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Found 36 results
  1. Content Article
    This report outlines the findings of an independent investigation into the conduct of a spinal consultant, Doctor F, who formerly worked at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust).
  2. Content Article
    The early recognition and treatment of deterioration in patients in clinical settings can help reduce avoidable deaths. NHS England commissioned Florence Nightingale Foundation (FNF) to examine the barriers which prevent worries and concerns being raised about a deteriorating patient. Evidence suggests that organisational culture, professional hierarchies, and the nature of leadership in healthcare environments are the three key factors behind this reluctance. The findings highlight the importance of psychological safety which is highly influenced by authentic leadership in overcoming these barriers.
  3. Content Article
    This is the protocol for a Campbell systematic review. The main aim of this systematic review was to identify whether hospital leadership styles predict patient safety as measured through several indicators over time. The second aim was to assess the extent to which the prediction of hospital leadership styles on patient safety indicators varies as a function of the leader's hierarchy level in the organisation.
  4. News Article
    Patient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said. Rob Behrens, who investigates complaints about the NHS in England, warned that the hierarchical and high-handed attitude of clinicians was undermining the quality of care in some hospitals. He called for medical training to be redesigned to encourage a more empathetic and collaborative approach from doctors. Pointing to failings in the treatment of sepsis and the problems in maternity services, Behrens said he was “shocked on a daily basis” by what he saw as ombudsman. Too often, “organisational reputation has been put above patient safety”, he told The Times Health Commission. The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they’re not very good at working together,” he said. “Time and again, the handover from one clinician to another, from one shift to another, or the inability to raise the issue at a senior level has been a key factor in what has gone wrong.” Read full story (paywalled) Source: The Times, 18 November 2023
  5. Content Article
    It was recently reported that NHS Finance Directors were ‘incensed’ that the Health Services Safety Investigations Body (HSSIB) should think that they could be working more closely with patient safety chiefs. Whereas medical staff and clinicians represent the sharp end of healthcare delivery, the administrative functions, including finance, are the blunt end. Removed in space and time from the action, it can be hard to see how their behaviour can directly influence workplace outcomes. To understand the issue, Norman MacLeod reflects on how systems behave and the decision-making hierarchy within healthcare organisations.
  6. Content Article
    In this blog, Dr Faisal Saeed talks about the patient-provider power imbalance using an AI generated image of two chairs to illustrate his points. 
  7. News Article
    The NHS should not be given greater control of social care because it is ‘hierarchical, centralised and not person-centred’, according to a government-commissioned review which is repeatedly scathing about the health service. The review was ordered by then health and social care secretary Matt Hancock in June 2020. Cross-bench peer, writer and former Number 10 adviser Baroness Camilla Cavendish was asked “to make recommendations for social care reform and integration with health in the wake of the Covid-19 pandemic, which could fit alongside the funding reforms planned by the department in the context of the NHS long-term plan.” In her final report, Baroness Cavendish wrote that “one answer” to the problems facing the sector “would be to let the NHS take over social care. On paper, this would join up the care continuum.” However, she rejected the idea because of the NHS’ “hierarchical” and “centralised” nature. Baroness Cavendish also suggested the NHS’ role should be limited because it is “still struggling to join up primary and secondary care”. In contrast to the NHS, she claimed: “Social care is more innovative, more responsive and human.” She added: “The culture of the NHS is still largely one of ‘doing to’ patients, and the NHS has much to learn from social care about how to be responsive and human facing.” Referencing “recent attempts to import the successful [Buurtzorg] model of self-managing teams into the NHS”, the cross-bench peer said these “have foundered, because the NHS culture cannot seem to cope with giving staff the autonomy required”. Read full story (paywalled) Source: HSJ, 23 February 2022
  8. Content Article
    In December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed.  This blog first appeared on the Whistleblowers UK website in December 2022.
  9. Content Article
    Modern healthcare is burgeoning with patient centred rhetoric where physicians “share power” equally in their interactions with patients. However, how physicians actually conceptualise and manage their power when interacting with patients remains unexamined in the literature. This study from Laura Nimmon and Terese Stenfors-Hayes explored how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians. Although the “sharing of power” is an overarching goal of modern patient-centred healthcare, this study highlighted how this concept does not fully capture the complex ways experienced physicians perceive, invoke, and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enact ethical patient-centered therapeutic communication through reflective, effective, and professional use of power in clinical encounters.
  10. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  11. Content Article
    The ‘improvement’ of healthcare is now established and growing as a field of research and practice. This article by Cribb et al., based on qualitative data from interviews with 21 senior leaders in this field, analyses the growth of improvement expertise as not simply an expansion but also a multiplication of ‘ways of knowing’. It illustrates how healthcare improvement is an area where contests about relevant kinds of knowledge, approaches and purposes proliferate and intersect. One dimension of this story relates to the increasing relevance of sociological expertise—both as a disciplinary contributor to this arena of research and practice and as a spur to reflexive critique. The analysis highlights the threat of persistent hierarchies within improvement expertise reproducing and amplifying restricted conceptions of both improvement and ‘better’ healthcare.
  12. Content Article
    This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting."
  13. Content Article
    This article in the Financial Times by Alicia Clegg discusses how cronyism corrodes workplace relationships and destroys trust. It shows that the issues are common to both public and private sectors and demonstrates the need to seek out and resolve root causes.  
  14. 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?
  15. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  16. Community Post
    The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey
  17. News Article
    Nearly 150 doctors have been disciplined for sexual misconduct in the last five years, as surgeons call for action on the “systemic” and “cultural” problem of sexual assault within healthcare, The Independent can reveal. Doctors campaigning for the UK’s healthcare services to address widespread problems with sexual harassment and assault in medicine have warned that people do not feel safe to come forward with allegations amid deep-seated “hierarchies” within healthcare. The Royal College of Surgeons’ Women in Surgery chair has said the issues are “widespread” across the health services and improvements to protecting whistleblowers needed to be made nationally. Last year, surgeons Becky Fisher and Simon Fleming wrote an academic paper exposing the problem of sexual assault, harassment and rape in surgery and surgical training. In interviews with The Independent, both have warned the “institutional” problem goes beyond surgery and across all of the healthcare services. Mr Fleming said the figures from the GMC were the “the very tip of the iceberg” in terms of actual levels of sexual assault within healthcare. Talking about the role of the GMC, Mr Fleming said he’d been told “by more than one person” that when they’ve reached out to the GMC over sexual assault or misconduct they were “failed” by the regulator and were “either not helped, abandoned or told to deal with it locally”. Read full story Source: The Independent, 15 February 2022
  18. Content Article
    On 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
  19. Content Article
    Sharing her story in the Guardian, Merope gives a heart breaking account of how her daughter, Martha Mills, was allowed to die, but also what happens when you have blind faith in doctors – and learn too late what you should have known to save your child’s life.
  20. Content Article
    This article from Wood and Wiegmann, in the International Journal for Quality in Healthcare, discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
  21. Content Article
    The quality and safety of patient care relies on good communication, teamwork and respect between staff. However, in many areas of the NHS hierarchical attitudes lead to a dictatorial approach in which senior nurses make decisions affecting their colleagues without any discussion or consideration of the impact and practicality of these decisions. This can lead to dysfunctional organisational cultures in which staff either tolerate and emulate disrespect or leave the profession. Ellen Wightman, a staff nurse at University Hospitals Bristol NHS Foundation Trust, reflects on the importance of nurses being supported in developing leadership skills – and having the motivation to create collaborative and positive cultures.
  22. Content Article
    This blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
  23. Content Article
    The COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
  24. Content Article
    Paul Batalden has defined quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. Quality improvement (QI) goes beyond traditional management, target setting and policy making. QI methodology is best applied when tackling complex adaptive problems – where the problem isn’t completely understood and where the answer isn’t known – for example, how to reduce frequency of violence on inpatient mental health wards. QI utilises the subject matter expertise of people closest to the issue – staff and service users – to identify potential solutions and test them. East London NHS Foundation Trust (ELFT) is a provider of mental health and community services, to a population of approximately 1.5 million people, mainly across East London, Bedfordshire and Luton.
  25. 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. 
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