect and honesty. This was particularly the case for families and carers of people with a mental health problem or learning disability. However, there is currently no single framework for NHS trusts that sets out what they need to do to maximise the learning from deaths that may be the result of problems in care. This means that there are a range of systems and processes in place, and that practice varies widely across providers. As a result, learning from deaths is not being given enough consideration in the NHS and opportunities to improve care for future patients are being missed. This reports sets out the next steps.