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Content Article
In this LinkedIn blog, Judy Walker outlines four ways that After Action Reviews (AARs) differ from more informal 'Lessons Learned' events, and how AARs can result in more effective learning. She also highlights four topics that organisations affected by recent cyberattacks can explore in AARs: Leadership and co-ordination - Large cyber-attacks demand that robust command and control structures are switched on, to respond to the initial chaos that inevitably ensues when disasters strike. Large incidents also involve a multitude of agencies, each of which must direct its own resources and co-ordinate with each other. Communications. Systems of command, control, and coordination are predicated on being able to communicate efficiently and requires that people are willing to share information with each other. Planning - Gaps in emergency plans cause serious problems when disaster strikes and weaknesses in plans often go unnoticed because actual plans are not trained fully or exercised realistically. Resilience – AARs should always address what supportive behaviours, processes and structures enabled efficient and effective response and recovery so that these can be repeated and strengthened as required.- Posted
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This download is the first of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. It's structured around the different levels of a system, where practitioners might place their focus. For each level, the nature of issues that are frequently addressed is given, followed by a characterisation of available human factors methods and approaches. Then, a selection of representative and important human factors methods and approaches is described in detail using a practical example, helping guide practitioners through the many opportunities for human factors interventions and the wide range of methodological choice. Chapter 1 objectives and learning outcomes: To explain what human factors and the systems approach are. To understand what to look at within a healthcare work system. To be familiar with how human factors approaches improve system outcomes. To understand how human factors practitioners work.- Posted
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NHSE - Always Events®
Patient-Safety-Learning posted an article in NHS England
Always Events are defined as “those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the health care delivery system”. NHS England has been leading an initiative for developing, implementing, and spreading an approach to reliably integrate Always Events into routine frontline services. Always Events® is a co-production quality improvement methodology which seeks to understand what really matters to patients, people who use services, their families and carers and then co-design changes to improve experience of care. Genuine partnerships between patients, service users, care providers, and clinicians are the foundation for co-designing and implementing reliable solutions that transform care experiences with the goal being an “Always Experience.” This webpage contains: information on the Always Events national programme Always Events toolkit Evaluation of Always Events Always Events film- Posted
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Content Article
This download is the second of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students. The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. Chapter 2 objectives and learning outcomes: To describe, in simple terms, the concept of organisational culture, and specifically how safety culture relates to this. To recognise features of good safety culture. To define key concepts of proactive risk management. To briefly introduce the idea of safety management systems and safety cases. To introduce methods for assessing safety culture (and consider their strengths and weaknesses). Using a worked example, to introduce a tool for helping you to understand and strengthen safety culture in your own organisation.- Posted
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Appreciative Inquiry (AI) is a transformational change methodology grounded in theories from the disciplines of human sciences and philosophy. It invites people to see themselves and the world through an appreciative or valuing eye. This article by AI strategist Robyn Stratton-Berkessel aims to provide an overview of AI for beginners, and covers: What is Appreciative Inquiry How it is a strengths-based, positive framework What it can achieve through collaborative conversations The 4-D process of Appreciative Inquiry – known as the Appreciative Inquiry Model How it can be applied personally and professionally The guiding principles (Including the new addition of the five emerging principles) The importance of Appreciative Inquiry questions – affirmatively-framed questions The value of story-telling in Appreciative Inquiry- Posted
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Judy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).- Posted
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Ambulances lined up outside hospital Emergency Departments (EDs) are a vivid, and politically embarrassing, indication of inadequate capacity in the NHS. Media reports of diktats demanding that hospital CEOs meet performance targets suggest a desire for action, but are the local solutions being implemented to ease the pressure in the best interest of patient safety? The use of ‘safety cases’ in healthcare has received some interest in recent years but the conclusion drawn by, for example, Leberati and her colleagues,[1] was that while they have some potential value they are "fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors". A survey of the literature suggests that there is a danger of conflating ‘safety cases’ with ‘safety management’ or ‘quality’ systems. Part of the problem might be that safety cases are more a concept rather than a methodology: there is no script to follow. In this blog, Norman MacLeod discusses whether the the current crisis in hospital capacity can be explored through the safety case lens. What is a safety case? Safety cases are used to manage complex socio-technical systems. The goal is to provide evidence that the system described by the 'case' is safe. A safety case has three elements. First, we have some top-level, over-arching statements about the system. For example, you might say that a hospital is ‘fit for purpose.’ Another top-level statement might be that the hospital ‘meets the needs of its hinterland.’ While these examples may seem very broad, they aim to capture the essence of why the hospital exists and what its function is. Next, we need corroborating data. The top-level statement is, in effect, a logical proposition and the safety case owner must provide data to prove the proposition to be true. If a statement cannot be proven to be true then the safety case fails and the system must be considered to be unsafe. Finally, we need to declare any inference rules used to provide the data necessary to support the top-level statement. For example, direct performance measures might not be available and we might choose to use surrogates or data derived from extrapolations instead. Both direct evidence and that derived from inference rules must be valid and reliable – that is, they must be shown to measure what they claim to measure and must function consistently across time. A hospital safety case would require, as a minimum, evidence to show that the estate (design and maintenance), resources (equipment and consumables) and staff (numbers, grades, skills mix, recruitment, retention, training, etc.) were appropriate to satisfy the requirements of the top-level statement; in this case that the hospital was fit for purpose. However, the safety case is not static. It must be applicable to the lifecycle of the entity it covers. Which means that it must cope with change. And now we come to the ways hospitals are currently trying to cope with excessive demand. Hospital responses to increased demand The solutions being implemented by hospitals to cope with demand seem to fall into two groups: buffers and lubricants. Buffers are ad hoc capacity where patients can be held prior to moving to the next stage in their care. For example, EDs are creating additional spaces where patients can be held between arriving in an ambulance and entering the ED, or after treatment and being accepted on a ward. Some Trusts have made provision for discharge-ready patients to be moved to local hotels pending community care becoming available. Corridor nursing is an example of buffering. Lubricants include those measures aimed at expediting flow. The Positive Flow philosophy, where patents are force-fed from ED onto wards at fixed intervals, is one example. Discharging surgical patients from recovery rather than a discharge suite is another. A safety case would require changes to the existing system to be tested against the top-level arguments. So, we would need to understand the steady-state condition and then be able to compare the impact of any changes made. We need to assure that the new provisions are equally fit for purpose. Unfortunately, the experience to date suggests not. The creation of buffers is adding to the burden of supervision and increasing the requirement to move patients between stages of treatment. In some cases, inadequate logistical provision means that patients are in spaces with no oxygen supply or call bells. Care is being delivered in spaces where the minimum levels of dignity and privacy cannot be met. Rooms are being used that are difficult to observe and, in one case, had access to an exit allowing a patient to abscond undetected. Meeting the demands of positive flow can require additional beds in rooms or corridors. In one case, a Trust is replicating measures it had already removed because they were deemed unsafe in a previous Care Quality Commission report. Patients are being discharged without appropriate follow-up because the staff involved are untrained in the necessary procedures. It seems, then, that measures taken to solve one problem – capacity – have introduced new risks. Conclusion Applying the safety case concept requires an organisation to answer a simple question: are you configured to function in a safe way? The answer to that question must apply equally to the steady state and to any changes, no matter whether permanent or temporary. In the example of coping with excessive demand, local fixes are being implemented but it is not at all clear that solutions are safe. Perhaps it is time to look again at the safety case concept? Reference Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case study. BMJ Quality & Safety 2024 Feb 19;33(3):156-165. doi: 10.1136/bmjqs-2023-016042. Further reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift What is a ‘safety management system’? A blog by Norman MacLeod Can you measure safety? Part 1 - Improving patient safety Errors as clues in the search for safety measures: Measuring safety part 2- Posted
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A swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. They can prevent: those affected forgetting key information because there is a time delay before their perspective on what happened is sought fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred. This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done).- Posted
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Event
Organised by SingHealth Duke-NUS Institute for Patient Safety & Quality (IPSQ), this webinar features the distinguished speaker, Ms Melanie Leis from Imperial College London. The session will delve into the critical role of research in patient safety improvement, exploring qualitative and quantitative methodologies. Don't miss the opportunity to gain valuable insights and engage in a Q&A session at the end of the webinar. Register- Posted
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Safety voice is the act of speaking up about safety in order to prevent accidents and physical harm. This systematic review in the journal Safety Science aimed to determine how safety voice differs conceptually from employee voice, is described across levels of analysis and could be best investigated. The authors found that there are important challenges for safety voice in terms of developing methodologies and interventions.- Posted
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- Speaking up
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This article in the journal IJQHC Communications examines how looking at the ‘Head’, ‘Heart’ and ‘Hands’ aspects of quality improvement can accelerate adoption of change, optimise the use of resources and maximise the impact and sustainability of interventions. It defines the different elements of Head, Heart and Hands approaches and looks at how these could be applied to rapidly changing environments such as healthcare systems during the Covid-19 pandemic.- Posted
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This is draft material and is not live guidance. It is shared for information and will be tested with organisations who have agreed to pilot the new Complaint Standards. The model complaint handling procedure describes how your organisation will meet the expectations of the NHS Complaint Standards in practice. Download a Word version of the model complaints handling procedure from the link below to test within your NHS organisation.- Posted
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How are Trusts measuring safety culture? A blog from Annie Hunningher
Annie Hunningher posted an article in Culture
Annie Hunningher highlights the difficulties in measuring an organisation's safety culture and the lack of validated measurement tools available. Measurement of safety culture – a necessary suite in any Trust's safety measures? Well it seems not! This quick Twitter poll, along with observations from a number of large trusts and discussions at webinars, indicate that culture is not a measure many Trusts have got a handle on. The Patient Safety Incident Response Framework (PSIRF) implementation recommends in the pre-framework preparation that we are meant to be doing culture measurement for this important piece of work to land. With a range of tools around, it’s difficult to know how best to measure this sadly often pervasive and complex metric. There is MapSaF, Safety attitudes, Safety climate and Psychological safety measures. A useful booklet from The Health Foundation, 'Measuring Safety Culture', gives an overview of them all. The booklet also says that Trusts that are measuring culture are usually higher performing. There are a number of companies that provide fee paying links to administer it for you, but without resource it’s unlikely to be widely delivered. Some Trusts take a few of their staff survey questions to guide them rather than send out another survey to all their staff, but there are questions of validity around this practice. We also need to be able to break down results into areas, specialties and sites to measure for improvement. A validated tool to measure safety culture across organisations along with a platform to administer it is yet to become clear and we need a national solution to make its measurement standardised and possible. I'd love to hear if and how you are measuring safety culture and what tools you are using. Add your comments below.- Posted
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Throughout Jens Rasmussen’s career there has been a continued emphasis on the development of methods, techniques and tools for accident analysis and investigation. In this paper, Waterson et al. focus on the evolution and development of one specific example, namely Accimaps and their use for accident analysis.- Posted
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Patient safety, staff moral and system performance are at the heart of healthcare delivery. Investigation of adverse outcomes is one strategy that enables organisations to learn and improve. Healthcare is now understood as a complex, possibly the most complex, socio-technological system. Despite this the use of a 20th century linear investigation model is still recommended for the investigation of adverse outcomes. In this review, Isherwood and Waterson use data gathered from the investigation of a real life healthcare near incident and apply three different methodologies to the analysis of this data. They compare both the methodologies themselves and the outputs generated. This illustrates how different methodologies generate different system level recommendations. The authors conclude that system based models generate the strongest barriers to improve future performance. Healthcare providers and their regulatory bodies need to embrace system based methodologies if they are to effectively learn from, and reduce future, adverse outcomes.- Posted
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This dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. This dissertation uses case studies to show the interweaving of organisational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sense making at both the field and organisational leadership levels of the organisation.- Posted
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This review in the Journal of Clinical and Diagnostic Research explains the basics of audit and describes in detail how a clinical audit should be performed and monitored. It includes information on the 'Audit Cycle' and 'Ten Tips for Successful Audits'. -
Content Article
Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses. To improve the effectiveness and utility of these efforts, the Institute of Healthcare Improvement have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so they have renamed the process Root Cause Analyses and Actions, or RCA2 (RCA “squared”) to emphasise this point. The purpose of this document is to ensure that efforts undertaken in performing RCA2 will result in the identification and implementation of sustainable systems-based improvements that make patient care safer in settings across the continuum of care. The approach is two-pronged: Identify methodologies and techniques that will lead to more effective and efficient RCA2. Provide tools to evaluate individual RCA2 reviews so that significant flaws can be identified and remediated to achieve the ultimate objective of improving patient safety. The purpose of an RCA2 review is to identify system vulnerabilities so that they can be eliminated or mitigated; the review is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues.- Posted
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BioPhorum has developed a risk-based deviation management system (DMS). 13 member companies have implemented this approach, and summary data from these companies shows improved quality performance plus an average time saving of 22,200 work hours per site per year, which is equivalent to a $888k cost saving. An effective deviation management process is one that identifies and removes risk from processes using root cause analysis (RCA) principles and a corrective and preventive action (CAPA) programme. The current model used by many biopharmaceutical companies considers all deviations or events are equal and require a 30-day closure, known as the ‘30-day rule’1. Treating all events as equal and following the ‘30-day rule’ drives an inefficient process and wasteful behaviours. This guide outlines the work of the BioPhorum DMS Workstream in defining and creating a simplified and effective risk-based deviation management system with advanced RCA methodologies, and a track-and-trending process of low-risk events. It includes everything required to build a risk-based approach to DMS, including the business case for change, the new process, risk-based tools, and a detailed sharing of post-implementation benefit.- Posted
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The Health Index is a new tool to measure a broad variety of health outcomes and risk factors over time, and for different geographic areas. This methodology article explains how the Health Index has been constructed.- Posted
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The Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.- Posted
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This programme referred to as CUSP is an intervention methodology that will help you to learn from mistakes and improve your team's (and organisation's) safety culture. Watch this Johns Hopkins Medicine's video on CUSP.- Posted
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Improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable. It’s about giving the people closest to problems affecting care quality the time, permission, skills and resources they need to solve them. As we shift from the emergency phase of COVID-19 it is vital that health and care workforces are able and supported to lead radical service change and improvements through re-starting, re-designing or developing new processes, pathways and services. This guide from the Health Foundation offers an explanation of some popular approaches used to improve quality, including where they have come from, their underlying principles and their efficacy and applicability within the healthcare arena. It also describes the factors that can help to ensure the successful use of these approaches and methods. to improve the quality of care processes, pathways and services. It is written for a general health care audience and will be most useful for those new to the field of quality improvement, or those wanting to be reminded of the key points.- Posted
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NHS East London: QI Essentials. Beyond Projects
Claire Cox posted an article in Implementation of improvements
Improvement is now becoming a way of life and a way of being. How do we hold onto and strengthen our approach to QI projects? Have a read of Amar’s latest QI Essentials Blog. Amar Shah is a consultant forensic psychiatrist and Chief Quality Officer at East London NHS Foundation Trust.- Posted
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When patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer. This framework provides staff and medical staff with: a standardised methodology including a common analysis language; and standardised analysis tools for reviewing clinical adverse events and close calls. There are three methodologies described within this handbook that can be used to review clinical Adverse Events. These methodologies are designed to suit the scope of a clinical adverse event or multiple clinical adverse events, and provide flexibility for the user. The Concise method is commonly used for a succinct review of close calls or clinical adverse events that result in no, low, or moderate harm to the patient or may focus on a new event for which a Comprehensive analysis was recently completed. The concise method is generally used for reviews conducted by one or two individuals. The Comprehensive method is used for a thorough review of a single clinical adverse event and involves a team approach. The Aggregate method involves a thorough review of multiple clinical adverse events and/or quality assurance reviews. This method is resource intensive and involves a team approach.- Posted
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