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Found 31 results
  1. News Article
    NHS board members must speak up against discrimination, challenge others constructively and help foster a safe culture, under a new NHS England assessment framework. The new leadership competency framework, published today, sets out six domains which board members are required to assess themselves against as part of an annual “fitness” appraisal. Each domain (see below) contains competencies directors must exhibit, such as: Speak up against any form of racism, discrimination, bullying, aggression, sexual misconduct or violence, even when [they] might be the only voice; Challenge constructively, speaking up when [they] see actions and behaviours which are inappropriate and lead to staff or people using services feeling unsafe, or staff or people being excluded in any way or treated unfairly; and Ensure there is a safe culture of speaking up for [their] workforce. Each competency statement gives board members a multiple choice to assess themselves against, ranging from “almost always” to “no chance to demonstrate”. Organisations have been told to incorporate the six competency domains into role descriptions from 1 April, and use them as part of board member appraisals. Read full story (paywalled) Source: HSJ, 28 February 2024
  2. Content Article
    This framework is for chairs, chief executives and all board members in NHS systems and providers, as well as serving as a guide for aspiring leaders of the future. It is designed to: support the appointment of diverse, skilled and proficient leaders support the delivery of high-quality, equitable care and the best outcomes for patients, service users, communities and our workforce help organisations to develop and appraise all board members support individual board members to self-assess against the six competency domains and identify development needs.
  3. News Article
    NHS England has announced the first details of its ‘Leadership Competency Framework’, and revealed it will be launched this September. The LCF will underpin the annual appraisal of NHS board directors and, in turn, adherence to the revamped Fit and Proper Person Test. NHSE also revealed that leaders, including senior clinicians, who hold “significant roles” but are not board members may be subject to the FPPT in the near future. The new FPPT framework said the LCF would contain “six competency domains which should be incorporated into all senior leader job descriptions and recruitment processes”. Read full story Source: HSJ, 3 August 2023
  4. Content Article
    The Fit and Proper Person Test (FPPT) Framework has been developed by NHS England in response to recommendations made by Tom Kark KC in his 2019 review of the FPPT (the Kark Revew). This framework introduces a means of retaining information relating to testing the requirements of the FPPT for individual directors, a set of standard competencies for all board directors, a new way of completing references with additional content whenever a director leaves an NHS board, and extension of the applicability to some other organisations, including NHS England and the CQC. It will help prevent directors who have been involved in or enabled serious misconduct or mismanagement from joining a new NHS organisation.
  5. Content Article
    Successful day surgery requires a day surgery team with the correct knowledge and skills to enable safe, early recovery and discharge but there is an absence of national guidance on supporting competencies. Applying in-patient competency criteria is inappropriate as this pathway is not aimed at promoting early discharge. This joint publication between AfPP and BADS (the British Association Of Day Surgery) provides recommendations for core competencies for adult day surgery through (1) admission, (2) anaesthetic room, (3) theatres, (4) first-stage recovery and (5) second-stage recovery and discharge. They are relevant for staff new to or after a long absence from day surgery and acknowledge some members of the day surgery team may include non-registered practitioners. All can be used as a reference for workbook competency documents in place or in development.
  6. Content Article
    In July 2018, the then Minister of State for Health, Stephen Barclay MP, commissioned Tom Kark QC to write a report and to make recommendations in relation to the fit and proper person test (FPPT) as it applied under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Tom Kark QC review of the fit and proper person test (the Kark review) was published in February 2019 and made seven recommendations on how to improve the operation and effectiveness of Regulation 5.
  7. Content Article
    An independent review of how effectively the test prevents unsuitable staff from being redeployed or re-employed in health and social care settings.
  8. Content Article
    This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics
  9. Content Article
    The purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.
  10. News Article
    A residential care home failed to notify the health watchdog about the deaths of people they were providing a service to, its report has found. Kingdom House, in Norton Fitzwarren, run by Butterfields Home Services, was rated "requires improvement". The home cares for people with conditions such as autism. The Care Quality Commission (CQC) said the registered manager and provider lacked knowledge of regulations and how to meet them. Inspectors found the provider failed to notify the CQC about the deaths of people which occurred in the home, as required by Regulation 16 of the Health and Social Care Act 2008. The report also found people were at "increased risk" because the provider had not ensured staff had the qualifications, competence, skills and experience to provide people with safe care and treatment. Inspectors did, however, praise the "positive culture" at the home, that is "person-centred", and noted the provider was "passionate about their service and the people they cared for". Read full story Source: BBC News, 2 January 2020
  11. News Article
    Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training. The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017. In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital. Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered. Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”. She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication." Read full story Source: The Independent, 18 December 2019
  12. News Article
    A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand. When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise. In this article in The Independent, Patient Safety Learning's Trustee Alison Leary discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce. Read full story Source: The Independent, 15 December 2019
  13. Content Article
    People in Place highlights the fundamental skills and people issues which will determine the future of health and care in the UK. The Covid-19 pandemic has made these issues clearer and more pressing, but it has also revealed an appetite for change and resulted in innovative ways of working. This report argues that building effective collective leadership into systems and places is vital to overcome staffing and governance issues in the NHS. Focusing on building long-term frameworks for change rather than responding to immediate pressures, it suggests practical tools and resources that could be used to bring about transformation within the system.
  14. Content Article
    Robbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's  case.
  15. Content Article
    This education and training guide is a resource for every Guardian’s self-development, whatever their experience in the role. Commissioned by the National Guardian’s Office and Health Education England in August 2017, the Guide was compiled by Louisa Hardman from the NHS Leadership Academy with invaluable contributions and guidance from an Advisory Group comprising Freedom to Speak Up Guardians and members of the National Guardian’s Office.
  16. Content Article
    With the widespread adoption of electronic health records (EHRs), there is an increased focus on addressing the challenges of EHR usability; that is, the extent to which the technology enables users to achieve their goals effectively, efficiently, and satisfactorily. Poor usability is associated with clinician job dissatisfaction and burnout and could have patient safety consequences. Using EHR surveillance data collected by the ONC, researchers from the MedStar Health National Center for Human Factors analysed over 350 reports regarding EHR issues that violated the federal certification programme. They found that roughly 40% of ONC-certified EHRs had the potential for patient harm.
  17. Content Article
    Team-targeted rudeness may underlie performance deficiencies, with individuals exposed to rude behaviour being less helpful and cooperative. The objective of this paper, published by The Official Journal of the American Academy of Pediatrics, was to explore the impact of rudeness on the performance of medical teams. In conclusion,  rudeness had adverse consequences on the diagnostic and procedural performance of the neonatal intensive care team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
  18. Content Article
    This guidance is issued by the Health and Safety Executive, the Institution of Engineering Technology and the British Computer Society. Following the guidance is not compulsory but if you do follow the guidance you will normally be doing enough to comply with the law in Great Britain where this is regulated by the Health and Safety Executive (HSE). HSE inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.
  19. Content Article
    This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.
  20. Content Article
    This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the Royal College of Nursing (RCN) make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. 
  21. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
  22. Content Article
    In this commentary, I reflect on how we may all suffer from some degree of professional complacency. Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities and, thus, the risks we bring into the healthcare environment.
  23. Content Article
    What patient safety beliefs get in the way of preventing harm? In this video, the Institute for Healthcare Improvement's (IHI) Frank Federico lists some common misunderstandings, including the tendency to think of the Institute of Medicine’s six quality aims for improvement in silos.
  24. Content Article
    Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare in the world.” CPSI’s mission is: “to inspire and advance a culture committed to sustained improvement for safer healthcare.” CPSI develops system-wide strategies to ensure safe healthcare in two ways: by demonstrating what works to improve safe care in Canada, and by strengthening commitment to patient safety priorities among all healthcare stakeholders. It has, however, become clear that not only are more robust commitments required to advance patient safety in Canada, but health systems need additional evidence and support to complete end-to-end patient safety improvements and to measure and sustain results. To this end, CPSI drafted the Strengthening Commitment for Improvement Together: A Policy Framework for Patient Safety to stimulate conversation and action on the following policy levers: legislation, regulations, standards, organizational policies and public engagement.
  25. Content Article
    Safety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programmes will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support this, Bowie et al. in this article published in Medical Teacher offer professional guidance as “tips” for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.
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