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In the late eighties, I attended a presentation on the future of the UK Medtech sector presented on behalf of the government by KPMG. The main message being the government’s desire for the industry to focus on research and development whilst transferring manufacturing to China! What relevance does this have to patient safety? Fast forward some twenty years and I am presenting the case for adoption of one of our most successful unique patented patient safety products (successful global use at this point around the 5 million patient level) to one of the largest NHS trusts. The difficulties faced by industry The trust we presented to operates a clear policy that industry should not even provide literature on products to any clinician unless procurement permission is given. We complied with this policy and were invited in to present after an anaesthetist had highlighted that the trust had experienced patient injury from the current standard practice of using rolls of tape to secure patients' eyes during anaesthesia to protect from hazards and prevent the eyes from drying out causing potentially serious harm. Our product literature carries an endorsement from the Association of Perioperative Practice who clearly state that the practice of using tape to address these issues is “not recommended and that Eyepads fit for purpose should be used”. The meeting is attended by a man from procurement and a Sister from the trust with many years of experience in her role. I present the product case and pass samples to the Sister. Within a minute of handling the product she dismisses the product as “expensive nonsense”! The man from procurement proclaims the session over and we part company. The anaesthetist that initiated the meeting was not present and was not allowed to take her desire to try our solution any further. This story is reflective of not only our experience but typical of the path we and other Medtech companies encounter in attempting to introduce new innovative patented solutions to the NHS UK companies. The drive towards ever cheaper manufacturing adoption by the NHS is led by NHS supply chain, dominating the tendering market for products with multiple manufacturing sources. The NHS is now globally recognised as a procurement-driven market, focussed on reducing costs through purchasing and negotiating lower pricing. An organisation that issues “zero inflation pricing increase” policies. This can be very effective and is certainly a major driving factor in the success of the multitude of Chinese manufacturing companies supplying the NHS. A market that has produced a multitude of failed schemes for the adoption of new technologies in favour of sourcing ever cheaper, often poor quality products. But we did not jump on that bandwagon and instead chose to continue working with the best patented technological solutions emerging. We recently had the pleasure of working with Helen Hughes and Patient Safety Learning on a webinar presenting one such product. We introduced this product over a year ago and immediately engaged with the latest NHS Accelerated Access Collaborative innovation adoption scheme. In the webinar I described how this and all of our other efforts had failed to make any serious impact other than producing great results with a small band of community health nurses. Then COVID-19 strikes and almost overnight procurement is bypassed. There is a priority in addressing shortages of products perceived as vital in maintaining care levels in the impending increased demand due to COVID-19. This leads to the successful sale of several hundred of our units. However, when the government moves to address the issue through large scale purchase of the product, our solution is dismissed and offered no part of the contracts awarded in a process that was uncannily like the experience described above. A culture of cost cutting and fear Management of the NHS is an enormous undertaking. However, I would suggest that many years of focus on cost cutting has delivered a culture of fear and apathy toward the adoption of the amazing new technologies that can transform care. The plethora of schemes for innovation adoption that we have engaged with over the years have failed, often at the outset, simply due to inadequate funding and planning. During this period industry has also had to bear the substantial increased costs of product and staff regulatory changes. When I engage with some of these schemes, I cannot understand why there are so many companies in the mix pitching products and services that have nothing to do with healthcare, but offer instead procurement or management “more efficient management” tools! Some trusts appear to be more concerned with this aspect than the actual delivery of healthcare. One trust insists that we supply our products through a third-party purchase company because the product they buy is not listed on NHS supply chain. They have now ceased to order after the third-party supplier entered administration, owing us several thousand pounds! In November we will launch a new patented product with patient safety benefits, invented by two operating department practitioners (OPDs) in Liverpool. We will manufacture the product in the UK and manage global marketing from the UK. However, we are currently focused on marketing the product overseas; engaging with NHS procurement is not a priority. I know other companies have that same view. It’s recognised that efficient procurement is an important element of NHS management, largely developed from the political direction in the Eighties on cheaper globalised manufacturing policies. Unfortunately, whilst to some degree it has been very successful in cutting costs, patient and staff safety has on occasion been compromised. There is now a culture of cost cutting with procurement completely focused on this. Call for action NHS adoption of new beneficial technologies is woefully inadequate and remains largely under the control of procurement services often disinterested in it and unqualified to manage it. For patient and staff safety to benefit, I would like to see: Simplified fast-tracked product assessment procedures managed by appropriately qualified staff. The removal of products and services designed for healthcare management from the assessment of products directly involved in improving healthcare outcomes. Our current structures are simply not fit for this purpose.

Over the last 3 months we have seen NHS organisations work at lightning speed to adapt and serve their communities in response to the COVID-19 pandemic. With the shutting down of routine surgeries and outpatient services, care providers have adapted in an extraordinary way. Wards have been emptied as beds have been made available, while theatres and recovery rooms have been turned into intensive care beds – capable of looking after acutely unwell ‘level 3’ patients – overnight. These unprecedented changes deserve praise and commendation but, beyond this praise, what can we learn from COVID-19 and the scale of change we have seen? It was famously argued that it takes 17 years for research to impact frontline services.[1] . Due to this, immense interest has centered around how innovations, or new ideas, are diffused and how this process can be sped up.[2] Various barriers exist to the spread of new ideas and change – not limited to bureaucracy, a lack of resources to create change, and cultures – for example organisational culture. Due to these barriers the NHS and its subsequent organisations can appear as monolithic – slow to change or adapt to any innovations. But COVID-19 has turned this assumption on its head, with expansive structural and procedural overhaul seen in the last few months alone. It has led observers to ask how this has happened and, more importantly, how we can facilitate change in the future. As we reflect on these months, the psychology of a crisis can be helpful in understanding staff behaviour. There are three stages – emergency, regression and recovery.[3] In the emergency stage, energy and performance goes up as staff ‘fire fight’ in the crisis. However, the move towards the regression and recovery stage will see staff become tired and lose their sense of purpose before needing direction on how to recover and rebuild. These latter stages are symptomatic of the current state for NHS staff. Utilising theories of change, perhaps we can identify why this change happened so quickly. The impending doom felt by staff was palpable in March. The Nightingale field hospital was being built to cope with the immediate storm of COVID-19 patients needing ventilatory support and providers were told to free up beds. In business, this is coined the ‘burning platform’ and is a key driver of change. A burning platform is a term which describes the process of informing people of an impending crisis and is used to cultivate immediate change. This ‘burning platform’ is a simple analogy and based on an incident in 1988 of an oil rig worker who, when faced with an impending burning platform, jumped into freezing water. Whilst of course this sense of urgency can’t be replicated every time change needs to happen, for professionals working at the start of the pandemic, this is exactly what was replicated. Perhaps change happened so fast as professionals and staff had no other choice but to respond to the burning platform of COVID-19. Creating a sense of urgency is also argued as being integral to another organisational theory of change – Kotter’s 8 Step Process for leading change. The first stage – creating a sense of urgency – is characterised by a distinctive attitude change which leads workers to seize opportunities to make changes imminently. But NHS staff have already responded to the immediate urgency presented by COVID-19, so what happens next will be telling. Apart from creating the NHS’s own burning platform, adaptations that can be seen across the NHS are not following any other theory of change. The NHS – a highly complex and bureaucratic set of organisations – has seen providers innovate, change and adapt without the traditional ‘red tape’ of the NHS. NHS providers are no longer following a model, instead working out what is best for the patients they serve. For community providers and primary care this includes virtually treating patients to limit their risk to COVID-19. Changes that have taken years to discuss are now happening overnight – for example some hospital providers integrating IT systems to improve cohesion. With so many innovations, it is crucial that we learn from what is happening. Organisations should be supported to identify and collect information on the changes that are happening on local levels. With this wealth of information, organisations can learn what made local change possible and what the drivers of innovations were. This insight is undeniably useful as it can help us all understand the drivers of change locally and galvanise change in the future. This must be made into an organisational priority. While organisations remain in firefighting mode, now is a crucial time to take stock, capture these changes, and hold on to what is useful as the NHS – and wider society – recovers. References 1. Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011;104:510-20. 2. Turner S, D’Lima D, Hudson E, Morris S, et al. Evidence use in decision-making on introducing innovations: A systematic scoping review with stakeholder feedback. Implementation Science 2017;12. 3. Wedell-Wedellsborg M. If You Feel Like You’re Regressing, You’re Not Alone. Harvard Business Review [Internet] 2020.

Ideas about resilient systems are now becoming better known in the healthcare community, but the most common question asked is “this is great but how do I put it into practice?” CARe QI provides the answers. The aim of CARe QI is to help people to apply the insights of resilient systems and ‘Safety II’ to the design, implementation and evaluation of quality improvement interventions. It is a structured collection of information, tools, guidance and documents that helps you to develop interventions to strengthen system resilience and in turn improve quality and safety. In the handbook you will find an overview of the arguments for improving quality through resilience, followed by step by step guidance in applying the method and downloadable worksheets to help you to document your own project. There are four main steps to CARe QI – setting up the project, capturing work as done, describing resilience in everyday work and choosing resilience interventions and outcome measures. The foundation of CARe QI is that you understand your clinical system in depth before starting to design and implement interventions.

After working last week and caring for patients who were pending COVID-19 swab results, four days later I woke feeling unwell. A slight cough, tired, pale, feeling freezing cold but no temperature and generally feeling rubbish. This carried on for a few days, I then ended up with common cold-like symptoms and a residual cough. Normally, I probably wouldn’t call in sick, I would have just carried on. Following current guidance, I called in sick and was advised to take the next 7 days off. At this point testing was unavailable for NHS staff. I was sat at home not knowing if I had the virus or not while my colleagues were having to pick up the slack. If I am completely honest, I was glad I didn’t have to go back. I was anxious that we didn’t have the right personal protective equipment (PPE), systems for donning and doffing were not in place, we didn’t know what to expect over the coming days, training for redeployed nurses and doctors was not happening. I just didn’t want to go back anyway. I felt a coward. Over the coming days while I was at home, my husband then became ill, then my youngest son, then the eldest. All with mild symptoms, but still no idea if we had it or not. While I was off, I was contacted by the ‘staff welfare team’. It was just a quick phone call to see how I was, but it made all the difference. I felt like I wasn’t just a ‘worker’ off sick, I was someone that they cared about and were obviously keen to make sure I was coming back! This has never happened before. Reluctantly, I return to work, but it was like I had stepped into a different Trust. Wards with infected patients were labelled as RED wards; huge signs were outside the wards with designated places to don and doff PPE. There were clear guidance on which PPE to wear displayed in poster format. There were green footsteps and red footsteps on the floor enabling you to know which area you were in. PPE safety officers had been deployed to reassure and ensure all departments have enough stock. It felt safer. Leadership at all levels is being tested at this time. Where I work in Brighton, we are invested in ‘Patient First’. This is headed up by our Kaizen Team. All staff are trained in differing levels of quality improvement (QI). All wards and departments have improvement huddles, where they can raise a mini project and see it through. We all speak the same QI language. I dread to think what would happen if we didn’t have this in place during this awful time. By having this process, it has empowered ALL staff to speak up and give permission for frontline staff to improve processes where they work. Our executive leadership team have done an amazing job in such a small amount of time. They have increased ITU capacity, they have reshaped rotas, redeployed staff, re employed staff, transformed patient pathways (red and green pathways), pooled staff, set up systems for donations… There has been so much achieved in a short amount of time; the top-level organisation has been incredible. All this in seven days. They have been phenomenal at strategy, planning and overall management and leadership of what I call ‘the big stuff’. What they are not so good at is the ‘small stuff’. We, frontline workers are brilliant at this. The practicalities of work – where can I don and doff, where the bins should be, how do I know this bed has been cleaned? What do we do when someone dies? Can relatives visit? How do we know who is who in PPE? How can we make sure we don’t contaminate clean areas? How do we take blood now? We know what needs to be improved, we know what is missing. It’s the small details that worries staff, it’s the small details that can save lives. As I was walking seeing patients from different wards, I heard staff saying – this isn’t right – we could improve that. They can raise a ticket on the huddle board and they could initiate the change. If the change could be replicated else where in the Trust, the Matron or ward manager can then raise it at the Bronze meeting, the bronze would then raise it to Silver and then implemented. I often hear that we use a top down, bottom up approach but never really thought it works, as there is so much red tape involved in healthcare. Quite often frontline ideas never reach the top level and they fall flat. This time it’s very different. To test the system, you need to stress the system. This system of QI and communication is working. We are all learning together. None of us have dealt with a pandemic before. Frontline staff have been given the permission to improve the way real work is done, quickly and safely, while the top-level management are concentrating on strategy, planning, implementation and co-ordination of services. We are listening to each other, we are rapidly changing and adapting, the whole Trust is in a constant state of PDSA cycles. It feels dynamic, proactive and controlled. If this pandemic happened 10 years ago in our trust, I am convinced that we would not be in the position we are now. We have enough intensive care beds, we have the capacity to expand further, we are ready.

Increased use of telephone and video consultations is expected during the current COVID-19 situation. In this video, the AccuRX (https://www.accurx.com/) system is being used. The system and process used by other practices may vary. A link to this video can be sent to a patient's phone by the surgery when a video appointment is booked so that they can prepare themselves for their video consultation.

The following four initiatives were selected to receive the HQCA’s 2019 Patient Experience Awards: NowICU Project, Neonatal Intensive Care Unit (NICU), Misericordia Community Hospital Rapid Access, Patient Focused Biopsy Clinic; Head and Neck Surgery, Pathology; University of Alberta Hospital Edmonton Prostate Interdisciplinary Cancer Clinic (EPICC), Northern Alberta Urology Centre Transitional Pain Service, South Health Campus Take a look at their presentations and find out more about these great initiatives.

Five tips: People aren't machines Push the button Differeing shapes and sizes Stamina and repetition Look around

In this book, Atul Gawande makes a compelling argument for the checklist, which he believes to be the most promising method available in surmounting failure. Whether you're following a recipe, investing millions of dollars in a company or building a skyscraper, the checklist is an essential tool in virtually every area of our lives and Gawande explains how breaking down complex, high pressure tasks into small steps can radically improve everything from airline safety to heart surgery survival rates.

This guide is for reviewers undertaking Structured Judgement Reviews (SJR's). A SJR is usually undertaken by an individual reviewing a patient’s death and mainly comprises two specific aspects: explicit judgement comments being made about the care quality and care quality scores being applied. These aspects are applied to both specific phases of care and to the overall care received. The phases of care are: admission and initial care – first 24 hours ongoing care care during a procedure perioperative/procedure care end-of-life care (or discharge care) assessment of care overall. While the principle phase descriptors are noted above, dependent on the type of care or service the patient received not all phase descriptors may be relevant or utilised in a review.