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Showing results for tags 'Organisational Performance'.
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Community PostI'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.
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News ArticleYesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients. Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated. However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent. "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive." Read full story Source: The Independent, 17 September 2020
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Event
Introduction to Human Factors & Performance Science - Distance Learning
Patient Safety Learning posted a calendar event in Community Calendar
untilThis unique 1-day distance-learning course from Medled is delivered via Zoom by our expert trainers in a format designed to maximise learning retention and application of knowledge. You'll learn to: Understand the concept of systems thinking and models of safety – looking beyond the individual and the flawed concept of ‘Human Error’. Gain an introduction to human capabilities & limitations & how those influence quality and safety of care – how humans can be heroes and hazards. Be able to unpick the nature of human fallibility and why practice does not always make perfect. Have the knowledge to proactively contribute to the safety culture in your organisation. Be able to recognise error-provoking conditions and influence your systems of work. Understand the relationship between stress and performance/risk of error. Take away a tangible model for understanding the relationship between our physiological needs and performance – do we set ourselves up to fail? Understand strategies to optimise high-performance teamworking with ad hoc teams. Evidence-based, utilising cutting edge safety & performance science this course is suitable for all Healthcare Professionals, both clinical and non-clinical; it is applicable to all departments and multi-disciplinary teams. Accredited by Chartered Institute of Ergonomics & Human Factors, you'll take part in interactive actitvities and leave with practical tools to take away. Registration -
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Letter from America: “We got trouble my friends”
lzipperer posted an article in Letter from America
Meredith Wilson’s “The Music Man” is an American musical set in 1900’s River City Iowa. First seen on Broadway and then as a 1960s film, the story rests on hope that arrives in town on the shoulders of a con man, Harold Hill. There are lots of themes we could track from this story into our times today – but one scene in particular is on point for this month’s letter. Hill distributes music and instruments to his students with instructions to practice on their own and they come together to play for the town. Let’s just say it doesn’t go so well. Although committed to the goal, the kids can’t play the music without solid instruction, synchronised development, collective practice and effective leadership. A band needs to follow the same score of the same tune in order to MAKE music that works. The COVID response in the US seems to have put patients, the public and clinicians in a situation similar to that of the River City kids. States, schools and cities seem to be playing from different arrangements of the same tune resulting in a lack of coordination and consistency across the country. The result is not just noise but profound failure. Ed Yong in The Atlantic summarises the systemic discord that has contributed to an estimated 183,000 deaths in the US. He highlights how despite ample warnings the country was unprepared for a pandemic, and suggests it remains unprepared for the next one. Weaknesses in leadership, testing, state policies, data capture and dissemination, public health infrastructure and information inaccuracies set the stage for the spread of COVID. Lack of respect for science, ingrained bias against people of colour and an ineffective health system perpetuated much of what could have been prevented. The situation Yong describes in his article has led the USA to a patchwork response to the pandemic. Across the country a variety of populations are being put at risk. For example, students and teachers at colleges and universities are having to navigate their way through the crisis – sorting through local concerns and statistics to devise a course that will serve their communities best while serving a mobile population of students who come from home to learn while potentially carrying or picking up the virus to take home or to their dorms. As examined in Kaiser Health News students arriving for classes are experiencing varying approaches to testing, hybrid online/in person class models and stay-at-home and masking orders. And should students become ill, universities may not be well equipped to keep those patients safe. Strategies to address these problems from politicians, researchers and healthcare abound. There is a recognised need of a national policy that aligns efforts to manage the COVID situation. As noted in USA Today, countries that have had relative success in managing the virus, such as Germany and Denmark, have a collective approach to address the problem they have committed to. The article compares international responses to those of the US to illustrate gaps and highlight areas where coordination and collaboration are desperately needed to move the country’s effort forward. Healthcare seems particularly suited to offer suggestions for improving the situation. The American Association of Medical Colleges recently published a guidance to set a direction for a safer future. The Way Forward on COVID-19: A Road Map to Reset the Nation’s Approach to the Pandemic outlines 11 recommendations to support and motivate the nation to adopt a systemic, collective plan to reset the country. Informed by expert insights from a variety of fields, the document shares actionable suggestions on topics such as testing improvement, national standards on face coverings and other safety protocols, and vaccine deployment planning. Suggestions include undertaking research to determine efficacy of face coverings to reduce transmission of COVID-19, distribution data to compare the impact of school reopening and designing a government-funded vaccine distribution and use process that involves a wide range of providers. The Music Man ends with a rousing performance of “76 Trombones.” The kids in the band follow a course toward success, resplendent in full uniform, high stepping and proud, seamlessly working together. The families and townsfolk people beam with accomplishment and join in on the celebration of collective achievement. When will we be ready to take up our instruments and perform cohesively together with no one left behind due to having a different COVID-19 score? -
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News ArticleA quiet revolution in the NHS has happened. After decades of an internal market, NHS England has outlined new changes tying financial allocations and incentives to system-level performance instead. Over the past six months, providers had been allocated block funding based on activity from 2019/20 with top-ups and retrospective funding to support covid pressures, ensuring they financially break even during the crisis. Now, in a letter accompanying funding envelopes for Integrated Care Systems and Sustainability and Transformation Partnerships around the country, NHSE outlined how health service finances will be system managed for the remainder of the year. Systems will have not only control of the kitty (with all system costs to be met from its allocation) but funding will be linked to the performance of their member organisations, with some incentive payments or penalties for over/under performance at a system level. Glen Burley, the chief executive of a group of three acute trusts in the West Midlands, branded the move “very risky” and suggested a more traditional tariff performance would drive performance. Highlighting another of his concerns he said: “We have very little experience of doing so at system level, so this is a very risky tactic in a very risky year.” How systems will manage the shortfalls will hinge on elective delivery, system co-ordination, how to reduce forecast costs and recover income, set, of course, against the threat of a second wave of COVID-19. Read full story Source: HSJ, 17 September 2020
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The challenge of culture change in the NHS
Claire Cox posted an article in Culture
The first presentation draws on a recent National Institute for Health Research (NIHR) funded mixed-methods evaluation of the translation into practice of several ‘post-Francis’ policies that have aimed to improve openness in the NHS, and identifies key conditions necessary for policies to make sustainable impact on culture and behaviour. The second presentation reflects on material from a forthcoming book which will offer unfiltered accounts from patients, carers and healthcare professionals about their good and bad experiences of how care is organised, from birth up to the end of life. Their testimonies indicate the salience of kindness and attentiveness combined with efficiency and competence. Finally, the context for a culture of openness and for patient-centred services will be presented, alongside the development of a culture change programme which is being used in 70 Trusts in England. Significant and unacceptable variations in the availability of high quality care and in staff wellbeing persist across the NHS and social care, exemplified by very different COVID-19 experiences across the sector. How far does this kind of research on culture and these kinds of programme interventions help us to gain whole system traction in this important area of laying the conditions for reliably compassionate patient care? How can positive cultures and new working practices that have developed during the COVID-19 pandemic be sustained? -
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News ArticleA GP practice serving one of Greater Manchester’s most deprived communities has been banned from operating for four months after regulators uncovered a catalogue of basic failures - including failing to follow up on a child reporting breathing difficulties for three days. Jarvis Medical Practice in Glodwick has had its registration with the Care Quality Commission (CQC) suspended after ‘serious concerns’ passed to the body led to a snap inspection last month. Inspectors found the practice, based at Glodwick Primary Care Centre, was failing 20 separate standards, many of them relating to patient safety. It noted ‘poor quality’ and conflicting records that were sometimes impossible to properly understand and urgent home visits delayed or not carried out at all. In one case a patient with a lump apparently received no physical examination and was not referred for tests or scans ‘due to Covid-19’. Inspectors also found examples of patients with breathing difficulties, including a child, who were not dealt with for days after they got in touch. In one case no further contact was made for 11 working days, with no explanation provided in the patient's notes. The practice, which serves more than 5,000 patients in the Oldham neighbourhood of Glodwick, has now been suspended by the CQC until October 11. Read full story Source: Manchester Evening News, 17 July 2020
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News ArticleDaniel Mason was born half a century ago without hands, with missing toes, a malformed mouth and impaired vision. From an early age, he and his family had to deal with people asking about his disabilities. The impact on his life has been considerable. Daniel’s mother Daphne long suspected the cause of his problems was a powerful hormone tablet called Primodos that was given to women to determine whether they were pregnant. But when she raised her concerns with doctors, they were dismissed. Now, at last, Daphne has been vindicated with official confirmation this week that her fears were right, in the landmark review by Baroness Cumberlege into three separate health scandals that has exposed a litany of shameful failings by the NHS, regulatory authorities and private hospitals. This damning report shows again the danger of placing a public service on a pedestal, with politicians happy to spout platitudes but scared to tackle systemic problems or confront the medical establishment. But how many more of these inquiries must be held? How many more disturbing reports and reviews must be written? How many more times must we listen to ministerial apologies to betrayed patients? How much more must we hear of ‘lessons being learned’ when clearly they are largely ignored? Read full story Source: Mail Online, 9 July 2020
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Content ArticleHealthcare safety is complex every day – yet the emergence of the novel coronavirus has made holes in the Swiss cheese of the system more apparent. UK psychologist James Reason’s now famous “Swiss Cheese Model” serves as a metaphor for this month’s Letter from America. As more details on the coronavirus emerge, and time enables reflection on what has transpired, deeper analyses will no doubt materialise. Knowledge is developing in real time, helping us see gaps in our safety barriers and providing valuable insight to the challenge of reducing harm. The Swiss Cheese model illustrates how latent weaknesses in the protective barriers that systems build exist and become more apparent after failures occur – if we look for them. COVID-19 is just such a test; it is amplifying the holes in today’s healthcare system. A recent New Yorker essay highlights the known weaknesses in healthcare visible long before COVID-19 – racial inequities, bureaucratic inefficiencies, drug shortages, under resourced public health initiatives and fiscal prioritisation to the detriment of preparedness. Others are more specific to the pandemic: lack of access to personal protective equipment and medical devices, supply chain disruptions, hording behaviours, misinformation and patients not seeking chronic, emergency or preventive care. The essay suggests that we should not seek to return to this “normal”, but to learn, revise and improve. Holes in processes to keep patients and workers safe are also expanding as the cheese melts. Healthcare worker illness, psychological strain and suicide are revealing fractures across US healthcare delivery that undermine the ability of clinicians to provide care as they work to keep patients and themselves safe. The US National Academies of Medicine has outlined an approach to protect clinicians’ wellbeing. Through a focus on organisational and national priorities, it aims to help sideline the negative after-effects that first responders to the COVID-19 crisis may experience through a call for funding, epidemiology and real-time support for providers. Efforts to diagnose COVID-19 are thick slices of cheese with a myriad of holes that affect both clinical and policy responses. As summarised in a recent commentary, the system response is a fundamental challenge: measurement is a mess, data are inconclusive, testing processes are inconsistent and results in some cases unreliable. While this state of affairs is rapidly changing, foundational concerns are likely to remain. Economic support for organisations and States rests on the data that are apt to be skewed, ineffective and counterproductive. The international disease codes used to document COVID-19 cases are being imprecisely applied. The authors of the commentary provide suggestions to impove the use of the diagnostic codes and thus the quality of the data collected. Actions in this area are needed to inform the research so we can understand what has happened and fund and design public health initiatives and reopening strategies that enable containment, testing and equitable treatment. As time passes, suggestions for improvement informed by national and local experience appear. Communities are painfully aware of the situation COVID-19 places them in. Experts there are contextually situated to address local challenges such as population instability due to unemployment, homelessness and food insecurity. A Health Affairs blog calls for strengthening the community-based workforce to assist in propping up vulnerable populations after disaster of any kind strikes, including COVID-19. Community health workers, volunteers and nonprofit organisations are highlighted as important players in testing and contact tracing strategy implementation, psychological support provision and establishment of the infrastructure communities need to face their specific challenges. It will take resources, tenacity and courage to facilitate and sustain community level COVID-19 response. Watching media coverage can be overwhelming but can also illustrate the complexity of addressing the disruptive tendencies of the coronavirus pandemic. Newspapers and healthcare media services can provide insight into the system-level complexity of the pandemic. These services are flagging and providing access to articles from the press or literature to provide a well-rounded collection of materials to track what is happening. It’s one way to remain keep abreast of the issues: who from racial, ethnic and socioeconomic groups are impacted, what programmes and industries are being altered, where specifically in the US the virus touches, when the threat emerged to affect a particular segment of the population or workforce and why the connections between them all are important to consider. This is highlighted in a recent commentary in the Lancet, which illustrated some of the interacting components in a society responding to the threat of COVID. Tools such as these can assist in keeping us informed to combat weaknesses in failure barriers that emerge due to bias from listening to one outlet or seeking only one point of view. No matter what slice of the COVID-19 Swiss cheese sits on the plate in front of us – its holes are apparent. Experts are calling for coordinated system-wide action to prevent further loss of life and economic hardships. Other challenges are likely to emerge the longer COVID-19 influences lives. We all need to learn from the lack of success during the current response manifestation and use those insights to inform actions to prepare for the next virus wave. It will help to navigate future choppy, uncharted waters. To prepare for the 'new normal', courage to see value in failure is paramount. We should also proactively apply learnings based on what went well to better prepare organisations, systems and governments to close holes in the global approach before the next wave.
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NHS: Specialty guides for patient management
Claire Cox posted an article in Guidance
These guides include: Surgical patients Othopaedics Critical care Endocrinology Trauma Acute General medical Burns Cancer ED Paediatrics NIV Rheumatology Management of COVID positive patients Cardiothoracics plastics Max Fax Vascular Spinal Surgery Radiology Cardiology Muscular Skeletal Haematology Maternity TB. -
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Revealed: The trusts which will struggle most to deliver quality care in 2020
Patient Safety Learning posted a news article in News
The trusts which are likely to face the fiercest struggle to deliver quality care in the immediate future have been identified through an analysis carried out exclusively for HSJ. Analyst company Listening into Action has taken data from the NHS Staff Survey 2019 to produce “a set of ‘workforce at risk’ numbers that point to the likelihood (or not) of workforce stability and continuity challenges adversely affecting the care a trust’s key assets are able to deliver in the year ahead”. The analysis shows a strong correlation between staffs’ perceptions of how well they are supported, and care quality — and therefore reveals which trusts face the toughest challenge to improve performance. Read full story (paywalled) Source: HSJ, 9 March 2020 -
Content ArticleKey take-away messages The healthcare organisation you work in is a system of interacting human elements, roles, responsibilities and relationships. Quality and patient safety are performed by your human-designed organisational structures, processes, leadership styles, people's professional and cultural backgrounds, and organizational policies and practices. The level of interconnection of all these aspects will impact the distribution of perception, cognition, emotion and consciousness with the organisation you work for. What goes on between people defines what your health system is and what it can become.
