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Showing results for tags 'Organisational Performance'.
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The Patients Association: A&E waiting times survey
Patient Safety Learning posted an article in Emergency medicine
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News ArticleAn Essex maternity department has been served with further warnings by the Care Quality Commission (CQC) and again rated “inadequate”. Serious concerns were raised about the services at Basildon University Hospital in the summer, after several babies were found to have been starved of oxygen and put at risk of permanent brain damage. Despite the CQC issuing warning notices to Mid and South Essex Foundation Trust in June 2020, a subsequent visit on 18 September found multiple problems had persisted. The CQC’s findings at Basildon included: the service was short-staffed and concerns were not escalated appropriately multidisciplinary team working was “dysfunctional”, which sometimes led to safety incidents doctors, midwives and other professionals did not support each other to provide good care. Read full story (paywalled) Source: HSJ, 19 November 2020
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Content ArticleStory highlights Organisations are more resilient when employee engagement is strong, Hiring employees based on talent will help organisations thrive. Changes in the employee experience may help retain your top talent.
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Content ArticleProblems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?
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Content ArticleI believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
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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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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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