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Found 34 results
  1. Content Article
    This video gives a summary of the PRAISe project - a QI project about antibiotic stewardship, based on Learning from Excellence philosophy. Funded by the Health Foundation.
  2. News Article
    In early January, authorities in the Chinese city of Wuhan were trying to keep news of a new coronavirus under wraps. When one doctor tried to warn fellow medics about the outbreak, police paid him a visit and told him to stop. A month later he has been hailed as a hero, after he posted his story from a hospital bed. It's a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak. Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like SARS - the virus that led to a global epidemic in 2003. On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection. What Dr Li didn't know then was that the disease that had been discovered was an entirely new coronavirus. Four days later he was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order". "We solemnly warn you: If you keep being stubborn, with such impertinence, and continue this illegal activity, you will be brought to justice - is that understood?" He was one of eight people who police said were being investigated for "spreading rumours". At the end of January, Dr Li published a copy of the letter on Weibo and explained what had happened. In the meantime, local authorities had apologised to him but that apology came too late. For the first few weeks of January officials in Wuhan were insisting that only those who came into contact with infected animals could catch the virus. No guidance was issued to protect doctors. "A safer public health environment… requires tens of millions of Li Wenliang," said one reader of Dr Li's post. Read full story Source: BBC News, 4 February 2020
  3. Content Article
    Summit objectives: to foster connections and support networking across the Alliance to surface key issues that are top of mind to Alliance leaders to support capacity around personal, organisational, and industry leadership to promote discussion and activities that foster and advance courageous, creative, collaborative leadership across the network to inform and advance the direction of engagement, collaboration, and collective action opportunities across the Alliance network.
  4. Content Article
    In conclusion, although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.
  5. Content Article
    Movies from 1939 are engrained in American culture. They share narrative, characters and quotes that people are aware of even if they, alas, haven’t seen the films. The list of films produced in what some consider the finest year in Hollywood history speaks for itself; it includes Stagecoach, Ninotchka, Destry Rides Again, Mr Smith Goes to Washington, The Wizard of Oz and both my and the Academy’s favourite, capping the impressive output with a December 1939 release, Gone with the Wind. While recognising that certain characterisations in these movies haven’t aged well, the films have made an indelible mark on Hollywood history. The films of 1939 laid the groundwork for great things to come. They launched the careers of artists that have made a cultural mark worldwide: need I say more than John Wayne or Judy Garland? Another capstone to a productive year is the end of the 20th year post the publication of To Err in Human. The widely influential 1999 US publication showed us how to fight for patient safety – our Tara. It outlined approaches to address the seemingly reoccurring tornadoes in healthcare built to instead point toward home – a safe health system. Scarlett’s tenacity, her force of personal will and sustained belief in Tara is what pulled her through the maelstroms of civil war Georgia. Clinicians, however, cannot rely on grit and willpower alone to address clinical and organisational threats to safety. The lack of control to minimise systemic pressures on their moral imperative to do a job well in non-supportive situations reduces a clinician’s ability to practice safely. Building on the To Err is Human legacy, The US National Academy of Medicine (NAM) is committed to understanding factors that contribute to unsafe care. A NAM recent report on burnout lays out a system-focus strategy for organisations to reduce conditions that degrade physician health and, thus, safe practice. Dorothy’s quest to return home energised her instead to engage a multidisciplinary team. The skills of Scarecrow, Tin Man, Cowardly Lion and, yes, even Toto got them through the forest to safety. Without their individual commitment to the mission, humanness and competence the team would have never gotten to Oz. The American Association of Medical Colleges (AMMC) recently released a set of competencies expected in physicians to support quality practice. By suggesting what educators embed in their training efforts, the AAMC helps ensure learning opportunities that build competencies are embedded in programmes on the yellow brick road to safe care provision. Transparency helps us to see situations as they really are. Peaking behind the curtain enables exploration that, if used appropriately, can drive improvement. Toto pulled back the curtain to expose a threat that, once clarified, launched a collaboration that got Dorothy back to Kansas. The US-based Leapfrog Group has also forged a partnership to look behind the curtain. The latest release of the Hospital Safety Score data has focused attention on what isn’t working to support safety while celebrating hospitals that demonstrate sustained safety and quality. The scores track weaknesses in hand hygiene, infection control, and patient falls as elements of whether a hospital is safe. There have been challenges: wicked witches, budget constraints, refusal to accept change and conflicts. It has not been an easy road to Tara since Err is Human was released. Experts in the field have shared their dismay in the lack of progress. Yet stories of resilience, partnership and teamwork continue to motivate the resolve of Dorothy and Scarlett to keep going. Goal-focused efforts can backfire and not live up to their expected purpose. The South didn’t win the Civil war though they believed it was their destiny to do so. Scarlett never won back Ashely no matter how hard she tried. A recent article published in Health Affairs highlights the lack of correlation between the US Medicare and Medicaid programme reimbursement initiative and direct impact on patient safety in the state of Michigan. Its impact is questionable—which for a large-scale solution embedded throughout the system—is humbling. Questionable actions can be a human reaction to stress that needs to be called out and managed to reduce their presence and impact. While centering her as a force for action, Scarlett’s spoiled and selfish behaviour also destroyed her most meaningful relationship. Such destructive behaviours degrade relationships needed for the safety of care. A large US study published in NEJM found that harassment and inappropriate behaviours effect one-third of general surgery residents surveyed, particularly women. The mistreatment and bias generated by both patients/families and medical team members were identified as a key factor in burnout and physician suicide. The stories from great films of 1939 illustrate the power of grit, resolve, focus and leadership as elements of achievement. They share with us memorable characters that live with us long after the movie theatre lights come up. Through the embodiment of the tenacity of Scarlett and the team-focus of Dorothy we can and will work through the known barriers to reduce patient harm due to medical care. We have not yet arrived at Tara, but we continue to work tomorrow toward getting over the rainbow.
  6. Content Article
    Speaking on 2 October at the Healthcare Excellence Through Technology conference, Heather Caudle and Ijeoma Azodo, both members of the Shuri Network, stressed the importance of diversity when developing new technologies like artificial intelligence (AI).
  7. Content Article
    Patient safety made headlines at the recent Patient Safety Learning Conference when Professor Ted Baker (Chief Inspector of Hospital for the CQC) declared that there has been “little progress' for NHS patient safety over past 20 years”. Such an assessment feels overly harsh, but in the context of the Mid Staffordshire incident and the more recent events in Liverpool, it is clear that sometimes hospitals do fail to protect the patients they are caring for. When Aidan Fowler, NHS National Director of Patient Safety, called for “Directors of Patient Safety” to be appointed in every NHS organisation it was a positive move towards reducing the variation in patient safety across the country. And if the enthusiasm at the recent Patient Safety Learning Conference is anything to go by, then we may soon be able to reach that goal. One of the interesting discussions at the conference was what do these future directors of patient safety look like? What are the skills and attributes that they will possess? Professor Ted Baker pinpointed three key areas, but what would these look like in practice? The first identified attribute was that a leader of patient safety should be “humble”. A true leader must be able to reflect on when they are wrong. Based on some misplaced Machiavellian leaderships beliefs, we've often trained leaders to feel like they have to be infallible. However the art of a true leader is actually someone who can reflect and take accountability for their mistakes. In healthcare there is no room for cover-ups, the stakes are too high. We need a leader who can put their hands up when things are not safe, and be an advocate for the patients that they are working to protect. Often when things have gone wrong, it's because organisations have failed to be transparent about the problems that they are facing. The leaders of patient safety must be able to be a torchbearer of safety and be humble enough to admit when the right standards are not being met. The second element of a good leader for patient safety is “strong values”. To be a real leader and an advocate for patients they must truly believe in the values of NHS organisations. They must be genuine and believe that the values are there to be upheld. Too often leaders pay mere lip service to values and fail to exhibit the right behaviours. We see examples of bad behaviour in the workplace but too often they are left unchallenged. A patient safety leader must act with integrity and be prepared to challenge individuals when their behaviours fail to live up to the organisation’s values. The final attribute of a good patient safety leader is one that works “collaboratively”. Healthcare works at its best when it utilises the skill sets of all its staff. Only through a multi-disciplinary approach can we hope to keep our patients safe. The best knowledge is gleaned from a wide range of staff, and patients are kept at their safest when teams work together. Therefore, a patient safety leader of the future would need to be collaborative and able to engage a wide range of expert clinicians. Only then can we learn to share our mistakes and improve the care we deliver so that every patient gets the standard of treatment they deserve. Not all people will be able to stay humble, value focused and collaborative whilst delivering patient safety to an organisation. We must be able to have the right conversations with patients to ensure that they are able to make informed decisions to keep themselves safe in our care. Only through patient engagement can we get the full picture and make care safer in the NHS. Patient safety is a discipline in its own right and we must not assume all healthcare staff possess the knowledge and skill sets to be leaders in the field. Patient safety is complex, it is multifaceted, and it cannot be done by one person alone. We must work to train more staff in patient safety so that all healthcare professionals can see its value and the impact that poor patient safety has. We must all work to be patient safety leaders of the future and work openly and collaboratively to learn from our mistakes.
  8. Community Post
    One of the interesting discussions at our Patient Safety Learning Annual Conference was what do future directors of patient safety look like? What are the skills and attributes that they will possess? Andy Burrell wrote an excellent blog for the hub following this: What are you thoughts and suggestions?
  9. Community Post
    My first thought on coming to this community was, is it a bit abstract to be talking about leadership in a sub-community of a patient safety learning platform, when in the real world leadership is part of, or influences so many of the other sub-communities (culture, patient engagement, patient safety learning itself, to name but a few). However, I can definitely see the value in creating a special space to explore and stimulate some cross-fertilisation of ideas and learning on leadership for patient safety. It would be great to get some ideas flowing on how patient safety leaders across all levels of health care could use this community. I’ve found that leadership in the academic literature is sometimes a little vague, it’s common to see “leadership is critical for [X-aspect of] patient safety” written in various ways, but when you try and drill down on concrete examples of what that means it can be frustratingly non-specific. Could we start by stimulating some sharing of tangible real-world examples or vignettes that describe how leadership/leadership development is linked to making care safer or addressing a patient safety-related problem. This may mean infiltrating or drawing on some of the parallel discussions in other sub-forums and seeding the leadership angle into these discussions!
  10. Content Article
    In this blog, David Naylor, a senior leadership consultant at The King’s Fund, reflects on ‘imposter syndrome’, considering its impact on third sector leaders and beyond.
  11. Content Article
    The report argues that better engaged staff have higher morale, make fewer errors and deliver better patient experience. It demonstrates that patients receive more appropriate care and better outcomes when they are actively engaged in their care and highlights how leaders must be increasingly effective at integrating healthcare activities across healthcare systems. It sets out recommendations and outlines the argument for engagement, looking at what engagement means and why it matters. It looks at engaging across the system as well as with specific groups: Staff Patients Doctors Nurses and allied health professionals Boards
  12. Content Article
    The guide includes: How to select, implement and evaluate the guide’s strategies. How patient and family engagement can benefit your hospital. How senior hospital leadership can promote patient and family engagement. Strategy 1: Working with patients and families as advisors shows how hospitals can work with patients and family members as advisors at the organisational level. Strategy 2: Communicating to improve quality helps improve communication among patients, family members, clinicians and hospital staff from the point of admission. Strategy 3: Nurse bedside shift report supports the safe handoff of care between nurses by involving the patient and family in the change of shift report for nurses. Strategy 4: IDEAL discharge planning helps reduce preventable readmissions by engaging patients and family members in the transition from hospital to home.
  13. Content Article
    This blog highlights solutions to the problem of poor culture of speaking up and bullying within healthcare. Dr Blair Bigham and Dr Amitha Kalaichandran propose three solutions to enable a culture without fear. Measure culture within the organisation. Hire talented leaders. Embrace diversity and inclusion and reject hierarchy.
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