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Found 24 results
  1. Content Article
    According to the responses we received, the four themes that became most obvious - the four things you think staff most need to be safe - are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff form burnout
  2. Content Article
    Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff. Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS. Work-as-imagined This represents our imagination of others’ work and "is a gross simplification, is incomplete, and is also fundamentally incorrect in various ways, depending partly on the differences in work and context between the imaginer and the imagined." In the context of the NHS we could think about how the delivery of frontline clinical services is imagined by those not directly involved in delivering care, for example; senior managers, commissioners, regulators, patients and the public. This inaccurate mental model invariably informs decisions which impact upon frontline services such as decisions regarding how services will be delivered, funded, regulated, overseen and monitored. Work-as-prescribed This represent the rules, regulations, policies, procedures, checklists, job descriptions etc. which describe the 'correct' way to work. In the NHS context we could envisage this by way of Care Quality Commission regulations, organisational policies and procedures, clinical guidelines, NICE guidance etc. The fundamental limitation of work-as-prescribed is: "It is usually impossible to prescribe all aspects of human work, even work that is well-understood, except for extremely simple tasks". Moreover, "Assumed system conditions - staffing levels, competency, equipment, procedures, time - are often somewhat more optimal than those found in practice". In essence, work is invariably more messy and complex than assumed by rules, regulations and procedures that outline best practice. Anyone who has had experience of developing and implementing standard operating procedures will know that how things are supposed to be done as per the procedure and how they are done in reality often diverge. I think this also helps partly explain why so-called 'Never Events' happen at a regular frequency – the assumption that implementing national guidance based on work-as-prescribed will eliminate the risk of their occurrence is faulty. There are many error provoking conditions in the workplace that cannot easily be eradicated. Work-as-disclosed This is an intuitive concept, it represents what those doing the work are prepared to disclose to others about how they do their work. Inevitably this is limited and partially based on "what we want and are prepared to say in light of what is expected and imagined consequences". We can think about this in the context of the NHS as to how staff may relay their activities to senior managers, regulators, commissioners, patient groups etc. The message is tailored to the audience and when it comes to being scrutinised by others we will inevitably say what we think will paint us in the best possible light. Work-as-done This represents the reality of how day-to-day work is actually done as compared to all of the above. Inevitably there are shortcuts, variations, deviations based on reality of working conditions, expectations and demands of others. The key insight here is that work-as-done is actually quite hard to understand: even where there is observation this can change behaviour and there may be technical and practical limitations to our understanding when work being done is complex or unsafe to observe. Shorrock includes a very interesting quote from Hollnagel in his article as to how we account for differences between work-as-done and work-as-imagined or work-as-prescribed, we typically do this: "by inferring that what people actually did was wrong – an error, a failure, a mistake – hence that what we thought they should have done was right. We rarely consider that it is our imagination, or idea about work-as-imagined, that is wrong and that work-as-done in some basic sense is right.” This is an important consideration to bear in mind when it comes to the investigation of patient safety incidents in the NHS, it is commonplace for fault to be found in the aberrant behaviour of staff who did not adhere to policy or procedure. A more meaningful insight into what has happened would be derived from understanding why this happened and what conditions led this to occur. Were the policies and procedures themselves based on a limited understanding of work-as-done and the real-life working conditions which staff are faced with? In relation to all of the above, it is important to understand that there can be a disconnect between all of these varieties of human work and that when it comes to decision-making and activities which can impact upon how services are delivered and overseen we need to be humble and recognise the limitations of our knowledge. In practical terms, what might these mean for those who work in roles which are detached from the work-as-done of frontline staff? Some suggested considerations are below: Recognise that assurance visits, observation and discussions with staff only give a partial and limited picture: firstly, observation changes behaviour and work-as-disclosed to those outside an organisation may vary considerably from the reality of work-as-done. Be aware that any prescriptive requirements regarding how work is to be done may have unintended consequences or create perverse incentives. There needs to be the involvement and engagement of those who are directly involved in delivering frontline services and/or those who can articulate on their behalf when it comes to prescribing how work is to be done. It isn't possible to develop all-encompassing prescriptive requirements of how work is to be done which are realistic and achievable. Where a prescriptive top-down approach is taken, based on a ill-informed view of how frontline services are being delivered, the results will not be good so a collaborative approach is needed. When it comes to the investigation of patient safety incidents, acknowledge that adherence to policy and protocol is driven by a variety of complex factors. An effective investigation needs to understand why policies and procedures have not been followed from a human factors and systems perspective including consideration that the policies and procedures themselves may be inherently flawed. In summary, we need to be humble and recognise the limitations of our knowledge and work in partnership with others in a collaborative way rather than trying to instil or enforce change via a limited mental mode of how work is done.
  3. Event
    until
    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
  4. Content Article
    As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK.
  5. Content Article
    Ideas about resilient systems are now becoming better known in the healthcare community, but the most common question asked is “this is great but how do I put it into practice?” CARe QI provides the answers. The aim of CARe QI is to help people to apply the insights of resilient systems and ‘Safety II’ to the design, implementation and evaluation of quality improvement interventions. It is a structured collection of information, tools, guidance and documents that helps you to develop interventions to strengthen system resilience and in turn improve quality and safety. In the handbook you will find an overview of the arguments for improving quality through resilience, followed by step by step guidance in applying the method and downloadable worksheets to help you to document your own project. There are four main steps to CARe QI – setting up the project, capturing work as done, describing resilience in everyday work and choosing resilience interventions and outcome measures. The foundation of CARe QI is that you understand your clinical system in depth before starting to design and implement interventions.
  6. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  7. Content Article
    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
  8. Content Article
    In this remarkable documentary, you can follow Kym Bancroft and Sidney Dekker in one organisation's (Urban Utilities) successful adoption and implementation of Safety Differently principles.
  9. Community Post
    The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey
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