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Showing results for tags 'Evaluation'.
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Content ArticleThis evidence review aims to examine what it feels like to experience ‘well-led’ health and/or care services and organisations, from the perspectives of people with lived experience and people working in health and social care. It is an extension to ‘Making it Real’ - a framework and set of statements co-produced by Think Local Act Personal (TLAP) and the Care Quality Commission (CQC) that describe what good, co-ordinated and personalised care and support look like from the perspective of people drawing on it.
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News ArticleMore than 500 people have received potentially life-saving care thanks to Martha’s rule, which gives hospital patients the right to seek a second opinion about their health. They were moved to intensive care or a specialist unit after they, a loved one or a member of NHS staff triggered the patient safety mechanism, which the NHS in England began using in 2024. Martha’s rule lets patients, relatives and staff call a helpline run by the hospital if they are worried about the person’s condition or treatment and ask for a “rapid review” of their care. In the 18 months between September 2024 and February 2026, a total of 524 adults and children about whom concerns had been raised were moved to an intensive care or high-dependency unit, a specialist hospital or a specialist ward at the hospital where they were already an inpatient. Wes Streeting, the health secretary, said the figures proved that Martha’s rule is “already having a life-saving impact”. It has been widely hailed as a major advance in patient safety. Martha’s rule is named after Martha Mills, who died aged 13 in 2021 after her family’s concerns that she was deteriorating went unheeded by staff at King’s College hospital in London. NHS England’s latest data on how Martha’s rule is operating shows that 12,301 calls were made to Martha’s rule helplines during those 18 months. About one in three – 4,047 – helped to identify a patient whose health was getting worse. Three-quarters of them (2,967) were made either by a patient and their carer or by the patient themselves. Hospital staff made the other 1,080. Read full story Source: The Guardian, 1 May 2026 Further reading on the hub: Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026
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Content ArticleIn June 2024, Martha’s Rule was introduced into 143 NHS Trusts. This rule allows patients, families and staff to quickly request an urgent review from an independent medical team if they’re worried a patient is worsening and feel their concerns aren’t being heard. It also requires hospitals to regularly check in with patients and families about how the patient is doing. This interim report presents findings from an independent evaluation of Martha's Rule carried out between November 2024 and February 2026. This was undertaken by the patient safety arm of the National Institute for Health and Care Research (NIHR) Policy Research Unit in Quality, Safety and Outcomes for Health and Social Care to understand how the first rollout of Martha’s Rule is working for patients, families and healthcare staff. It draws on a prospective in depth case study across three hospital trust pilot sites, involving observations, interviews and documentary analysis, accompanied by a systematic review of literature and a public awareness survey, which was conducted in collaboration with Picker. Key learning points highlighted by this report include: To date, one in three people (public, patient and family) are aware of Martha's Rule, and some minoritised groups face additional barriers to understanding. Patients, families, and staff value Martha's Rule for its ability to amplify their voices, facilitate open communication, promote collaborative care and improve escalation pathway between ward and critical care outreach teams. Patients and families lack clear information about the purpose of the structured wellness question and its role in their care. There is variation in the way in which the wellness question is being operationalised, with a shift to informal ways of asking and inconsistencies in recording patient and family voice. Awareness appears limited amongst some staff groups, particularly medical and specialist teams and transient staff. Callers to the helpline are seeking clearer information about ongoing care and support after escalating concerns. There may be barriers for some groups - those most in need may be least able to access Martha's Rule; these are not limited to those with protected characteristics. Not all trusts/wards/teams are 'equal' - differences in responding team (critical care outreach) and ward cultures (and priorities), as well as staff attitudes and delivery models, can influence the adoption of Martha's Rule and ultimately, patient, family and staff involvement in the identification of deterioration. Implementation has placed additional demands on critical care outreach staff, who are routinely tasked with managing escalations of deteriorating patients. This has raised concerns about responding to general concerns via the helpline leading to emotional burden, delayed responses and potential compromises in care for other critically ill patients. Related reading Embedding Martha's Rule into practice—Lessons from the national pilot Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026) Martha's Rule: Jo and Anna share their patient experience of Martha’s Rule (NHS England, 31 March 2026)
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EventuntilThis webinar from GovConnect will look at: Developing a successful Virtual Ward CUH Virtual Ward @ home (Cambridge University Hospitals) Challenges CUH faced and why they implemented Virtual Wards The journey so far and working with stakeholders What equipment is needed? Platform/technology selection Daily management: referral, on-boarding, care plan Performance and pathways Patient experience Challenges and obstacles Next steps Agenda Welcome and introduction with moderator Dr Iain Goodhart Developing a Virtual Ward @ home with Gemma Czech, Clinical Nurse Lead for Virtual Wards at Cambridge University Hospitals NHS Foundation Trust Outcomes, performance and next steps for CUH Virtual Ward @ home with Andy Bailey, Operations Manager Virtual Wards, Cambridge University Hospitals NHS Foundation Trust will cover how Interactive panel discussion Register for the webinar
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Content ArticleThe Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 aimed to: minimise burdens on public, independent and third sector employers and ensure businesses in UK are not placed at competitive disadvantage relative to EU counterparts offer good standards of protection to healthcare workers from risk of sharps injury at work see a fall in sharps injury numbers. This post implementation review (PIR) aimed to assess the success of these objectives. It found that: stakeholder consultation provided evidence of the increasing use of safer sharps across all healthcare sectors. evidence from RCN research and HSE inspections indicates that risks to healthcare workers from sharps injuries remains high. The policy conclusion from this evidence is that the Regulations are still required, and that the Regulations’ objectives cannot be met with a system that imposes less burden to business.
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Content ArticleInconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. The Safer Tracheostomy Care in Adults bundle was a programme of 18 interventions implemented across 20 hospitals in England between August 2016 and January 2018. These interventions were designed to improve the quality and safety of care for patients who have had tracheostomies. This evaluation report outlines why the interventions were needed and assesses their impact, including an estimated reduction in total hospital length of stay per tracheostomy admission of 33.02 days, corresponding to a potential reduction of over £27,000 per admission. Hospitals that implemented the Safer Tracheostomy Care initiative interventions saw improvements across a number of quality, safety and efficiency for patients who had tracheostomies, these improvements included: reduced length of stay in hospital reduced incident severity reductions in anxiety and depression. The level of these improvements varied across hospitals, as did the type of interventions implemented. The hospitals also had different characteristics and populations which they served.
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Content ArticleThe Covid-19 pandemic had an adverse impact on the detection and management of cardiovascular disease (CVD) risk factors including hypertension. In June 2022, nearly two million fewer people with hypertension were recorded as being treated to target, compared with the previous year. As a result, NHS England commissioned the AHSN Network to deliver a new national Blood Pressure Optimisation (BPO) programme building on its portfolio of work around cardiovascular disease. This report lays out: evidence about the impact of the BPO programme how it has been received by frontline staff how it has been implemented nationally.
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News ArticleThe Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
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Content ArticleThe Learning Together Evaluation framework for Patient and Public Engagement (PPE) in research is an adaptable tool which can be used to plan and to evaluate patient engagement before, during and at the end of a project. The Learning Together Framework can be used in multiple ways with the purpose of mutual learning and understanding by all partners. It is rooted in seven guiding principles of patient engagement defined by the patient-oriented research community: Relationship building Co-building Equity, diversity and inclusion Support and barrier removal Transparency Sustainability Transformation
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Content ArticleThis long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
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EventuntilHealth and care, and academic environments can have specific expectations that influence the evaluation of public involvement. These expectations may shape why the evaluation takes place and the approaches deemed ‘valid’. The hosts of this ‘Necessary Conversation’ argue that these environments and the approaches that they tend to favour, can lead to public contributors being absent from the conversation about what matters. Lynn Laidlaw leads this session with Niccola Hutchinson-Pascal and others to be confirmed. Lynn will be asking who is pushing the impact and evaluation agenda, where does the power lie, and what are the different forms of impact that exist? Sign up for this event
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News ArticleThe US Food and Drug Administration (FDA) has approved convalescent plasma for emergency use in hospital patients with COVID-19. The announcement on 23 August said that the FDA had concluded that plasma from recovered patients “may be effective” in treating the virus and that the “potential benefits of the product outweigh the known and potential risks.” The move came despite the absence of results from randomised controlled trials, with only a preprint paper on the effects on hospitalised COVID-19 patients being published to date. Experts have warned that although these early findings show promise there is not enough evidence to show that it works. Plasma from recovered patients was approved on a case by case basis by the FDA for people critically ill with COVID-19 in March. Since then more than 70 000 patients have been treated with plasma. Emergency use approval allows clinicians to use unapproved medical products to diagnose, treat, or prevent serious or life threatening diseases or conditions when there are no adequate, approved, and available alternatives. The FDA’s commissioner, Stephen Hahn, said, “I am committed to releasing safe and potentially helpful treatments for covid-19 as quickly as possible in order to save lives. We’re encouraged by the early promising data that we’ve seen about convalescent plasma. The data from studies conducted this year shows that plasma from patients who’ve recovered from covid-19 has the potential to help treat those who are suffering from the effects of getting this terrible virus.” But Martin Landray, professor of medicine and epidemiology at the University of Oxford and lead researcher for the RECOVERY trial, which is comparing treatments for COVID-19, including convalescent plasma for hospital patients, urged caution. He said, “There is a huge gap between theory and proven benefit. That is why randomised clinical trials are so important. At present, we simply don’t know if it works." Read full story Source: BMJ, 25 August 2020
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News ArticleThe Health Research Authority has launched a new strategy to ensure information about all health and social care research – including COVID-19 research - is made publicly available to benefit patients, researchers and policy makers. The COVID-19 pandemic has highlighted the importance of sharing details of research taking place - to understand the virus and find the tests, treatments and vaccines - so that results can inform best quality care and preventive measures. This also means researchers do not duplicate efforts and can build on each other’s work while the public can see what research is going on. Now the new Make it Public strategy aims to build on this good practice and make it easy for researchers to be transparent about their work. The strategy, delivered by the HRA in partnership with NHS Research Scotland (NRS), Health and Care Research Wales and Health and Social Care Northern Ireland, is about making transparency ‘the norm’ in research and making information more visible to the public. New measures set out in the strategy – will improve transparency and openness in health and social care studies, by: expecting researchers to plan how they will let research participants know about the findings of the study from the beginning introducing additional monitoring to check that researchers are reporting results and to collect information about study findings making information on individual research projects – and their transparency performance - available to the public introducing a system to consider past transparency performance when reviewing new studies for approval and in the future introducing sanctions.
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Content ArticleA glimpse of moving and powerful Rounds discussions that took place at the Massachusetts General Hospital Cancer Center and at Emerson Hospital in Concord, MA, USA
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Content ArticleFor some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia. I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care. "Many voices are not heard in British mental health care (and beyond), significant flaws are overlooked. If you are not satisfied with the status quo or just curious, follow us!" Here's a sample of some of the podcasts: Episode 33 - Basaglia's International Legacy: From Asylum to Community... review Episode 8 - Lived experience in Trieste, a mental health system without psychiatric hospitals, with Marilena and Arturo Episode 25 - Clinical Psychology vs Psychotherapy in Italy and the UK Episode 18 - The Trieste model cannot be exported to the UK because... let's unpack the main objections Episode 27 - Substance dependency, colonialism and sexism with Dr Sonia Soans (@PSYfem) Episode 26 - From the horse's mouth...patient & nurse teaching together as equals Listen to all the podcasts from link below.
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News Article
Chaos and panic': Lancet editor says NHS was left unprepared for Covid-19
Patient Safety Learning posted a news article in News
The NHS could have prevented “chaos and panic” had the system not been left wholly unprepared for the pandemic, the editor of the BMJ has said. Numerous warnings were issued but these were not heeded, Richard Horton wrote in the Lancet. He cited an example from his journal on 20 January, pointing to a global epidemic: “Preparedness plans should be readied for deployment at short notice, including securing supply chains of pharmaceuticals, personal protective equipment, hospital supplies and the necessary human resources to deal with the consequences of a global outbreak of this magnitude.” Horton wrote that the government’s Contain-Delay-Mitigate-Research plan had failed. “It failed, in part, because ministers didn’t follow WHO’s advice to ‘test, test, test’ every suspected case. They didn’t isolate and quarantine. They didn’t contact trace." “These basic principles of public health and infectious disease control were ignored, for reasons that remain opaque. The result has been chaos and panic across the NHS.” Read full story Source: Guardian, 28 March 2020 -
Content ArticleConsumer-focused digital healthcare apps are widely used for health maintenance. This scoping review from Millenson et al. examined evidence on interactive direct-to-consumer diagnostic applications and found a lack of robustness on evaluation methods.
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Content ArticleThe State of Care is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. The care that people received in 2019/20 was mostly of good quality. But while the quality of care was largely maintained compared with the previous year, there was generally no improvement overall. And in the space of a few short months since then, the pandemic has placed the severest of challenges on the whole health and care system in England. Quality of care before the pandemic The care that people received in 2019/20 was mostly of good quality However, while quality was largely maintained compared with the previous year, there was no improvement overall Before the arrival of the coronavirus pandemic, we remained concerned about a number of issues: the poorer quality of care that is harder to plan for the need for care to be delivered in a more joined-up way the continued fragility of adult social care provision the struggles of the poorest services to make any improvement significant gaps in access to good quality care, especially mental health care persistent inequalities in some aspects of care The impact of the coronavirus pandemic As the pandemic gathered pace, health and care staff across all roles and services showed resilience under unprecedented pressures and adapted quickly to work in different ways to keep people safe. In hospitals and care homes, staff worked long hours in difficult circumstances to care for people who were very sick with COVID-19 and, despite their efforts to protect people, tragically they saw many of those they cared for die. Some staff also had to deal with the loss of colleagues to COVID. A key challenge for providers has been maintaining a safe environment – managing the need to socially distance or isolate people due to COVID-19. Good infection prevention and control practice has been vital. The crisis has accelerated innovation that had previously proved difficult to mainstream, such as GP practices moving rapidly to remote consultations. The changes have proved beneficial to, and popular with, many. But many of these innovations exclude people who do not have good digital access, and some have been rushed into place during the pandemic. The pandemic has had a major impact on elective care and urgent services such as cancer and cardiac services, and there is huge pent-up demand for care and treatment that has been postponed. The pandemic is having a disproportionate effect on some groups of people, and is shining a light on existing inequality in the health and social care system. It is vital that we understand how we can use this knowledge to move towards fairer and more equitable care, where nobody’s needs go unmet. It is important that the learning and innovation that has been seen during the pandemic is used to develop health and social care for the future. New approaches to care, developed in response to the pandemic and shown to have potential, must be fully evaluated before they become established practice.
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Content Article
Airway Device Evaluation Project Team (ADEPT)
Claire Cox posted an article in Keeping patients safe
The aim of the Airway Device Evaluation Project Team (ADEPT) is to establish a process by which the airway-management community within the profession could lead a process of formal device/equipment evaluation. There is increasing number of airway management devices being introduced into clinical practice with little or no evidence of their clinical efficacy or safety. While there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (purchased). ADEPT has formulated such advice, emphasising evidence based principles and defined a minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. ADEPT advises that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. This paper, published by Anaesthesia journal, describes how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained. -
Content ArticleMindful organising is a key integrating concept in resolving the organisational accident. Mindful organising is both the unique source of critical information about the normal operation, as well as the key recipient of intelligence about the operation, ensuring that operational actions are always informed by the most current, relevant information about potential risks no matter how remote. Highlights of the paper: Principles of mindful organising are operationalised in a Mindful Governance model. The model is grounded in two cases studies in contrasting aviation organisations. The case studies led to the development of three prototype web applications.
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Content Article
How does the NHS in England work? An alternative guide (2017)
Claire Cox posted an article in Health care
This animation by The Kings fund, presents a whistle-stop tour of how the NHS works in 2017 and how it is changing. -
Content ArticleIn the light of the current national guidance to reduce the number of inpatient learning disability beds, a review was completed of the quality of lives of the people who had been former inpatients in Cornwall at the time of closure of the learning disability inpatient facilities almost 10 years before transforming care. This study highlights that people with complex concerns with a history of placement breakdowns and past institutionalisation can be settled successfully and safely in local communities. However, it is difficult for many of them to achieve a satisfactory quality of life long term. The obligation for this lies with service providers to provide adequate support to overcome that difficulty.
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Content ArticleWith 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.
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Content Article
Healthcare Safety Investigation Branch: Annual Review 2018/19
Claire Cox posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) conducts independent investigations into patient safety concerns in NHS-funded care across England. Formed in April 2017, they are funded by the Department of Health and Social Care (DHSC) and hosted by NHS Improvement , but operate independently. Overview in numbers (2018/19) 12 national investigations launched. 440 maternity referrals received. 100 safety awareness notifications submitted for national investigations. 127 investigators trained. 174 members of staff recruited. -
Content ArticleIn recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes. A scoping review was undertaken to describe the availability of evidence related to care homes’ patient safety culture, what these studies focused on, and identify any knowledge gaps within the existing literature. Included papers were each reviewed by two authors for eligibility and to draw out information relevant to the scoping review. Safety culture in care homes is a topic that has not been extensively researched. The review highlights a number of key gaps in the evidence base, which future research into safety culture in care home should attempt to address.
