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Background: Acute kidney injury (AKI) in critically ill patients is multifactorial. There is little reliable UK data on the incidence and outcomes of patients with COVID-19 and AKI outside the ICU. At this stage we do not have a full understanding of the aetiology of AKI in COVID-19 and the pathogenic role of systemic inflammation, hypovolaemia or other COVID-19 related pathology (such as thrombotic microangiopathy) in its genesis. Volume status is critical in reducing the incidence of AKI but the balance between respiratory and kidney function can be challenging. Preventing avoidable AKI should be a key goal of the management of hospitalised patients, to reduce demand for renal replacement therapy (RRT). AKI should be promptly recognised and managed appropriately, within the limits of our current understanding. AKI confers an adverse risk of mortality and its presence reflects underlying morbidity and current illness severity. The presence of AKI should inform assessments of prognosis and in some cases the appropriateness of escalation of care. It is critical that we build on existing processes and knowledge and carry on doing the things we currently do well.

"The book describes how a process oriented management system, already well established in other safety critical industries, can be used in the healthcare industry to ensure patient safety. The principles of the management system are rooted in Safety 2 and the book gives practical. detailed instructions on how to create such a system, with processes that map out 'work as done'. The book also explains how healthcare differs from other industries and describes how to implement a safety management system within a healthcare organisation. Leadership, culture and learning also have central roles to play in patient-safe care and the author explains how the management system must work with these three elements. Aside from this, I particularly like the practical nature of the book and the way you give detailed instructions so it can serve as a manual for creating and implementing a management system, based on learning from other industries and the principles of Safety 2. I've seen other people advocate for the use of a safety management system in healthcare, but you have taken it much further than that. I've certainly not seen anyone giving such detail on the practical steps to take to create one." Jonathan Hazan Chairman at Patient Safety Learning. Chief Executive at Perfect Ward

In July, the PHSO submitted a report to the Public Administration and Constitutional Affairs Select Committee exploring the state of local complaints handling across the NHS and UK Government Departments. Drawing on evidence from a wide range of individuals and organisations, Making Complaints Count identified three core weaknesses in the existing complaints system: There is no single vision for how staff are expected to handle and resolve complaints. Staff do not get consistent access to complaints handling training. Public bodies too often see complaints negatively, not as a learning tool that can be used to improve service.[1] The PHSO stated in this report its intention to consult on a new Complaint Standards Framework for the NHS, aiming to “help create a stronger culture in which complaints are genuinely learned from”.[2] Patient Safety Learning believes that having an effective complaints process in healthcare is vital to improving patient safety, and in this blog we will set out our response to the consultation on this new Framework. Complaints: an untapped patient safety resource Too often complaints processes in healthcare are viewed in a negative light and patients and their families are not recognised as being a “primary source of learning for safety”.[3] Having an effective complaints system provides an important opportunity to learn from incidents of unsafe care. Patients experiences can be used to help identify patient safety problems, ascertain the causes of these issues and put in place remedial measures to prevent them from recurring. The absence of an effective system has often been cited in patient safety scandals as contributing towards the persistence of unsafe care. Robert Francis identified this in the Public Inquiry into the Mid Staffordshire NHS Foundation Trust, noting that complaints “were not given a high enough priority in identifying issues and learning lessons”.[4] More recently, the Independent Medicines and Medical Devices Safety Review stated that the current complaints system is “both too complex and too diffuse” to promptly identify safety issues arising from a medication or device.[5] It has also been long acknowledged that the complaints system in the NHS requires significant improvements, in terms of both the processes and finding an effective way of learning from complaints to bring about improvements. In the wake of the Mid Staffordshire Inquiry, a review of NHS hospital complaints, co-chaired by Ann Clwyd MP and Tricia Hart, made a number of recommendations for change in complaints handling and procedures.[6] More recently, a report from Healthwatch England which focused on how hospitals report on and communicate their work on complaints highlighted concerns about inconsistency in reporting and a focus on counting complaints rather than learning from them.[7] The consultation process for the PHSO’s Complaint Standards Framework was composed of a survey with several questions and a section in which to add any additional comments. Below is the response provided by Patient Safety Learning in the additional comments section. Consultation response Patient Safety Learning welcomes the PHSO’s Complaint Standards Framework and its recognition of the need to reform the NHS complaints system. From a perspective of making improvements for patient safety, we welcome: The statement that organisations should “have clear processes in place to show how they capture learning from complaints, report on it, and use it to improve services”. Its acknowledgement of the importance of sharing learning and complaints widely with other organisations in healthcare. The identification of the need for clear complaints governance structures, ensuring the feedback is regularly reviewed by staff at a senior level. Its recognition that an effective complaints system is intrinsically linked with promoting a Just Culture in healthcare, one that is less focused on blame and encourages transparency and accountability when mistakes occur. Implementation We note that this Framework is focused on providing “a shared vision for NHS complaints handling” rather than looking in more detail at how this would be put into practice.[8] While we welcome many of the aspirations set out in this, its implementation will ultimately determine its effectiveness in reforming the NHS complaints system. Too often, there exists a gap between learning and implementation in healthcare. We may know what improves patient safety, but in practice such measures can often remain siloed in specific organisations, resulting in patients continuing to experience harm from problems that have already been addressed. If this Framework is to create a more effective complaints process, one which contributes to improving patient safety, we feel that there are several issues that will need to be addressed prior to its implementation: It will need to be clear how organisations report on their progress in implementing the Framework. There will need to be guidance on how organisations report on their implementation of the Framework and a level of transparency and consistency to allow for monitoring and comparison. It needs to be made clear who is responsible for ensuring that organisations will design this approach to complaints into their governance structures. There is also the question of how this change will be monitored. In the consultation survey, the PHSO pose a question related to this, asking whether they “should be given legislative powers to set and enforce national complaint standards for the organisations it investigates”. At Patient Safety Learning, we think that it is vital that this process is monitored. However, we question whether the PHSO, specifically, can do this, in terms of whether it has both the legislative remit and the resources for this undertaking. In practice, we suggest that this role would sit better within the remit of the Care Quality Commission and its existing inspections regime. We feel this issue needs further consideration. Public reporting As mentioned previously, we believe a key question that needs to be addressed before implementing the Framework is how it will be reported on by organisations, and whether reporting will be consistent to allow for monitoring and comparison. A recent report from Healthwatch earlier this year looking at hospital complaints highlighted the difficulties around this. It noted significant variations amongst different hospitals regarding how they reported on complaints (in terms of the data provided publicly) and, in some cases, whether they did actually report on these complaints.[7] It stated “because the regulations don’t require trusts to publish their annual complaint reports, we can’t know for sure how many of them are fully compliant with the regulations”.[9] Achieving the goals of the Framework may encounter similar challenges, not providing clear indications of how its suggestions should be implemented. For example, the Framework states that organisations should “report on the feedback they have received and how they have used that feedback to improve their services”.[10] We believe that this needs to be accompanied by clear guidance, for instance, stating that feedback should be publicly reported on a quarterly basis. Sharing good practice We welcome the strong emphasis that the Framework places on the need to learn from complaints, and to share this learning widely. We believe that complaints too often remain an untapped resource for making patient safety improvements; a negative view of these processes present a barrier to effectively utilising the insights they can provide. In our report, A Blueprint For Action, we note that “healthcare is systematically poor at learning from harm”.[3] This has also been recognised in the CQC’s report, Opening the door to change, stating that “there is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well”.[11] How we achieve this ambition of sharing learning from patient complaints widely between NHS organisations requires further consideration. Organisations need the means to be able to share learning from complaints widely and effectively with other organisations in the NHS, without this getting lost in “the avalanche of other information that bombards organisations daily”.[3] Patient Safety Learning welcomes the opportunity to collaborate with PHSO on this issue and to promote and share good practice on the hub. References PHSO, Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. Ibid. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020; Patient Safety Learning, Findings of the Cumberlege Review: patient complaints, 30 July 2020. Rt Hon. Ann Clwyd MP and Professor Tricia Hart, A Review of the NHS Complaints System: Putting Patients Back in the Picture, October 2013. Healthwatch, Shifting the mindset: A closer look at hospital complains, January 2020; You can find further reading on complaints in healthcare on the hub. PHSO, Have your say in shaping the future of NHS complaints handling, Last Accessed 18 September 2020. Ibid. PHSO, Complaint Standards Framework: Summary of core expectations for NHS organisations and staff, July 2020. CQC, Opening the door to change: NHS safety culture and the need for transformation, 2018.

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. Stewart Munro is Managing Director of Pentland Medical Ltd.

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.

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.