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Found 68 results
  1. Content Article
    In March 2020, the pandemic hit. They needed to take the approach online and find an engaging way to keep the conversations going, whilst maintaining the quality and integrity of the Whose Shoes? approach which is known for promoting energy and action, tapping into passion for quality improvement. How could the best ideas emerging during the pandemic, be nurtured and grown? This report Keeping the conversations alive during the pandemic to build the future of health and social care looks at how they have managed to maintain the momentum of their work at such an important but challenging time.
  2. Event
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, will be joined by a multidisciplinary group of patient advocacy experts and clinicians to understand the various meanings of the term 'patient advocacy' and to evaluate how an empowered patient can improve healthcare delivery, experience, and outcomes for all involved. The group will discuss the history and current state of patient advocacy, and will propose recommendations regarding the extent to which various healthcare disciplines and patients and their families can improve patient advocacy. Register
  3. Content Article
    Video 1: Gill explains her background and how she came to develop Whose Shoes Video 2: Gill explains how Whose Shoes was inspired by hearing about the person-centred approach to healthcare Video 3: Gill discusses the different groups that have been involved in Whose Shoes workshops and what impact it's had on them Video 4: Gill talks about future plans for Whose Shoes, as well as her virtual Whose Shoes workshops
  4. Content Article
    In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback. The WHO Global Patient Safety Action Plan Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6] We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles: Treat patients and families as partners in safe care. Achieve results through collaborative working. Analyse data and experiences to generate learning. Translate evidence into measurable improvement. Base policies and action on the nature of the care setting. Use both scientific expertise and stories of care to educate and advocate. These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7] The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders. Tackling the implementation gap and sharing learning A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8] There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere. At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety. Building high reliability health systems and organisations The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9] We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives. We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes. Working with partners to bring about change The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners: Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11] Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise. International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list. How do we create a global patient safety movement? Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety. In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3] How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change. References 1. WHO, World Health Assembly Update, 25 May 2019. 2. WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020. 3. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020. 4. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020. 5. WHO, Patient Safety Fact File, September 2019. 6. National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018. 7. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. 8. Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016. 9. Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019. 10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020. 11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020.
  5. Content Article
    The ACT-Accelerator is organized into four pillars of work: diagnostics, treatment, vaccines and health system strengthening. Each pillar is vital to the overall effort and involves innovation and collaboration. Dr Jake Suett from the UK, has been selected as a community and civil society representative on the WHO ACT-accelerator diagnostics pillar. You can hear more about Jake's own experience of Long Covid on the hub. To read more about the Access to COVID-19 Tools (ACT) Accelerator, follow the link below.
  6. News Article
    A key player in the junior doctor disputes with Jeremy Hunt has now joined the former health secretary’s patient safety charity. Jeeves Wijesuriya, former chair of the British Medical Association’s junior doctors committee, is among the nine people who will serve on the advisory board of the Patient Safety Watch charity. Mr Hunt has also announced that Sir Robert Francis, who led the Mid Staffs inquiry; England’s former chief medical officer Dame Sally Davies; former medical director of the NHS, Sir Bruce Keogh; and Dame Marianne Griffiths, chief executive of Western Sussex Hospitals Foundation Trust, will also serve on the advisory board. Mr Hunt announced Patient Safety Watch last year to establish data to report on levels of patient safety and avoidable harm in healthcare, and commission research from leading universities. He has previously said he will invest hundreds of thousands of pounds in the charity over several years. He told HSJ: “Patient safety has moved massively up the agenda because of the issue of nosocomial infections that have affected both staff and patients during covid." “This high powered advisory board will help Patient Safety Watch make measured but decisive interventions so that we get better at learning from what inevitably goes wrong - not just in a pandemic but in normal times as well.” Read full story Source: HSJ, 8 October 2020
  7. Event
    At THIS Space, we welcome researchers, patients, carers, NHS staff and anyone with an interest in the evidence base for improving the quality and safety of healthcare. THIS Space 2020 event will take place entirely online and create an opportunity for people interested in the study of healthcare improvement to gather, connect, and share ideas remotely. THIS Space aims to: provide a focus for knowledge sharing in healthcare improvement stimulate innovation and fresh thinking help researchers to develop the habits, knowledge, skills, and experiences to support their professional growth connect colleagues from across different disciplines who share a common goal be a means of accelerating the development of the field of the study of healthcare. Plenary sessions: Professor Bob Wachter will explore an international perspective on the legacy of COVID-19 in healthcare improvement and research. Professor Ramani Moonesinghe will discuss the impacts of rapid innovations in healthcare. Dr Victoria Brazil will examine the role of simulation in healthcare improvement studies. Registration
  8. Content Article
    A sequential qualitative method study was conducted and integrated with the quantitative study performed by Matos, Weits, and van Hunsel to complete a mixed method study. The qualitative phase expands the understanding of the quantitative results from a previous study by broadening the knowledge on external barriers and internal barriers that patient organizations face when implementing PV activities. The strategies to stimulate patient-organisation participation are the creation of more awareness campaigns, more research that creates awareness, education for patient organisations, communication of real PV examples, creation of a targeted PV system, creation of a PV communication network that provides feedback to patients, improvement of understanding of all stakeholders, and a more proactive approach from national competent authorities. Both study phases show congruent results regarding patients’ involvement and the activities patient organisations perform to promote drug safety. Patient organisations progressively position themselves as stakeholders in PV, carrying out many activities that stimulate awareness and participation of their members in drug safety, but still face internal and external barriers that can hamper their involvement.
  9. Content Article
    Seven features of safety in maternity units 1. Commitment to safety and improvement at all levels, with everyone involved 2. Technical competence, supported by formal training and informal learning 3. Teamwork, cooperation, and positive working relationships 4. Constant reinforcing of safe, ethical, and respectful behaviours 5. Multiple problem-sensing systems, used as basis of action 6. Systems and processes designed for safety, and regularly reviewed and optimised 7. Effective coordination and ability to mobilise quickly
  10. News Article
    The NHS has announced that Dr Hilary Cass OBE, former President of the Royal College of Paediatrics and Child Health, will lead an independent review into gender identity services for children and young people. The review will be wide-ranging in scope looking into several aspects of gender identity services, with a focus on how care can be improved for children and young people including key aspects of care such as how and when they are referred to specialist services, and clinical decisions around how doctors and healthcare professionals support and care for patients with gender dysphoria. It will also set out workforce recommendations for specialist healthcare professionals and examine the recent rise in the number of children seeking treatment. Dr Cass will then make clear recommendations for children and young people’s gender identity services reporting back next year. The Gender Identity Development Service for Children and Adolescents is managed by the Tavistock and Portman NHS Foundation Trust. The Care Quality Commission (CQC) is due to carry out a focused inspection of The Tavistock and Portman NHS Foundation Trust, Gender Identity Services for children and young people, during the autumn. The inspection will cover parts of the safe, effective, caring, responsive and well-led key questions and will include feedback from people using the service, parents, relatives, carers, and staff. Separately, Dr Cass will also review the service’s clinical practice with the support of the Royal College of Paediatrics and Child Health and engagement of other professional bodies to provide multi-professional insight working closely with the CQC. The review includes an examination of the issues surrounding children and young people who are prescribed puberty blocking and cross sex hormone drugs. Dr Hilary Cass OBE, independent chair, said: “It is absolutely right that children and young people, who may be dealing with a complexity of issues around their gender identity, get the best possible support and expertise throughout their care.” “This will be an inclusive process in which everyone will have the opportunity to make their views known. In particular I am looking forward to hearing from young people and their families to understand their experiences. “This review provides an opportunity to explore the most appropriate treatment and services required.” Read full story Source: NHS England, 22 September 2020
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