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Found 1,304 results
  1. Content Article
    This study examines associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture and job satisfaction. The authors conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. 30% of providers reported burnout and providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout. More pressures related to patient care and lower job satisfaction were also associated with burnout.
  2. Content Article
    When ECRI unveiled its list of the leading threats to patient safety for 2024, some items are likely to be expected, such as physician burnout, delays in care due to drug shortages or falls in the hospital. However, ECRI, a non-profit group focused on patient safety, placed one item atop all others: the challenges in helping new clinicians move from training to caring for patients. In an interview with Chief Healthcare Executive®, Dr. Marcus Schabacker, president and CEO of ECRI, explained that workforce shortages are making it more difficult for newer doctors and nurses to make the transition and grow comfortably. “We think that that is a challenging situation, even the best of times,” Schabacker says. “But in this time, these clinicians who are coming to practice now had a very difficult time during the pandemic, which was only a couple years ago, to get the necessary hands-on training. And so we're concerned about that.”
  3. Content Article
    Following the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008. As part of the review, CQC were asked to look at 3 specific areas: A rapid review of the available evidence related to the care of Valdo Calocane An assessment of patient safety and quality of care provided by NHFT An assessment of progress made at Rampton Hospital since the most recent CQC inspection activity In this report, CQC detail the findings of parts 2 and 3. They will publish a separate report on part 1 in relation to the care of VC in summer 2024.
  4. Content Article
    Improving maternity care is a key Government and National Institute for Health and Care Research (NIHR) priority. In March 2024, an NIHR Evidence webinar showcased research from their recent Collection, Maternity services: evidence to support improvement.  This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A. It highlights seven features of safety in the maternity units, kind and compassionate care around the induction of labour, and the role of hospital boards in improving maternity care.
  5. Content Article
    Technology is advancing at a fast pace and holds significant promise for the future of healthcare and the NHS, with the potential to enhance productivity through cost, resource and time efficiencies. Yet there is a gap in practical guidance for healthcare stakeholders on how best to take this agenda forward, and what key roles are required. Systems are now in a place where people can take a large-scale view and make connections across the system to advance the technology agenda. To support them, the NHS Confederation and Google Health have developed this guide.
  6. Event
    until
    A four-week introduction to Patient Leadership, led by David Gilbert. Patient Leadership signals a breakthrough in healthcare that moves beyond traditional engagement and uncovers the pioneering and transformative work of patient leaders – those affected by life-changing illness, injury or disability who want to lead change in the healthcare system. Or ‘those who have been through stuff, who know stuff, who want to change stuff’. About this programme This course lays the foundation for understanding patient leadership – it is designed for both patients and non-patients to explore together different facets of this emerging social movement. It is for Patient and Carer Leaders, health professionals, managers, non-clinical staff and those from the independent, voluntary and charitable sector. And open to international attendees. This programme lays the foundations for understanding patient leadership. It leads you through the principles of patient leadership, what it is and where it came from, the qualities of an effective patient leader, support needed and models of embedded patient leadership. For patients, users, carers and staff (clinical, managerial). The framework for May's course The four sessions take place on consecutive Wednesdays, between 4pm and 7pm UK time. Wednesday 1 May - Session 1 - What is Patient Leadership The different tributaries of the ‘patient movement’ The failure of traditional engagement approaches The emergence of ‘patient leaders’ Definitions and clarifications What we bring - Jewels of wisdom and insight from the caves of suffering Wednesday 8 May - Session 2 - The Effective Patient Leader The Different Roles for a Patient Leader What Matters – an anchor for the effective Patient Leader Benefits of Patient Leadership The four main capabilities The different sorts of support needed Wednesday 15 May - Session 3 - Embedding Patient Leadership in Healthcare The Patient Leadership Triangle (the Sussex MSK Model) The Patient Director – a new role in healthcare Culture, systems and processes Progression routes & creating opportunities The current climate for Patient Leadership Wednesday 22 May - Session 4 - Reflections and Next Steps Reflections on the programme Exploring issues in more depth Your next steps Your learning and support requirements Register
  7. News Article
    The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. Nine or more years have passed since these recommendations were accepted by the government of the day These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress. The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good. The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”. “Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. Read full story Source: The Independent, 22 March 2024 Read Patient Safety Learning's response to the report: Response to Select Committee report: Evaluation of the Government’s progress on meeting patient safety recommendations
  8. Content Article
    The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.
  9. Content Article
    This is the report of a review conducted by the Health and Social Care Select Committee’s Independent Expert Panel, examining progress the UK Government has made against accepted recommendations from public inquiries and reviews on patient safety. It focuses on five recommendations, giving the Government for each a rating in the style used by national bodies such as the Care Quality Commission. The overall rating across all recommendations is ‘requires improvement’.
  10. Content Article
    Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
  11. News Article
    The Royal College of Paediatrics and Child Health has called on the UK government not to wait until after the upcoming general election to approve an infant immunisation programme against respiratory syncytial virus (RSV), so that babies can be protected next winter. In June 2023 the Joint Committee on Vaccinations and Immunisations (JCVI) recommended developing an RSV immunisation programme for infants and for older adults.1 It issued a fuller statement reiterating the advice in September 2023.2 But the government has yet to make a final decision on rolling out an RSV immunisation programme. A letter signed by more than 2000 paediatricians and healthcare professionals says that the sooner a full RSV vaccination programme is implemented the more effective it will be and that it “could save child health services reaching breaking point.” Read full story (paywalled) Source: BMJ, 20 March 2024
  12. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  13. News Article
    William Wragg, the Tory chair of the Public Administration and Constitutional Affairs Committee (PACAC), has belatedly intervened in the growing crisis over the failure of the Prime Minister to appoint a new Parliamentary Ombudsman to replace Rob Behrens who quits the Parliamentary and Health Service Ombudsman on 31 March 2024. In a letter published on the committee’s website, Mr Wragg asks Sir Alex Allan, the senior non executive director on the Parliamentary and Heath Services Ombudsman board, what measures will be taken to keep the office going and what is going to happen to people who, via their MP, want to lodge a complaint to the Ombudsman. He also raises whether reports can be published and complaints investigated. The letter discloses that recruitment for a new Ombudsman began last October and a panel chose the winning candidate at the beginning of January. Since then the Cabinet Office and Rishi Sunak, who has to approve the appointment, have not responded. The silence from Whitehall and Downing Street means no motion can be put to Parliament appointing a new Ombudsman, who then appears before the PACAC for a pre appointment hearing. PACAC has only a couple of weeks to set up the hearing. Read full story Source: Westminster Confidential, 12 March 2024
  14. Content Article
    A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction—this is known as The Triple Aim.  However, this framework does not allow the experience and human factors of providing care to be integrated into high-level decision making. This report describes the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center, which resulted in an integrative model of patient safety and clinician wellbeing. Developing the fourth aim of improving the experience of providing care was widely accepted and aligned with other health system goals of optimisation of safety, quality and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations.
  15. News Article
    A board director has publicly criticised his trust for its treatment of Muslim staff and patients. Mohammed Hussain posted on social media that some board members at Bradford Teaching Hospitals “are not heard and listened to”, and that there is a “dissonance” between its espoused values and the “lived experiences” of minority ethnic staff. Mr Hussain, a non-executive director since 2019, was responding to a post by CEO Mel Pickup, who had said the trust had a “variety of support offers for colleagues observing Ramadan”. He said there are “many examples” of Muslim families experiencing poor responses to complaints to the trust, while claiming that “outstanding” Muslim staff are having to “move out of the area to progress because they are not promoted internally”. The trust said its launching an investigation into the concerns raised by Mr Hussain. Read full story (paywalled) Source: HSJ, 12 March 2024
  16. Content Article
    In this blog, I discuss the limitations associated with FFP3 (Filtering Face Piece) tight-fitting masks as respiratory protective equipment (RPE) for the healthcare sector during the ongoing Covid pandemic. I highlight inequalities in the distribution of effective RPE among healthcare workers (HCWs) and also draw attention to the underlying reasons for the shortage of RPE that has beset our healthcare services since the start of the pandemic.
  17. News Article
    Almost £35 million will be invested to improve maternity safety across England with the recruitment of additional midwives and the expansion of specialist training to thousands of extra healthcare workers. The investment, which was announced as part of the Spring Budget 2024, will be provided over the next 3 years to ensure maternity services listen to and act on women’s experiences to improve care. The funding includes: £9 million for the rollout of the reducing brain injury programme across maternity units in England, to provide healthcare workers with the tools and training to reduce avoidable brain injuries in childbirth investment in training to ensure the NHS workforce has the skills needed to provide ever safer maternity care. An additional 6,000 clinical staff will be trained in neonatal resuscitation and we will almost double the number of clinical staff receiving specialist training in obstetric medicine in England increasing the number of midwives by funding 160 new posts over 3 years to support the growth of the maternity and neonatal workforce funding to support the rollout of maternity and neonatal voice partnerships to improve how women’s experiences and views are listened to and acted on to improve care. Health and Social Care Secretary Victoria Atkins said: "I want every mother to feel safe when giving birth to their baby. Improving maternity care is a key cornerstone of our Women’s Health Strategy and with this investment we are delivering on that priority - more midwives, specialist training in obstetric medicine and pushing to improve how women are listened to in our healthcare system. £35 million is going directly to improving the safety and care in our maternity wards and will move us closer to our goal of making healthcare faster, simpler and fairer for all." Read full story Source: Gov.UK, 10 March 2024
  18. News Article
    The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS. Inquiry: NHS leadership, performance and patient safety MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings. The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues. An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry. Health and Social Care Committee Chair Steve Brine MP said: “The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety. Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made. We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers. Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.” Terms of Reference The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals. Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.  How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this? What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety? What progress has been made to date on recommendations from the 2022 Messenger Review? How effectively have leadership recommendations from previous reviews of patient safety crises been implemented? How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety? How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved? How could investigations into whistleblowing complaints be improved? How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule? What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear? Read full story Source: UK Parliament, 25 January 2024
  19. Content Article
    Over the years, we have worked with many amazing women who share our aim of reducing avoidable harm in health and social care. In this blog, to mark International Women’s Day 2024, we are celebrating women who campaign for patient safety. 
  20. News Article
    NHS leaders have welcomed the £6bn budget boost Jeremy Hunt handed the beleaguered service to help it meet rising demand, tackle the care backlog and overhaul its antiquated IT system. The chancellor gave the NHS in England an extra £2.5bn to cover its day-to-day running costs in 2024/25, after the Institute for Fiscal Studies had warned that it was set to receive less funding next year than this. Julian Hartley, the chief executive of hospital body NHS Providers, said the money would offer “much needed – but temporary – respite” and “some breathing space” from the service’s acute financial difficulties, which have been exacerbated by inflation and the costs incurred by long-running strikes by NHS staff. However, there was little to stabilise England’s creaking adult social care system, and Hunt’s budget delivered an ongoing squeeze on resources, said the Association of Directors of Adult Social Services (ADASS). “Millions of adults and carers will be disappointed,” said Anna Hemmings, joint chief executive of ADASS. “Directors can’t invest enough in early support for people close to home, which prevents them needing hospital or residential care at a greater cost.” Read full story Source: The Guardian, 6 March 2024
  21. News Article
    Patient safety has been put at risk by ministers striking a backroom deal with unions to cut the equivalent of 10,000 health service jobs by reducing the working week, NHS bosses have warned. Briefings prepared by the chief executives of Scotland’s NHS boards reveal top management thrown into chaos after appearing to be blindsided by the new health secretary, Neil Gray. Two weeks into the role, Gray, who replaced the scandal-hit Michael Matheson on 8 February met with unions without NHS staff present and signed off sweeping changes to working conditions, setting a deadline to implement them within five weeks. The Scottish Conservatives have called the deal “deeply alarming”, while Labour accused the new health secretary of “standing idly by while chaos looms”. Read full story (paywalled) Source: The Times, 4 March 2024
  22. News Article
    Medical leaders support a planned increase in the number of physician associates (PA) in the NHS. But the British Medical Association (BMA) is concerned about a new law allowing the General Medical Council (GMC) to regulate PAs, who must be supervised by a fully qualified doctor. The doctors' union says it blurs the lines between doctors and PAs and could risk patient safety. Two families whose relatives were seen by PAs want the roles defined. The NHS has 3,286 PAs, who assist healthcare teams and are not authorised to prescribe or request scans. PAs and anaesthetic associates (AA) qualify after a funded two-year master's degree. They often have a science undergraduate degree, but that is not a prerequisite. Their role includes taking medical histories, conducting physical examinations and developing treatment plans. Like PAs, AAs are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor. The Academy of Medical Royal Colleges said on Tuesday that it welcomes a push to increase the number of PAs in the NHS, but that it is "vital" that there are clear guidelines on how they are deployed. Read full story Source: BBC News, 5 March 2024
  23. News Article
    Medics and managers must overcome a system-wide “aversion” to risk after their integrated care system was identified as a national outlier for low numbers of patients discharged home, according to the ICS’s chief executive. Kate Shields, CEO of Cornwall and Isles of Scilly ICS, has highlighted a discrepancy between the ICS and the rest of England, with a lower proportion of patients discharged with no new social care requirements, or discharged directly to their own home, with only intermediate additional care (known as ”pathways” 0 and 1 in national discharge guidance). Problems with delayed patient discharges – known as “no criteria to reside” patients – are a major contributor to overcrowding and long waits in the emergency department at Royal Cornwall Hospitals Trust, as well as severe delays for ambulances to handover patients. Discharge on pathways 2 and 3 – to a care home or intermediate care bed, with substantial additional care requirements – typically take a lot longer, and require more resources. Ms Shields’ comments come 18 months after an external report warned of an “over-reliance on bedded care” in Cornwall. Speaking at a meeting of Cornwall and Isles of Scilly Integrated Care Board last month, Ms Shields said the health economy needed to “look at how we get people out of hospital faster”. Read full story (paywalled) Source: HSJ, 4 March 2024
  24. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  25. News Article
    Scrapping the new Therapeutic Products Act (TPA) will leave thousands of New Zealanders exposed to ongoing harm from dodgy medical devices, warn patient safety advocates and legal experts. The act, which was due to come into force in 2026, would have modernised the regulation of medicines and natural health products, and made medical devices, as well as cell, gene and tissue therapies, subject to a similar regulatory regime as drugs. The industry has backed the move, saying the new law was heavy-handed and would stop people getting access to the latest lifesaving technological advances. However, Auckland woman Carmel Berry — who was left in constant knife-like pain from plastic mesh implanted during surgery — said she was “living proof” of the old system’s failures. It took more than 10 years of lobbying by her and the other founders of Mesh Down Under to get authorities to take action — a decade in which hundreds of other people were injured. She is horrified that the TPA, signed into law in only July, is on the chopping block. Beginning work to repeal it was No 47 out of 49 points on the Government’s to-do list for its first 100 days. “I’m horrified. After so many years of developing and rewriting the act and getting it through ... shame on them.” Read full story Source: New Zealand Herald, 18 February 2024
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