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Found 500 results
  1. Content Article
    Patient safety culture (PSC) is crucial for reducing medical errors and improving patient outcomes globally. This study aims to identify key improvement targets in China’s PSC to promote a safer healthcare environment. It found that while teamwork is a notable strength, there is room to enhance the nonpunitive response to errors. Improving feedback and communication practices can further bolster openness and collaboration within teams, leading to an overall healthier work environment.
  2. Content Article
    High-reliability organizations (HROs) operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. Interventions are designed to change thinking about patient safety and system performance through distinct HRO principles. The purpose of this review was to determine the effectiveness of implementing HRO principles on patient safety outcomes.
  3. News Article
    Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said. The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate. The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels. Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services". Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies. "This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture." Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team." Read full story Source: BBC News,15 May 2025
  4. Event
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    Jointly organised by the Institute for Healthcare Improvement (IHI) and BMJ Group, the International Forum on Quality and Safety in Healthcare has a rich history of supporting and energising the international movement for health and care improvement. Improvers from around the world attend the International Forum conferences every year as the place to get involved in key quality improvement discussions and learning, and forge relationships that drive improvement and innovation in health and care. The International Forum in Singapore will explore the key themes in health and care in the region and bring in perspectives and knowledge from around the world. The speakers and the programme have been announced! Keynote speakers, including Maureen Bisognano, Jonathan Perlin, and Steve Davis will share powerful insights on resilience, leadership, and driving meaningful change in healthcare. Register
  5. Event
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    Join Aqua for their national event, ‘Transforming Tomorrow Through Leadership and Improvement Today’ to connect, learn, and shape the future of health and care through co-production and partnership working. It will be bringing together healthcare leaders, innovators, and change-makers for an afternoon of insightful discussion and meaningful connections as we mark 15 years of the Advancing Quality Alliance being the leading improvement partners. With an exciting line-up of speakers and time for discussion and networking, this event is an opportunity for you to gain fresh perspectives and reconnect with peers. Register
  6. Content Article
    The 'Learning Response Review and Improvement Tool' is intended to be used by: Health and care professionals conducting safety learning reviews and investigations and writing or signing-off related written reports. It would also be useful for written reports related to complaints from patients, service users, families, and carers. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Educators involved in designing and delivering training programmes related to safety and/or complaints learning reviews. Leaders charged with undertaking national inquiries and investigations. The tool was developed and validated by NHS Education for Scotland (NES) in partnership with the NHS England Patient Safety Team and the Health Services Safety Investigation Body. The latter two organisations also recommend its use as part of Oversight processes for safety investigation and learning. The Tool is embedded in NES training programmes related to safety learning reviews. It has also been adapted and recommended for use in the New Zealand health system. Related reading on the hub: Top picks: PSIRF insights and opinions Top picks: PSIRF tools, templates and examples
  7. Content Article
    The US Agency for Healthcare Research and Quality (AHRQ) has released this rapid review examining the current literature on the effectiveness of programmes used by healthcare organisations to respond after patients experience harm during their care. The review focused on communication and resolution programs (CRPs) that included communication with the patient and family, event review, quality improvement, and in a qualifying subset of events, an apology for causing harm and an offer of compensation. The review found that while studies of CRPs’ effects have focused on organisational liability and cost outcomes rather than patient-oriented outcomes they did find ‘CRPs appear to have positive or neutral effects on the measured outcomes, with no significant negative effects. The findings support the implementation of CRPs while highlighting the need for more research about patient, family, and clinician-oriented outcomes.
  8. Content Article
    Patient safety is being put at risk in Emergency Departments due to missed doses of vital prescription medicines. This is one of the findings of a study being carried out by the Royal College of Emergency Medicine (RCEM) which revealed that many patients who rely on prescription medication to manage chronic conditions such as diabetes and Parkinson’s, aren’t always getting these vital drugs when in A&E. These types of drugs are known as ‘time critical medication’ (TCM) and, as the name suggests, it is important they are taken at specific times. If a dose is delayed or missed, it can cause a person’s health to worsen. And if this delay is prolonged, the consequences can be severe. The RCEM’s new report – Time Critical Medication QIP 2023-24 is part of the College’s clinical Quality Improvement Programme  (QIP), which aims to improve the care of patients attending Emergency Departments. The three-year QIP examines how time critical medications are dealt with in practice when patients come to the Emergency Department and how clinical methods and patient safety can be improved. This report reflects the findings of the first year of the programme. Across the UK, 136 Emergency Departments collated and analysed data for people living with diabetes and Parkinson’s, who take certain medication such as insulin injections and a drug called levodopa, taken as tablets or capsules. Supported by Parkinson’s UK and Diabetes UK, the QIP found more than half of eligible patients (53.4%) taking TCM weren’t identified within 30 minutes of their arrival in ED. Meanwhile, around 68% of eligible patients’ doses weren’t administered within 30 minutes of the expected time. In response to the findings, the QIP team made the following recommendations: Patients on TCM need to be identified early to start the process of getting all doses whilst in the ED. Systems need to be in place that will facilitate the timely administration of TCM, including self-administration. Local EDs must have a clear governance structure in place to determine who is responsible for the prescribing and administering of TCM in the ED from when the patient arrives, to when they are admitted to the ward or discharged from the ED. Further reading on the hub: Time-critical Parkinson’s medication: the human cost of delays and mistakes HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department Parkinson's UK: Time critical medication guides for health professionals Improving safety for diabetic inpatients: 4 key steps D1abasics: Equipping staff to care safely for inpatients with diabetes
  9. Content Article
    Patient safety is the core foundation of healthcare quality. Unsafe care is a significant challenge globally, due to unsafe practices, processes, or structural inefficiencies within healthcare organisations, which in turn lead to patient safety incidents. This white paper from ISQua aims to address these challenging issues by providing a comprehensive framework to improve patient safety in hospitals and other healthcare settings. The white paper focuses on four foundation pillars that it identifies as critical for embedding patient safety into healthcare systems: 1) Advocacy and Leadership Advocate for prioritisation of patient safety within hospital policies, practices, and culture. Ensure that patient safety is embedded as a core organisational value in every level of healthcare delivery. Establish a strong hospital governance structure that ensures leadership commitment to patient safety and accountability. 2) Health Worker Education and Safety To empower health workers with the knowledge, skills, and tools to be proactive agents of patient safety within healthcare organisations through continuous education and training programmes. It prioritises the physical and psychological well-being of healthcare professionals to enhance workforce resilience to deliver safe and effective care. 3) Patient, Family and Carer Engagement and Empowerment To empower and engage patients, families, and carers in patient safety efforts. To ensure effective collaboration between healthcare providers and patients to improve safety and quality of care delivery 4) Improvement in Clinical Processes Adopt evidence-based practices to manage patient safety risks in clinical care. Ensure standardising care, utilising technology, and measuring progress and effectiveness.
  10. Event
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    This webinar will look at how we can collaboratively and effectively utilise clinical audit to continuously improve patient safety, prevent avoidable harm and work together within our patient safety systems. The Clinical Audit Hero Award for Patient Safety will be announced and there will be the opportunity to hear the winner present their project for wider learning for us all. The event is hosted by the National Quality Improvement (inc. Clinical Audit) Network (N-QI-CAN) and the Healthcare Quality Improvement Partnership (HQIP). Register for the event
  11. Event
    This event will explore successful strategies for enhancing patient safety and driving quality improvement in mental health services. This timely event addresses the critical issues highlighted by recent high-profile incidents in mental health care. Keynote speakers, including Adrian James, the National Clinical Director of Mental Health, and Shubulade Smith, President of the Royal College of Psychiatrists, will share their experiences of leading organisations through challenging situations. Jonathan Warren, co-author of the Edenfield report, will also provide unique insights. Key themes: Supporting staff through traumatic incidents. Amplifying patient and family voices. Service redesign for safer care. Innovative use of data for improved outcomes. Learning from significant events to prevent recurrence. Balancing human rights with public protection. Interactive workshops will showcase best practices from pioneering trusts and innovative approaches, including assertive outreach and data-driven improvements. The event also provides valuable opportunities to network with peers and experts. This event is essential for clinicians, managers, trainees, and those in the voluntary sector aiming to navigate current challenges and shape the future of mental health care. By attending, you will: Attend learning lessons from serious high profile incidents in mental health – participants will learn how incidents have been managed, lessons learned and how to reduce prevention of similar events in future by service redesign Learn how to support staff affected by serious incidents – participants will learn successful strategies for supporting staff after serious incidents Hear strategies for re-designing services to reduce harm to patients including the use of date for quality surveillance Know how to balance the human rights of individuals against protecting the public. Register
  12. Content Article
    Nominations are now open for the Patient Safety Hero Award—one of five main award categories in the Healthcare Quality Improvement Partnership's (HQIP's) 2025 Clinical Audit Heroes Awards. This award recognises clinical audits and quality improvement projects supporting improved patient safety. To enter, complete the nomination form by Sunday 27th April 2025. What are the judges looking for? Excellence in clinical audit and/or quality improvement, supporting real and impactful improvements in patient safety, should be demonstrated. More specifically, submissions will be judged on the following criteria: Clear project design involving robust clinical audit(s) or similar evidence/data-informed quality improvement Evidence of improvements in patient safety made as a result of the project, preferably providing data Wider impact on patient outcomes and experience, or on healthcare service provision. The following additional criteria will also be taken into consideration: Consideration of sustainability and/or longevity Innovative approach.
  13. Content Article
    Integrated care systems (ICSs) have a key role in tackling health inequalities—this goal is set out as one of the four core principles of ICSs, alongside improving population health, enhancing value for money and making a wider social and economic contribution to society. Tackling health inequalities and their causes are at the centre of ICS strategies and joint forward plans, but system leaders need support to do this. This framework was developed by the Care Quality Commission's (CQC's) partnership with National Voices and the Point of Care Foundation and aims to support a whole-system approach to embedding meaningful engagement and reducing health inequalities. It helps ICSs identify marginalised groups and assess their current engagement strategies. Where gaps are identified, the framework encourages collaboration with external networks that have stronger ties to these communities, all aimed at tackling health inequalities.
  14. Content Article
    Research suggests that insights from patient narratives—stories about care experiences in patients' own words—contain information that can be used to improve care. However, assessments of narratives reported by clinical personnel have been mixed. This US study aimed to systematically measure how useful staff in primary care perceive patient narratives to be. The authors surveyed 276 clinical and administrative personnel in nine primary care clinics in a large health system in the USA. We found that perceived usefulness of patient narratives is generally high, but varies by individual characteristics such as level of burnout and professional role, and with organisational characteristics such as a clinic's learning orientation and history of using patient feedback to improve quality. These findings imply that narratives can be useful for improving primary care and that their perceived usefulness is greater when organisational practices facilitate learning from patients' narrative feedback.
  15. Event
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    The International Forum on Quality and Safety in Healthcare is a series of international conferences that inform and inspire healthcare leaders, practitioners and patients towards a better, safer and higher quality of care. With almost 30 years of history, the International Forum supports and energises the movement for patient safety and healthcare improvement by bringing in knowledge, ideas and expertise that inform quality projects and practice transformation worldwide. Over 5,000 participants from 80+ countries attend our International Forums each year and tackle today and tomorrow’s critical health and healthcare challenges. They connect to form long-term partnerships and to consider new ways of thinking about healthcare. Register
  16. Content Article
    Despite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. The case study aimed to involve maternity service users in the co-design of clinical resources for a maternity improvement programme, using a four-stage approach: 1) establishing guiding principles for PPI in the pro gramme, 2) structuring PPI for the programme, 3) co-designing improvements with PPI, and 4) seeking feedback on PPI in the co-design process. Partnership-focused frameworks and other literature on PPI and co-design informed the guiding principles. The structure included a five-member PPI group who provided continuous input, and an additional 15-member PPI group who met twice to discuss experiences of obstetric emergency. PPI in the co-design processes shaped the development of the resources in multiple ways, such as strengthening the prominence given to listening to those in labour and their birth partners, ensuring inclusivity of visuals and language, and developing communication princi ples informing all resources. Feedback suggested that PPI members felt valued, listened to, and supported to provide unanticipated contributions. The case study demonstrated how a principled approach to PPI enabled service users to play a key role in co-design of clinical resources aimed at improving the quality and safety of maternity care in the UK. Further case studies, across different clinical areas and with varying levels of resources, are needed to validate this approach.
  17. Content Article
    The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox, in this blog for the hub. Understanding QI in healthcare Quality Improvement (QI) refers to systematic efforts to enhance healthcare processes and outcomes through data-driven interventions. QI frameworks, such as the Plan-Do-Study-Act (PDSA) cycle, Lean and Six Sigma, focus on continuous monitoring, identifying inefficiencies and implementing evidence-based solutions.[1] By targeting system vulnerabilities, inefficiencies and variations in care, QI initiatives aim to foster a culture of patient safety and deliver consistent safe and effective care. However, as healthcare systems become more complex, can QI alone address the multifaceted challenges of ensuring patient safety? The role of QI in enhancing safety within the NHS QI plays a crucial role in enhancing patient safety by adopting systematic, data-driven methodologies to improve healthcare delivery. Within the NHS, numerous organisations have established QI initiatives, teams and trained personnel to improve the safety and efficiency of care. The recently introduced NHS Impact framework aims to equip all NHS organisations, systems and providers with the skills and techniques required to embed continuous improvement into everyday practice.[2] Strengths of QI in enhancing safety Data-driven decision making QI frameworks rely on real-time data to identify trends, measure performance and implement solutions. This evidence-based approach helps in proactively addressing safety risks and reducing adverse events.[3] By leveraging robust data analysis, NHS organisations can identify systemic weaknesses and implement targeted interventions to enhance patient outcomes. Systematic and scalable interventions QI methods, such as Lean and Six Sigma, focus on standardising processes to minimise variability in care. This is particularly beneficial in high-risk environments, such as surgical units, emergency departments and intensive care units.[4] The NHS’s systematic approach ensures that successful QI initiatives can be scaled across multiple settings, fostering consistency and reliability in care provision. Continuous improvement culture A core strength of QI is its emphasis on continuous learning and adaptation. By actively engaging frontline healthcare professionals in problem-solving, QI fosters a safety-oriented culture that promotes innovation and accountability.[5] Within the NHS, the NHS Impact framework underscores the importance of building a shared purpose and vision, investing in people and culture, developing leadership behaviours, building improvement capability and capacity, and embedding improvement into management systems and processes.[2] Reducing costs while enhancing safety Preventing medical errors and reducing inefficiencies not only enhances patient safety but also lowers healthcare costs. Many hospitals have demonstrated significant financial savings by implementing QI-driven safety initiatives.[6] By reducing avoidable harm and improving workflow efficiencies, the NHS can achieve cost savings while maintaining high standards of care. Governance, patient safety and the quality dilemma Governance in healthcare, often referred to as clinical governance, is defined as “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.[7] This involves monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation. A key challenge in QI implementation is navigating the quality and patient safety dichotomy. While quality improvement aims to enhance efficiency and effectiveness, it must not compromise safety. Balancing these aspects requires a structured approach, integrating QI methodologies with robust governance mechanisms to ensure that safety remains paramount. Limitations of QI in complex health systems 1. Resistance to change Implementing QI initiatives requires cultural and behavioural shifts, which can face resistance from healthcare professionals. Without strong leadership and engagement, efforts to improve safety may fall short.[8] 2. Fragmented healthcare systems Modern healthcare systems involve multiple stakeholders, including hospitals, primary care providers, insurers and policymakers. QI initiatives often struggle with alignment across these diverse entities, limiting their effectiveness in ensuring comprehensive patient safety.[9] 3. The need for holistic safety strategies Although QI is a powerful tool, it may not be sufficient on its own. Addressing safety in complex systems requires integration with other approaches, such as human factors engineering, regulatory frameworks and digital health innovations.[10][11] 4. Data overload and implementation challenges Although data is essential for QI, excessive reliance on metrics can lead to ’analysis paralysis’. Additionally, implementing QI interventions at scale can be resource-intensive, requiring time, training and financial investment.[12] In my experience, teams often seek more data, sometimes requesting information that we don’t have access to or that isn’t always reliable. There are times when data merely describes a potential problem rather than addressing it directly—but because gathering data is easier than implementing solutions, it can become the default focus, slowing progress. The use of emerging safety science tools for reviewing ‘work as done’ has yielded valuable insights into the discrepancies between ‘work as imagined’ and ‘work as actually performed’. These insights highlight the complexities and adaptive nature of real-world work practices, often revealing gaps between prescribed procedures and practical execution. However, while these insights provide a nuanced understanding of workplace dynamics, they do not always translate into tangible, quantifiable data that directly supports QI methodologies. QI relies heavily on measurable data to assess performance, identify inefficiencies and implement evidence-based interventions.[13] Traditional QI approaches, such as PDSA cycles, Lean and Six Sigma, are data-driven, emphasising statistical analysis and process metrics.[14] In contrast, the insights derived from safety science tools often emphasise qualitative aspects, such as human factors, resilience engineering and system complexity.[15] While these insights enrich our understanding of organisational performance, they may not always align with the structured, empirical requirements of QI methodologies. Bridging this gap requires integrating qualitative insights with quantitative data collection methods. Techniques, such as ethnographic observations, safety culture assessments and frontline worker narratives, can complement QI initiatives by providing context to numerical performance indicators.[16] The way forward: Integrating QI with broader safety strategies To maximise its impact, QI should be integrated with other safety-enhancing approaches: Human factors engineering: Designing systems that account for human limitations can reduce errors and enhance safety.[17] Regulatory and policy support: Strong governance structures and safety regulations can reinforce QI efforts.[18] Digital health solutions: Leveraging artificial intelligence, electronic health records and predictive analytics can complement QI initiatives for improved safety outcomes.[19] Interdisciplinary collaboration: Engaging multiple stakeholders—patients, families, carers, clinicians, administrators and policymakers from differing healthcare sectors across the system—can ensure a holistic approach to safety improvement.[20] Conclusion QI is a vital component in enhancing patient safety within the NHS, providing a data-driven, systematic approach to continuous improvement and cost reduction. The NHS Impact framework ensures that governance and patient safety remain central to healthcare delivery.[21] However, in an increasingly complex system, QI should not be viewed as a standalone solution. Instead, it must be integrated with broader strategies, including human-centred design, technology, policy support and cross-sector collaboration.[22] A safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, is essential to embedding a proactive, system-wide perspective on patient safety.[23] Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements.[24] Furthermore, regulatory frameworks, such as the National Patient Safety Strategy and the NHS Patient Safety Incident Response Framework (PSIRF). provide additional guidance for fostering a learning culture and improving incident response. In conclusion, while emerging safety science tools offer profound insights into the realities of work as done versus work as imagined, these insights must be systematically incorporated into data-driven QI frameworks. By integrating qualitative and quantitative approaches, organisations can achieve a more comprehensive and effective strategy for continuous improvement and enhanced safety performance. The key challenge for healthcare leaders is not whether QI is essential, but how to optimally combine it with these frameworks and strategies to build a resilient, high-quality healthcare system that continuously evolves to meet patient safety needs. References Institute for Healthcare Improvement. The Model for Improvement, 2020. NHS England. About NHS Impact, 2024. [Accessed 21 February 2025]. Berwick DM. The science of improvement. JAMA, 2008; 299(10): 1182-4. Graban M. Lean hospitals: Improving quality, patient safety, and employee engagement. Taylor & Francis Group, 2016. Batalden PB., Davidoff F. What is "quality improvement" and how can it transform healthcare? Quality & Safety in Health Care, 2007; 16(1): 2-3. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ, 2016; 353, i2139. NHS England. Governance, patient safety, and quality, 2024. Greenhalgh T., et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly, 2004; 82(4), 581-629. Shortell SM., et al.  Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Quarterly, 1998; 76(4), 593-624. Carayon P, et al. (Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 2014; 45(1), 14-25. Carayon P, Schoofs Hundt A., Karsh, B-T, et al. Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 2014; 15(Suppl 1), i50–8. Pronovost P.J, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 2006; 355(26): 2725-32. Institute for Healthcare Improvement. Quality improvement essentials toolkit, 2021. Deming WE. Out of the crisis. MIT Press, 1986. Hollnagel E, Woods DD, Leveson N. Resilience engineering: Concepts and precepts. CRC Press, 2006. Vincent C. Patient safety. John Wiley & Sons, 2010. Reason J. Human error. Cambridge University Press, 1990. Leape LL, et al. Transforming healthcare: a safety imperative. BMJ Quality & Safety 2009; 18(6), 424-8. Wachter RM. The digital doctor: Hope, hype, and harm at the dawn of medicine’s computer age. McGraw-Hill Education, 2015. Grol R., et al. Improving patient care: The implementation of change in health care. John Wiley & Sons, 2020. NHS England. The NHS Impact Framework: Embedding Continuous Improvement. 2023. Dixon-Woods M, Martin G. Does quality improvement improve quality? Future Hospital Journal, 2016; 3(3): 191–4. Healthcare Safety Investigation Branch. Safety management systems: an introduction for healthcare. 2023. Patient Safety Learning. The Patient Safety Standards. 2020.
  18. Content Article
    Learning Health Systems help organisations to learn and act fast to drive improvement. Find out from UCL Partners Health Innovation the five core principles that underpin success.
  19. Content Article
    Internationally there is recognition that a holistic quality management system (QMS) approach will enable healthcare organisations to meet the needs of their populations and continuously improve the care and experience provided. In NHS Wales, the Duty of Quality was introduced in 2023 through the Health and Social Care (Quality and Engagement) (Wales) Act 20201 and requires Welsh NHS bodies to establish an effective QMS where appropriate focus is placed upon Quality Control, Quality Planning, Quality Improvement and Quality Assurance The 90-day cycle methodology was used to explore how high performing organisations manage for quality – identifying universal findings across all the organisations, a summary of what a QMS can achieve and the importance of the role of the Board. The findings informed the development of a QMS Framework for healthcare which has supported the development of the Duty of Quality and includes: A definition of quality: Continuously, reliably and sustainably meeting the needs of the population that we serve (aligned to the Duty of Quality). A definition of QMS for NHS Wales: An operating framework to continuously, reliably and sustainably meet the needs of the population we serve. Descriptions of the four aspects within a QMS: Quality Planning, Quality Improvement, Quality Control and Quality Assurance and examples of tools and resources that can be used to support their implementation. Descriptions of the organisation enablers for a QMS: leadership, workforce and culture; learning, improvement and research; whole system approach; and, information (aligned to the Duty of Quality Standards). A methodology to implement and embed a QMS: an adaptation of Quality as an Organisational Strategy (QOS) informed by the experience of piloting the approach at directorate and organisation level.
  20. Content Article
    PROMPT (Practical Obstetric Multi-Professional Training) is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team. This study describes the approach and process measures for national scaling of PROMPT across 12 obstetric-led maternity units in Wales.
  21. Content Article
    Juvenile idiopathic arthritis (JIA) is an autoimmune disease that affects around 10,000 children aged under 16 in the UK. It is a chronic disease and many patients will continue to have JIA into adulthood. JIA causes inflammation, pain and stiffness in joints, and can be have a big impact on a child's life. This study by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked at the quality of care provided to patients diagnosed with JIA. Patients were randomly selected for inclusion in the peer review process if their diagnosis had been made between 1st April 2019 and 31st March 2023, and they were diagnosed or experienced symptoms before their 16th birthday. Data included 374 clinician questionnaires and the assessment of 290 sets of case notes. In addition, 122 organisational questionnaires were returned along with 130 primary care questionnaires, survey responses from 68 parents/carers and 117 healthcare professionals. The study report  includes recommendations highlighting areas that are suitable for regular local clinical audit and quality improvement initiatives. Recommendations Raise awareness of juvenile idiopathic arthritis and its symptoms with the healthcare professionals who will see this group of patients. Streamline and publicise local referral pathways with clear measurable timelines for patients with suspected juvenile idiopathic arthritis. Provide timely access to appropriately trained physiotherapy, occupational therapy, pain and psychology services at the diagnosis of juvenile idiopathic arthritis, and then as needed through adolescence and adulthood. Offer age-appropriate information about juvenile idiopathic arthritis and medication risks and benefits to patients and their parents/carers at diagnosis and on an ongoing basis. Provide training to the patient, if age-appropriate, and/or their parents/carers on how to administer subcutaneous injections for juvenile idiopathic arthritis at the point treatment is initiated. Ensure timely access to intra-articular steroid injections by staff who have been trained to deliver age-appropriate care in units where local or general anaesthesia can be delivered. Provide a holistic, developmentally appropriate rheumatology service for patients with juvenile idiopathic arthritis. Develop NICE guidance for the management of juvenile idiopathic arthritis.
  22. Content Article
    Spire Healthcare’s cultural journey through 2024 highlights how any healthcare organisation can leverage frameworks like PSIRF, coupled with supportive initiatives like Quality Improvement and Freedom to Speak Up, to drive meaningful change and create environments where safety, trust, compassion and collaboration thrive. In 2024, Spire Healthcare took a bold step towards enhancing patient safety by implementing the Patient Safety Incident Response Framework (PSIRF) across its network of hospitals. This was a legal obligation for NHS patients in England, but Spire chose to implement for every patient – private and NHS – in England, Scotland and Wales. Developed by NHS England, PSIRF redefines how healthcare organisations approach patient safety incidents, shifting the focus from blame to system-wide learning and improvement. For Spire, this was not just a compliance exercise – it represented a cornerstone of cultural transformation, fostering openness, collaboration, and continuous improvement. This work culminated in Spire being named as a finalist at the 2024 HSJ Patient Safety Awards, in the ‘Developing a Positive Safety Culture’ category. This recognised Spire’s dedication to embedding safety principles into our DNA. Central to culture were two key enablers alongside PSIRF: a robust Quality Improvement (QI) strategy and the organisation’s commitment to the Freedom to Speak Up (FTSU) initiative, both of which were deeply integrated with PSIRF to support a positive cultural shift.
  23. Content Article
    Healthcare has, in many ways, always been a form of ‘learning system’. Driven by a diverse community of stakeholders, including health care professionals, patients and the public, a learning health system (LHS) uses internal and external knowledge to continually learn about and improve patient care. However, while LHSs have huge potential to support service transformation and population health, there is a lack of consensus about what an LHS actually is, and how to get started. This research report from The Health Foundation helps people understand LHSs and how they can be developed.  Key points A learning health system (LHS) is a way of describing a systematic approach to iterative, data-driven improvement. Learning health systems are able to learn from the routine care they deliver, and improve it as a result – as part of ‘business as usual’. This research suggests there is a large gap between the promise and practice of LHSs. This is partly due to the lack of a clear definition, vision and evidence base around LHSs, meaning it can be difficult to know where to start or how to make progress. This report, part of Health Data Research UK’s (HDR UK’s) Better Care programme, was informed by a literature review, interviews, a survey of more than 100 expert stakeholders and a series of practical case studies, offering real-world examples of LHS approaches already being taken. It explores four important areas especially relevant to LHSs: learning from data, harnessing technology, nurturing learning communities and implementing improvements to services. In these areas, targeted action by policymakers and organisational leaders could lead to tangible progress in developing LHSs. Amid all the pressures the health and care services are facing, we should be wary about seeing LHSs as a ‘nice to have’. A step change in the health service’s learning and improvement capability is needed if it is to find a sustainable route to recovery and effectively reshape care to meet future health needs.
  24. News Article
    Trusts are still keeping reports that reveal serious patient safety concerns secret, HSJ has discovered. So-called “invited reviews” are often commissioned by trusts’ management from a medical royal college, when they are trying to deal with concerns about safety, quality or staffing in a particular service — or, in some cases, about individual doctors. The providers are meant to publish a summary of the findings where they uncover safety or quality issues, but HSJ has established this is still routinely not happening. Using the Freedom of Information Act, HSJ traced at least 49 reviews commissioned since April 2020. Only six had been published by the trust in a meaningful way, despite many others surfacing concerns about care. Morecambe Bay inquiry chair Bill Kirkup told HSJ: “It is disappointing to see so many trusts continuing to treat invited reviews as confidential, despite clear recommendations. These are public services, and there should be transparency. Some detail may need to be redacted to maintain individual confidentiality, but I can see no justification for wholesale failure to disclose information that is in the public interest.” Patient Safety Learning chief executive Helen Hughes added: “These reviews have the potential to unearth patient safety insights that are applicable far beyond the organisations they are focused on. Currently however, this learning is not shared widely in a consistent way to inform our understanding of patient safety risks and the need for improvements across the system.” She said “privacy, personal sensitivity, and legal reasons… should not present an insurmountable barrier to extracting system-wide learning”. Read full story (paywalled) Source: HSJ, 4 February 2025
  25. Content Article
    The Quality and Patient Safety Competency Navigator is a self-assessment tool. It will help you identify and develop the key competencies needed to provide safe and quality care. It will also sign-post you to relevant educational resources and learning opportunities. Who can use the QPS Competency Navigator? This resource is for everyone and can be useful for: students to develop skills for safe patient care staff to self-assess competence and identify learning needs line managers to guide professional development conversations healthcare educators to inform the design of learning programmes. patients to learn how they can play a role in supporting quality and patient Safety. How to use the QPS Competency Navigator? The QPS Competency Navigator describes six topics related to quality and patient safety. You can explore these depending on your role. You can use the tool to identify specific knowledge and skills that you need to develop and discover ways to learn more about a topic.
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