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Found 35 results
  1. Event
    This one-day masterclass focuses on the Principles and Practice of a Restorative, Just, and Learning Culture, emphasising how empathy is crucial to fostering a fair and psychologically safe environment. Through experiential learning using a true story, participants will have the opportunity to see things differently; examining how empathy and compassionate leadership underpin a Just Culture, helping organisations move from blame to learning, accountability, and system improvement. The session will bring empathic thinking into real-life practice, guiding attendees to understand the emotional complexities of patient safety incidents, staff fears and wellbeing and working with human reactions. It will highlight the difference between retributive and restorative practices and how adopting restorative approaches can enhance both patient and staff outcomes. In a safe, supportive environment, participants will reflect on how personal biases affect communication, and explore how culture change can be achieved and the challenges. The session will integrate self-reflection activities to strengthen personal well-being, emotional resilience, and inclusive leadership skills, which are vital for creating a compassionate, high-performing team. Using emotive and thought provoking material, balanced with the science of emotional intelligence, the real impact of a restorative, just and learning culture principles are felt, ensuring attendees leave with actionable insights, combined with emotional understanding to drive systemic change in their teams and wider organisations. KEY LEARNING OBJECTIVES Understanding of Restorative vs. Retributive Practices: Dig deeper into a thought-provoking journey through a patient safety incident, understanding some of the complex emotional component, demystifying some of the myths. What is a Just Culture and Empathy in Practice: Participants will explore develop the ability to apply and promote empathetic practice and the psychological benefits of restorative practices that foster trust and transparency. Seeing Perspectives for Culture and Change: Understand emotional motivations within behaviour and how easily we all see things differently and come from a place of fear. Unpacking the ‘Funnel of Life’: Enhancing Compassionate and Inclusive Leadership while Cultivating Self-awareness of Our Own Funnel Restorative Care - Emotions at the Heart of Stakeholder Support: Explore how a restorative culture nurtures patients, carers, and staff by addressing emotional challenges and managing difficult incidents. Psychological Safety for Team Health: Understand how a lack of civility, empathy and emotional awareness has the potential to cause psychological harm, negatively impacting on being a just, fair and learning culture Shifting Perspectives: From Surface Critique to Systemic Restorative Thinking: Explore how psychological safety influences professional communication, and is all empathy useful for a restorative, just and learning culture? Register hub members get a 20% discount. Email [email protected] for discount code.
  2. Event
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    Restorative practice - learning culture, how do you create a culture where people feel able to speak up and be listened to. Freedom to speak up, enabling a culture where people feel able to speak up, governance, board assurance, Culture and Good Governance - OFLOG dept launched in July which will look at governance in local authorities. There’s been an incident in your organization. People are impacted. You need to do something. How do you avoid blame, and how do you start learning and improving? This session will explore the principles and theory behind a just and learning culture and give you some insights into how this can be implemented. Alongside an international thought leader on this subject we will hear from an NHS organisation’s experience of developing and sustaining their approach to this. This session will help you understand how your teams/services/organisations can create cultures that foster learning when things don't go as expected. People will leave with an understanding of a just and learning culture alongside insights around implementation in their own organisations. Register
  3. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its formal report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. At the beginning of its response to the Investigation and its recommendations, the Government states that at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach. Summary of the Government response to each of the recommendations Recommendation – The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use. NHS England (NHSE) has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes. NHSE have also formed a Maternity and Neonatal Outcomes Group, acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers. Recommendation – Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning. Department of Health and Social Care (DHSC) will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE. It will coordinate activity to: Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training. Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care. Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change. Recommendation – Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance. DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE. It will coordinate activity to: Map current responsibilities around oversight and direction. Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice. Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts. Recommendation – Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset. DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE. It will coordinating reports that will: Provide evidence through experience and examine existing research on how and where teamwork is being done well. Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps. Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions. Recommendation – Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development. DHSC will lead the response to this recommendation and be supported closely by NHSE. It will coordinate reports that will: Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this. Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups. Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers. Recommendation –The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies. Recommendation – Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. Recommendation – NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership. The Government has provided one response to the above three recommendations which includes the following points: The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations. When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course. To help monitor when reputation management is superseding transparency of trust boards, the CQC, as part of its new inspections approach, will continue to consider trust leadership at executive team and trust board level as part of its key lines of enquiry, using the well led framework. In the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations. Recommendation – The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input. In their response the Government note the actions that the Trust has taken following the publication of the report on the 19 October 2022, including that specific improvements in maternity and neonatology services will be overseen by a maternity and neonatal assurance group, reporting to the Trust’s board. Related reading 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022) Prevention of Future Deaths Report: Harry Richford (3 February 2020) Patient Safety Learning: Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report (17 November 2022)
  4. Content Article
    This blog (attached below) explores how far the nature of our relationships at work have an impact on patient safety. Lesley Parkinson – the executive director of Restorative Thinking, a social enterprise working to introduce and embed restorative and relational practice in the NHS and across public sector organisations – explores how six restorative practice habits add value in multiple teams and scenarios. You can also order Lesley's book Restorative Practice at Work Six habits for improving relationships in healthcare settings.
  5. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page. HSIB as experienced and observed vs HSIB as imagined and described (and not researched!): a patient system perspective Dear Ted and Rosie and all incoming Directors to HSSIB, In 2017 I wrote an open article making demands of HSIB to be patient centred. Six years later, having following HSIB closely, and in some aspects intimately, I write an open letter from a point of despair as HSSIB emerges from HSIB and I end my formal involvement as the patient safety expert from experience on the Advisory Panel. Nothing I say may surprise you, but I hope the incoming executive considers these issues seriously and urgently. I raise it in this public way as I believe if these issues are not transparently and explicitly addressed as a matter of urgency, I cannot assure other patients and families should they become involved with HSSIB. I say this for fear they will experience compounded harm and, related and additional to this (as I will expound below), I have significant concerns about the quality and output of HSIB investigations to achieve maximum impact, utilising the patient and family perspectives. HSSIB must prioritise its development to become exemplary and better than what has gone before (based on evidence) and to also be valuable not harmful for patients and families. Patient safety in England needs a place where trust and faith are restored, with evidence showing it listens, learns and acts by putting patients and their advocates at the centre. The issues can be examined from three perspectives relevant at this juncture: A review of its past work given it has new power. The new governance arrangements coming in to place, but without patient voice at its heart. Various concerns over the last 6 years that cannot be ignored, and a recognition already acknowledged by yourselves, Ted and Rosie, that the patient involvement aspects require more work. My full letter details the experiences I draw upon. I challenge the lack of evidence base and research on HSIB that claim it is truly independent drawing on patient and family perspectives. I do not go in to detail on other publicly shared criticisms of HSSB, but I believe these criticisms cannot be ignored and have not been adequately addressed. I bring to everyone’s attention that the Advisory Panel I was on had no explicit or expected role in even commenting on these types of issues but some members did at times. Given Governance at HSSIB is now being established in a more recognised, explicit and conventional way, I believe the Non-Executive Directors and Executive Directors have a vital role to immediately address these concerns drawing on independent expertise. I challenge the opinion that HSIB has an innovative or patient-centred engagement model. It focuses on the important issues of accessibility and basic, respectful communication with patients and families – something we have seen that has not been done by health bodies. But it does no more than this. This is not exemplar family involvement. The letter relates independence to patient-centredness in a way contrary to how HSIB has worked in the past and refers to the vital need to report authentic accurate accounts of patients. It argues that much work has to be done to avoid bias towards health service perceptions, and to make patients and their advocates more central in all HSSIB processes, from scoping to evaluation. Family involvement is so much more than engagement. And in all these processes, patients need not only empowerment but advocacy and support. If HSSIB does not do this, who will give it the recognition it needs? The letter looks at the relationship between restorative approaches and investigations and how to minimise or, ideally, eliminate compounded harm and to get quality investigations drawing on the valuable insights of families and the patient-led framework that is needed. This itself deserves ongoing research, development and typologisation. Engagement with whistleblowers in the NHS, and indeed within HSSIB, as a starting point to be any kind of exemplary service also requires explicit, transparent, evidence-based attention given HSIB’s previous history of this (and some key issues are identified in the letter). The letter recognises the innovative and challenging role HSSIB takes on and that it cannot shirk from addressing these if it seeks to be truly innovative. However, based on experiences to date, unless HSSIB urgently takes on this challenge, I cannot express any assurance to families who consider participating. I have been a critical friend for a very long time and now can just be a serious critic in making these challenges. One big question remaining is why these limitations still exist after more than six years of HSIB? One issue has to be to move away from a solely or predominantly technocratic and medically centred and medically organised framework. This also requires consideration. Richard von Abendorff, 12 October 2023 Download the full letter here or from the attachment at the end of the page: Open letter to HSSIB.pdf
  6. Content Article
    The Forgiveness Project shares stories of forgiveness in order to build hope, empathy and understanding. Founded in 2004 by journalist, Marina Cantacuzino, The Forgiveness Project provides resources and experiences to help people examine and overcome their own unresolved grievances. The testimonies we collect bear witness to the resilience of the human spirit and act as a powerful antidote to narratives of hate and dehumanisation, presenting alternatives to cycles of conflict, violence, crime and injustice. At the heart of The Forgiveness Project is an understanding that restorative narratives have the power to transform lives; not only supporting people to deal with issues in their own lives, but also building a climate of resilience, hope and empathy.
  7. Content Article
    This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences." Blog posts: It's about acceptance Put yourself in these scenarios Sorry - one important word Reassuring the patient My turn to apologise Emotional support Making ICU a bit more bearable Not what I wanted to hear Helping the patient forgive Not my fault either How time heals Psychological benefits of prehabilitation Talking to an independent person Be kind to angry patients Emotional intelligence Difficult conversations Forget-me-not Surgeons' coping mechanisms Showing his vulnerability A safe place to talk Social media My coping mechanisms Trusting my surgeon again Reconciliation
  8. Event
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    Te Ngāpara Centre for Restorative Practice invites you to attend the virtual symposium Restorative Health Systems: Healing, learning, and improving after harm. This free event is being held in association with the Health Quality & Safety Commission in Aotearoa New Zealand. The symposium will provide a virtual space for knowledge sharing and exchange among the growing international community of clinicians, researchers, consumers, investigators policymakers, and practitioners working in health settings. We aim to share what is happening globally in this emerging field and to reflect on the future of restorative initiatives in the health system context. The symposium will incorporate a series of different sessions, including interactive dialogues with international critical thinkers and advocates, presentations on key issues relevant for the field and research relating to restorative initiatives. View the programme (PDF) This is the first of a symposium series as part of the Te Ngāpara Centre for Restorative Practice’s commitment to supporting the development of restorative knowledge. The symposium will take place on Zoom on Wednesday 29 March, 8am - 12pm (NZDT) 0600 Australia (AEDT) 2000 London UK (BST) 1200 Vancouver (PDT) 1500 Montréal (EDT) Register for the symposium
  9. Event
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    This webinar from the Irish Health Services Executive National Quality and Patient Safety Directorate will enable you to: understand what restorative just culture means in practice appreciate how you can apply restorative just culture to your local context learn the benefits of restorative just culture for patients, staff and business hear top tips for applying restorative just culture Register for the webinar
  10. Event
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    The Yorkshire Quality and Safety Research Group continues its programme of seminars with 'Healing after harm: A restorative approach' presented by Jo Wailling, The Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, New Zealand. Further information and registration
  11. Event
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    Harmed Patients Alliance we will be hosting an online webinar focusing on restorative healing after healthcare harm. This online webinar will explore the issue of second harm in healthcare with a range of patient, academic and clinical expert members of our advisory group. Each panel member will give a presentation sharing their experience and perspective, followed by an interactive panel discussion chaired by Shaun Lintern, Health Correspondent for the Independent. Register
  12. News Article
    Organisations across the UK and beyond are set to benefit from a unique NHS- academic partnership which sees a focus on staff safety and morale – and delivers significant cost savings. Together Northumbria University and Mersey Care NHS Foundation Trust are pioneering professional development courses on Restorative Just Culture. This approach at the Liverpool-based Trust has seen reduced dismissals and suspensions, leading to substantial business savings, and has generated great interest across the health sector. Starting in 2016 Mersey Care has worked to deliver a Restorative Just Culture. And despite increasing its workforce by 135%, the Trust has since seen an 85% reduction in disciplinary investigations and a 95% reduction in suspensions – helping them drive down costs significantly. During the same period, it has also seen improved staff engagement and safety culture scores as measured by the NHS national staff survey. Mersey Care’s Executive Director of Workforce Amanda Oates says: “Mersey Care started on our journey towards a Restorative Just and Learning Culture after conversations with our staff about the barriers staff faced delivering the best care that they could possibly give." “The feedback was overwhelmingly about the fear of blame if something didn't go as expected. This was preventing staff from telling us what wasn’t working. More importantly, it was preventing the opportunity for learning from those things to prevent them from happening again. As a Board, we had the conversation - are we looking at problems the wrong way?” Read full story Source: FE News, 27 October 2020
  13. Content Article
    This new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
  14. Content Article
    Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. This study highlights the qualitative benefits from this implementation and also identifies the economic effects of restorative justice.
  15. Content Article
    In healthcare systems safety needs to be conceived in a relational as well as a regulatory framework, with resilience being understood as the interplay between both elements. This presentation from the Australian Institute of Health Innovation, critically appraises how harm is understood and responded to within the New Zealand health system and the potential contribution of restorative responses. A major and internationally unprecedented project, that employed a restorative approach to address the harm caused to patients and professionals by the use of surgical mesh in New Zealand (NZ), is used to illustrate the case for change. This webinar discusses: how we currently respond to harm how restorative justice practices differ why restorative justice is important in this complex healthcare environment application to practice.
  16. Content Article
    ‘Victim wellbeing’ is a phrase often linked to restorative justice, but what does that look like in practice? In this article, Greg Smith (restorative justice development manager at Thames Valley Restorative Justice Service (TVRJS)), Diana Batchelor (PhD researcher at Oxford University and independent evaluation researcher for TVRJS) and Becci Seaborne (assistant director for restorative justice at TVRJS) consider why, and how, restorative justice could become a default option for health service providers.
  17. Content Article
    Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. Could this be something that we could utilise as a new approach in healthcare?
  18. Content Article
    This report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm. This report, Hearing and Responding to the Stories of Survivors of Surgical Mesh, describes how restorative justice approaches were used to uncover the harms and needs created by surgical mesh use in New Zealand. The actions that consumers and healthcare stakeholders indicated would restore well-being, trust and safe healthcare in New Zealand are included. Skilled facilitators used restorative practices to create a safe space for consumers and health professionals to tell their stories. The same approach supported collaboration between multiple agencies so they could act for repair and prevention. The team that co-created the project includes academics, consumers, facilitators and New Zealand's Chief Clinical Officers. Formal research will evaluate the project next year and consider findings in the context of resilient healthcare systems
  19. Content Article
    Restorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.
  20. Content Article
    As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust.  We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts.  This interactive webinar was hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. View the webinar on demand and download the slides.
  21. Content Article
    In this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production. When considering the persistence of unsafe care, a recurring theme that emerges is a failure to involve patients in their own care. Patient safety concerns raised by patients and family members are too often not acted on and, when harm occurs, they are often left out of the investigation process. As set out in Patient Safety Learning’s A Blueprint for Action, we share the view that patient engagement is key to improving patient safety, with this forming one of our six foundations of safer care.[1] The NHS Patient Safety Strategy identifies the involvement of patients in patient safety “throughout the whole system” as a key part of achieving its future patient safety vision.[2] The strategy includes plans to create a patient safety partners framework; earlier this year, the NHS published a consultation on its draft Framework for involving patients in patient safety.[3] In this blog, we will provide a summary of our feedback to the consultation. You can find our full submission at the end of this blog. Involving patients in their own safety The NHS Framework is divided into two parts, the first of which sets out the broad approach that should be taken to involving patients in their own healthcare and safety. We particularly welcome its emphasis on: encouraging patients to ask questions; if problems occur, the importance of providing information and help to maintain patients’ safety; the role of patient incident reports and complaints as a source of learning. In our response, we fed back with our thoughts on improvements in two specific areas - complaints and patient safety incident reporting. Complaints We share the view set out in the Framework that patient complaints should be viewed as “a valuable resource for monitoring and improving patient safety”.[3] We believe it’s important the Framework is joined up with the ongoing work of the Parliamentary and Health Service Ombudsman (PHSO), who have recently completed a consultation on a new Complaints Standard Framework for the NHS.[4] We believe that this presents an opportunity to embed patient safety into these processes and we responded to the PHSO consultation highlighting this. Patient safety incident reporting The Framework highlights the importance of patients reporting patient safety incidents, noting that the future introduction of a new Patient Safety Incident Management System will create “new tools to more easily participate in the recording of patient safety incidents and to support national learning”.[3] We believe more needs to be to be done to address the cultural barriers that deter patients from reporting concerns. Patients, carers and families need to feel assured that their stories and testimonies are welcome. Alongside this, it is crucial that, when concerns are reported, they are used to inform the assessment of risk and patient safety. As noted in the Cumberlege Review, not only are incidents not being reported but the existing systems “cannot be relied upon to identify promptly significant adverse outcomes arising from a medication or device because it lacks the means to do so”.[5] Patient Safety Partners The second part of the Framework is concerned with the newly proposed role of Patient Safety Partners (PSPs) in NHS organisations. PSPs would formally participate in safety and quality committees, patient safety improvement projects and investigation oversight groups. In our consultation response, we highlighted several areas where we feel these proposals require strengthening if they are to be successful. Training and guidance for staff The Framework rightly acknowledges the importance of having appropriate training and guidance for staff to help support the new PSP roles, pointing towards the new National patient safety syllabus as a key source. We have concerns that the National patient safety syllabus, in its current form, does not have a strong enough focus on patient involvement to provide this support. We highlighted the need for a greater emphasis on the skills and knowledge required to understand why and how patients can be actively involved in patient safety in our response to the consultation on the draft syllabus earlier this year.[6] We believe the syllabus could be significantly strengthened by drawing on further research and resources available in this area, such as the World Health Organization (WHO) Patient Safety Curriculum Guide.[7] Support and peer networks for PSPs We believe there needs to be more clarity about the induction and training that would be made available to PSPs. We also make the case that PSPs need access to networks with their peers PSPs in other organisations, enabling them to share good practice for safety improvement and receive support from others. We believe that it would be beneficial to create these networks alongside the new PSP roles. We suggest it would be helpful to draw on experiences of other programmes involving patients in patient safety, such as the WHO Patients for Patient Safety programme in the UK and the Canadian Patients for Patient Safety programme.[8] [9] Patient Safety Specialists The Framework makes brief reference to the relationship between future PSPs and the newly proposed Patient Safety Specialists, which all trusts and CCGs have been asked to put in place by the end of November.[10] We believe that if Patient Safety Specialists are to work effectively in organisations then these roles will need to be filled by leaders with expertise in patient engagement. Responding to a consultation earlier this year, we commented that those filling these roles will need strong skills and experience.[11] We also believe the Framework should place a great emphasis on the role of Patient Safety Specialists in supporting the work of PSPs. Co-production In our feedback, we also argue that there should be a strong emphasis on co-production with PSPs and more broadly throughout this Framework. ‘Co-production’ is an activity, an approach and an ethos which involves members of staff, patients and the public working together, sharing power and responsibility across the entirety of a project.[12] In our view, projects and patient safety programmes should always be co-produced with patients where possible. What needs to be included in the Framework As well as commenting on the specific proposals of the Framework, we identified two additional areas which we believe should be added to it: 1. Measuring and monitoring performance Patient Safety Learning believes that, to make improvements in the involvement of patients in patient safety, we need to be able to clearly measure and monitor our progress. Publicly reporting on changes and improvements made through patient involvement and patient safety allows for sharing examples of good practice. It would also mitigate against concerns that the role of PSP could become tokenistic in some organisations, resulting in little real impact. 2. Restorative Justice Many national healthcare systems and organisations are actively listening to, and engaging with, patients for learning through restorative justice. Restorative justice in healthcare allows patients to be heard, listened to, and respected. By patients, clinicians, healthcare leaders and policy makers engaging with one another on patient safety, it can help to establish trust with the patient. This can also provide the impetus for learning and action to be taken to prevent future harm. We commend the approach adopted by New Zealand’s Ministry of Health in how it responded to harm from surgical mesh and the impact this has had on improvements in patient safety.[13] Closer to home, there are some beacons of good practice within the NHS, such as the Mersey Care NHS Foundation Trust.[14] We believe that the NHS should do more to share and promote a just and learning culture, asking organisations to develop and publish goals on their progress. Only one piece of the puzzle We welcome and recognise the positive steps being set out in the Framework to improve patient involvement in patient safety within the NHS. Our comments and suggestions for improvement are mainly centred around the need to ensure other key pieces are in place. Significant change is still needed. The Framework focuses on increasing patient involvement in governance and decision-making. This wider need for change in how we engage patients in patient safety is outlined in the recently published WHO Global Patient Safety Action Plan 2021-2030.[15] It promotes a range of actions for governments and healthcare organisations to help engage patients and their families in patient safety; we would expect to see this reflected in the work of NHS England and NHS Improvement. Strengthened as we suggest, we believe that the Framework could make a big difference to improving patient involvement with patient safety. References Patient Safety Learning. The Patient-Safe Future: A Blueprint for Action, 2019. NHS England and NHS Improvement. The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. NHS England and NHS Improvement. Framework for involving patients in patient safety, 10 March 2020. PHSO. Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. The Independent Medicines and Medical Devices Safety Review. First Do No Harm, 8 July 2020. Patient Safety Learning. Patient Safety Learning’s response to the National patient safety syllabus 1.0, 28 February 2020. World Health Organization. Patient Safety Curriculum Guide, 2011. Action Against Medical Accidents. Patients for Patient Safety, Last Accessed 15 October 2020. Canadian Patient Safety Institute, Patients for Patient Safety Canada, Last Accessed 16 October 2020. NHS England and NHS Improvement. Patient Safety Specialists, Last Accessed 15 October 2020. Patient Safety Learning. Response to the Patient Safety Specialists consultation, 12 March 2020. Dr Erin Walker, What should co-production look like?, 1 April 2019; National Institute for Health Research, Guidance on co-producing a research project, March 2018. Jo Wailling, Chris Marshall & Jill Wilkinson. Hearing and responding to the stories of survivors of surgical mesh: Ngā kōrero a ngā mōrehu – he urupare (A report for the Ministry of Health). Wellington: The Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, 2019. Mersey Care NHS Foundation Trust. Just and Learning Culture – What it Means for Mersey Care, Last Accessed 16 October 2020. World Health Organization. Global Patient Safety Action Plan 2021-2030: Towards Zero Patient Harm in Health Care, 28 August 2020.
  22. Content Article
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  23. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  24. Content Article
    The stressful nature of the medical profession is a known trigger for aggression or abuse among healthcare staff. Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. While incivility in nursing has been widely investigated, its prevalence among physicians and its impact on patient care are poorly understood. This review summarises current understanding of the effects of interprofessional incivility on medical performance, service and patient care.
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