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
UCL has been working on developing their Centre for co-production as a mixed group of members of the public, researchers, patients, carers, healthcare practitioners, charities, local authorities and students (really anyone who wants to get involved or is interested in co-production!), since back in October 2017. After almost exactly 3 years they are officially launching it
This event will be a celebration of all things co-production, highlighting the importance of this approach to research, policy-making and service development/improvement. It will include short snippets from UCL's ’Share your Co-pro Story’ campaign, the unveiling of their new strategy and new name, logo, and identity, and a chance to meet other likeminded people and have a chat...
Find out more and register
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.
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.
I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this.
This is the message I'm sharing:
**Important message for patients relating to clinical referrals in England**
We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'.
I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral.
Make sure you have a copy yourself too.
Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital.
If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed.
Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice.
The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards.
The following themes are suggested for briefings and discussions for the Seminar
1.The limits of only learning from unwanted events.
2. Individuals’ natural versus organisations’ consciously pursued resilience.
3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed?
4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety.
5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong?
6. Understanding performance adjustments of individuals to get the job done.
7. The blessings and perils of performance variability.
8. Learning from data versus learning from observing.
9. Learning from differences in operations versus learning from monitoring for excrescences.
10. Can risk- and resilience-based concepts work together?
11. Does just culture matter for learning from success?
12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS?
The 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.
Yesterday, Health Service Journal (HSJ) reported that the London Ambulance Service (LAS) NHS Trust is now looking into alternative defibrillators after receiving two warnings from Coroners Prevention of Future Deaths (PFD) reports due to problems with their existing machines. PFD reports are issued when, in the coroner’s opinion, the case they are reviewing requires action to be taken in order to prevent future deaths.
Delays in defibrillation
The reports in question relate to the deaths of Najeeb Katende in 2016 and Mitica Marin in 2019. In both cases, an issue had occurred when using the LP15 defibrillator, which had been started in ‘manual’ rather than ‘automatic’ mode. This resulted in the paramedic not initially realising the patient had a shockable heart rhythm and led to a delay before the first shock was administered. If the defibrillator had initially been in ‘automatic’ mode it would have detected a rhythm and prompted the paramedic to shock the patient.
In the coroner’s report into the death of Mitica Marin, it was noted that LAS had carried out a review of cases of delayed defibrillation with the LP15 and recognised that this specific machine “defaults to manual mode requiring the user to switch to automatic mode before use”. Garrett Emmerson, LAS Chief Executive, noted that they were now taking a series of actions to address this, “including putting warning stickers on the defibrillators and staff refresher training on how to use the machines”.
Preventing future deaths
While this case focuses a specific safety in use issue concerning the LP15 defibrillator, it also serves to highlight the broader issue we have previously raised at Patient Safety Learning; failure to harness learning from PFD reports. We believe that by learning from PFD reports, patient safety can be improved and the reports can achieve their aim of preventing future deaths.
One of our concerns in this regard is that learnings from PFD reports may be applicable beyond the organisation, however at present there appears to be no clear system of sharing learning more widely. We are pleased that LAS has identified this safety issue, however it is vital that this information is now widely shared so others can also take action to manage the risks to patients. If the concerns identified in PFD reports remain in silos, there is a danger that this could reoccur in a different trust.
At Patient Safety Learning, we believe there are a number of actions which could be taken to help address the current gaps in the system. Please refer to our previous blog on Learning from PFD reports to see these actions in detail.
1. HSJ, Patient deaths prompt ambulance chiefs to look for alternative defibrillators, 10 August 2020.
2. The Coroners (Investigations) Regulations 2013, SI 2013/1629.
3. Edwin Buckett, Prevention of Future Deaths Report – Najeeb Katende, 21 April 2017.
4. Graeme Irvin, Prevention of Future Deaths Report – Mitica Marin, 12 March 2020.
5. Patient Safety Learning, Learning from Prevention of Future Deaths reports, 25 February 2020.
General information about the NHS
Who does what?
How is the NHS regulated?
Why do we need to think about how people with a learning disability access the NHS?
How does The Equality Act 2010 ensure people with a learning disability have equal access to healthcare?
What are reasonable adjustments?
The Mental Capacity Act 2005 and access to healthcare
What to do if things do not go well: The NHS Complaints process
Top Tips to involve someone you support in their health care
Today, four leading global organisations dedicated to fighting preventable deaths due to medical errors announced their partnership to co-convene the #uniteforsafecare programme on World Patient Safety Day (September 17, 2020).
In June, the Patient Safety Movement Foundation announced the wide-ranging campaign to bring attention to system-wide improvements that will ensure better health worker and patient safety outcomes, called #uniteforsafecare. Now, the organisation will be joined by the American Society of Anesthesiologists (ASA), The Leapfrog Group, and International Society for Quality in Health Care (ISQua) in co-convening the slate of programming, which includes a virtual physical challenge to raise awareness of the issue; collaboration with the National Association for Healthcare Quality’s annual conference, NEXT; an in-person demonstration in Washington, D.C. and a free virtual event for the public and those who have experienced errors, harms, or death to themselves or loved ones.
“As the first medical specialty to advocate for patient safety, and as physicians on the front lines treating COVID-19 patients, we know firsthand how critical ensuring health worker safety is,” said ASA President Mary Dale Peterson. “The issue is especially timely. From having the appropriate PPE to strategies for stress management and wellness – ensuring health worker safety is patient safety and improves outcomes. We are happy to participate in this effort to advance safety in health care.”
Read press release
The Royal Society of Medicine's International COVID-19 Conference brings together thought leaders from around the world to share the key clinical learnings about COVID-19.Session 1: Respiratory effects: critical care and ventilationChair: Dr Charles Powell, Janice and Coleman Rabin Professor of Medicine System Chief, Icahn School of Medicine, Mount Sinai> Professor Anita K Simonds, Consultant in Respiratory and Sleep Medicine, RBH NHS Foundation Trust> Dr Richard Oeckler, Director, Medical Intensive Care Unit, Mayo Clinic, Minnesota> Dr Eva Polverino, Pulmonologist, Vall D’Hebron BarcelonaSession 2: Cardiovascular complications and the role of thrombosisChair: Rt Hon Professor Lord Ajay Kakkar PC, Professor of Surgery, University College London> Professor Barbara Casadei, President, European Society of Cardiology> Professor K Srinath Reddy, President, Public Health Foundation of India> Professor Samuel Goldhaber, Associate Chief and Clinical Director, Division of Cardiovascular Medicine, Harvard Medical SchoolSession 3: Impacts on the brain and the nervous systemsChair: Professor Sir Simon Wessely, President, Royal Society of Medicine> Dr Hadi Manji, Consultant Neurologist and Honorary Senior Lecturer, National Hospital for Neurology> Dr Andrew Russman, Medical Director, Comprehensive Stroke Center, Cleveland Clinic> Professor Emily Holmes, Distinguished Professor, Uppsala UniversitySession 4: Looking forwardChair: Professor Roger Kirby, President-elect, Royal Society of Medicine> Dr Andrew Badley, Professor and Chair of Molecular Medicine, Chair of the Mayo Clinic COVID research task force, Mayo Clinic> Professor Robin Shattock, Professor of Mucosal Infection and Immunity, Imperial College London> Professor Sian Griffiths, Chair, Global Health Committee and Associate Non-Executive member, Board of Public Health England> Dr Monica Musenero, Assistant Commissioner, Epidemiology and Surveillance, Ministry of Health, Uganda
Across the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process.
Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64.
She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later.
Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening.
Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted."
He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies".
In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training.
It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur."
Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April.
Read full story
Source: The Independent, 14 July 2020
Over the last 3 months we have seen NHS organisations work at lightning speed to adapt and serve their communities in response to the COVID-19 pandemic. With the shutting down of routine surgeries and outpatient services, care providers have adapted in an extraordinary way. Wards have been emptied as beds have been made available, while theatres and recovery rooms have been turned into intensive care beds – capable of looking after acutely unwell ‘level 3’ patients – overnight. These unprecedented changes deserve praise and commendation but, beyond this praise, what can we learn from COVID-19 and the scale of change we have seen?
It was famously argued that it takes 17 years for research to impact frontline services. . Due to this, immense interest has centered around how innovations, or new ideas, are diffused and how this process can be sped up. Various barriers exist to the spread of new ideas and change – not limited to bureaucracy, a lack of resources to create change, and cultures – for example organisational culture. Due to these barriers the NHS and its subsequent organisations can appear as monolithic – slow to change or adapt to any innovations.
But COVID-19 has turned this assumption on its head, with expansive structural and procedural overhaul seen in the last few months alone. It has led observers to ask how this has happened and, more importantly, how we can facilitate change in the future.
As we reflect on these months, the psychology of a crisis can be helpful in understanding staff behaviour. There are three stages – emergency, regression and recovery. In the emergency stage, energy and performance goes up as staff ‘fire fight’ in the crisis. However, the move towards the regression and recovery stage will see staff become tired and lose their sense of purpose before needing direction on how to recover and rebuild. These latter stages are symptomatic of the current state for NHS staff.
Utilising theories of change, perhaps we can identify why this change happened so quickly. The impending doom felt by staff was palpable in March. The Nightingale field hospital was being built to cope with the immediate storm of COVID-19 patients needing ventilatory support and providers were told to free up beds. In business, this is coined the ‘burning platform’ and is a key driver of change. A burning platform is a term which describes the process of informing people of an impending crisis and is used to cultivate immediate change. This ‘burning platform’ is a simple analogy and based on an incident in 1988 of an oil rig worker who, when faced with an impending burning platform, jumped into freezing water.
Whilst of course this sense of urgency can’t be replicated every time change needs to happen, for professionals working at the start of the pandemic, this is exactly what was replicated. Perhaps change happened so fast as professionals and staff had no other choice but to respond to the burning platform of COVID-19.
Creating a sense of urgency is also argued as being integral to another organisational theory of change – Kotter’s 8 Step Process for leading change. The first stage – creating a sense of urgency – is characterised by a distinctive attitude change which leads workers to seize opportunities to make changes imminently. But NHS staff have already responded to the immediate urgency presented by COVID-19, so what happens next will be telling.
Apart from creating the NHS’s own burning platform, adaptations that can be seen across the NHS are not following any other theory of change. The NHS – a highly complex and bureaucratic set of organisations – has seen providers innovate, change and adapt without the traditional ‘red tape’ of the NHS. NHS providers are no longer following a model, instead working out what is best for the patients they serve. For community providers and primary care this includes virtually treating patients to limit their risk to COVID-19. Changes that have taken years to discuss are now happening overnight – for example some hospital providers integrating IT systems to improve cohesion.
With so many innovations, it is crucial that we learn from what is happening. Organisations should be supported to identify and collect information on the changes that are happening on local levels. With this wealth of information, organisations can learn what made local change possible and what the drivers of innovations were. This insight is undeniably useful as it can help us all understand the drivers of change locally and galvanise change in the future. This must be made into an organisational priority.
While organisations remain in firefighting mode, now is a crucial time to take stock, capture these changes, and hold on to what is useful as the NHS – and wider society – recovers.
1. Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011;104:510-20.
2. Turner S, D’Lima D, Hudson E, Morris S, et al. Evidence use in decision-making on introducing innovations: A systematic scoping review with stakeholder feedback. Implementation Science 2017;12.
3. Wedell-Wedellsborg M. If You Feel Like You’re Regressing, You’re Not Alone. Harvard Business Review [Internet] 2020.
This web page includes:
Breaking bad news
Ceilings of treatment
Evidence-based advice for difficult conversations, by Professor Ruth Parry, Loughborough University
Poster and sketch note
Telephone call checklist
The free version of Hospify is available right now and is in daily use at over 150 clinical sites around the country including London North West University Healthcare Trust, County Durham and Darlington, University Hospitals North Midlands, Frimley Park and Lincolnshire Community NHS Trust. Hospify is also backed by Innovate UK, Wayra Velocity Health (in partnership with Telefonica and MSD Pharmaceutical), Kent Surrey Sussex AHSN and the UNISON and Managers in Partnership Unions.
A premium version of Hospify specifically designed for healthcare teams is also now available. Called the Hospify Hub, it features an online admin portal for onboarding staff, a web app that syncs with users’ phones, broadcast messaging/paging with document attachments and a survey and data collection tool.
Please email firstname.lastname@example.org for more details or visit hub.hospify.com to set up a Hub and give it a try for yourself.