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Found 36 results
  1. Content Article
    Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must: tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong apologise to the patient (or, where appropriate, the patient’s advocate, carer or family) offer an appropriate remedy or support to put matters right (if possible) explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened. Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns
  2. Content Article
    Over the past ten years, I have helped dozens of organisations in the NHS, higher education and in corporate contexts start using AAR to improve the quality of learning after events. Yet despite the proven value of AAR to patient safety and team performance,1 AAR has still not made the impact it can and should. This short article explains some of the barriers to implementation that I have encountered during this time so that you can mitigate for them in your own context. In 2009, I joined a team at University College London Hospitals (UCLH) that had adapted the AAR concept from the military for use in the NHS. AAR provides a deceptively simple vehicle to structure healthy blame-free team interactions and the aim was to improve patient safety, clinical practice and team behaviours.2 The AAR approach has since become business as usual at UCLH where it is now widely understood and frequently used. What my colleagues at UCLH recognised so well is that AAR is so much more than the four questions you get when you type After Action Review into a search engine3 and, thus, designed the introduction of the approach with this in mind. A paper in the Harvard Business Review4 describes why AAR has so often failed in the corporate environment and this gives useful insights, but I have witnessed three particular challenges in the healthcare setting. 1. Fear The organisational and psychological barriers to being able to talk honestly about errors in multi-professional teams are accentuated by the hierarchical nature of the clinical context. Put simply, this means, despite everyone’s best intention to learn from a near-miss or an unexpected event, there will be fear about being fully open in front of those more senior or junior and those from other disciplines. If we are being really honest with ourselves, we know this to be true. Fear of what others think about what we have done, and whether it will affect our standing in some way, is a universal human trait which is increased when the boss is in the room. This fear is in direct tension with the AAR concept of openness and cross-disciplinary learning and will act as a barrier to calling AARs unless leaders act as role models in AARs and set the scene by being honest and open themselves. 2. Blame The emotive nature of clinical care heightens the response when things go wrong meaning the tendency to find something or someone to blame is increased. Not only do we have institutional demands pressing hard for straightforward answers, meaning we look for something obvious to blame, we also have our own human reaction to distance our self from responsibility. This traditional reaction again lies in direct tension with the very idea of AAR, where the process is not to blame but to learn. The research is clear, that in this most complex of operating environments there is rarely a single point of failure or a single individual who is to blame, instead there are multiple causes and effects, which ,when better understood, provide a firm place from which to make effective changes. 3. Responsibility The concept of clinical professionalism is centred around the individual’s’ responsibility to deliver safe effective care and it is rooted in the very foundations of how the NHS was created. Clinicians are raised in the belief that they should know the answers to problems and the whole structure of career progression is based around acquiring more knowledge, research papers and letters after your name. AAR is a process of learning as a group and taking responsibility together to find out how to improve, so it is not surprising that it sits in tension with the historical emphasis on the individual healthcare professional and the value of their existing knowledge. AARs allow for the creation of new knowledge through a collaborative process. The joint guidance from the General Medical Council (GMC) and Nursing & Midwifery Council (NMC) on the professional duty of candour states: “Clinical leaders should actively foster a culture of learning and improvement.”5 AAR is one of the best mechanisms to both foster and drive a culture of learning and improvement, but the simplicity of the AAR process itself should not blind you to the need to be very considered in how you mitigate and manage the barriers in a clinical setting. If you would like to discuss AARs further, I'd love to hear from you. Contact me at: judy.walker@its-leadership.co.uk References 1. Tannenbaum SI, Cerasoli CP.  Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors 2013;55(1):231-45. .2. Walker J, Andrews S, Grewcock D, Halligan A. Life in the slow lane: making hospitals safer, slowly but surely. J R Soc Med 2012;105(7):283-7. doi: 10.1258/jrsm.2012.120093. 3. NHS Improvement. Online library of Quality, Service Improvement and Redesign tools: After Action Review. 4. Darling M, Parry C, Moore J. Learning in the Thick of It. Harvard Business Review: July-August 2005 issue. 5. Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour. June 2015. Read Judy's previous blog: How can After Action Reviews improve patient safety?
  3. Content Article
    PIDA provides a remedy for a worker who suffers a detriment or any form of retribution as a result of their whistleblowing, provided that: the information is a protected disclosure. it is made in good faith. the worker reasonably believes that information, and any allegations contained in it, are substantially true. making the disclosure does not involve the worker committing a criminal offence.
  4. Content Article
    Attached is a presentation (December 2019) by Andrew Pepper-Parsons, Head of Policy at Protect. The presentation outlines Protect's Better Regulators Campaign. The objectives of the campaign are to: start to create a more consistent approach in how whistleblowers are interacted with set and shape the standards expected from internal whistleblowing processes start a dialogue between the regulators themselves and with Protect.
  5. Content Article
    In this guidance, the term ‘worker’ refers to a person who is directly employed by the provider, an agency worker, someone who is in training with them or who provides services to them. It explains: the CQC whistleblowing why you should have a whistleblowing policy the protection the law gives to workers who raise concerns the benefits of encouraging workers to raise concerns what the CQC will do when we receive information from a whistleblower.
  6. Content Article
    I was once working in a private operating theatre where, to my horror, the surgeon accidentally dropped an instrument on the floor, picked it up and reused it without it going through a steriliser. In my 30 years of working as a theatre nurse, I had never seen anything like this. I felt sick to my stomach! Is this what happens in private hospitals? I reported it immediately to the senior staff on duty and also the theatre manager. I also sent through a report at the end of the case. Nothing happened, except my shifts were blocked for reporting the incident . I no longer work in that hospital. I feel hurt. My mental health has also suffered as I feel tortured. I question myself. Did I do the right thing by reporting it? Because now I do not have a job and I am using my savings to survive. If I was a permanent member of staff, I would still be working. Is this why staff do not report incidents? For fear of losing their jobs? What about the safety of the patient? I tried calling to speak to anyone who would listen. I did not have any luck – I found all avenues were blocked. There was no Speak Up Guardians in post. I feel I did the right thing by reporting it, but I was not supported by management. Where is the system in private hospitals to protect locum theatre staff? Why is this allowed to go on? In theatres, we are the patient's advocate. We are only there to ensure the patient is safe at all times. Would I do things differently if it happens again, now that I know the consequences? Yes! Absolutely 100%. I will continue to speak up and send through a report. What will you do?
  7. Community Post
    Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going gets tough. Be clear about what help you might need from outside of the team, and follow it up. When looking at your Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public. Too many times I see Ward Assurance results on ward corridors, for the attention of patients and families, written in 'NHS speak' ! When measuring your compliance with the Duty of Candour, don't just look at the numbers! Find a way that also establishes how families feel about the 'quality' of the response, i.e. was it open, honest and transparent and did it give what they needed. How do you think these tips could benefit your patients or service users? Have you tried anything similar that you've found has really helped? Let us know your thoughts and please feedback if you try any of them.
  8. Content Article
    This report is not exclusive to the NHS, they set out recommendations for all industries. In this report, the APPG sets out its findings as follows: The UK regulatory framework of whistleblower protection is complicated, overly legalistic, cumbersome, obsolete and fragmented. The remedies provided by PIDA are mainly retrospective and largely not understood. A general obligation for public and private organisations to set up whistleblowing mechanisms and protections is missing. The definition of whistleblowing and whistleblowers is too narrow. Consequently, the protections set by the law apply only to a limited number of citizens and do not properly reflect existing working practice or protect the public. As a result of the excessive complexity and fragmentation of the regulatory frame work, there is little public knowledge or understanding of the existing legal protections for whistleblowers. That policy and procedure, while looking good on paper, bears no resemblance to actual practice. There is a disconnect between what is understood to be and what is the role of the prescribed persons leading to confusion, mistrust on both sides and allowing crimes and other wrongdoing to escape scrutiny. The cost of litigation is too great for most citizens and this is known and exploited by employers.
  9. Content Article
    Guidance for NHS trust and NHS foundation trust boards on Freedom to Speak Up Freedom to Speak Up supplementary information Freedom to Speak Up self-review tool
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