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This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety: Past harm: this encompasses both psychological and physical measures. Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems. Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis. Anticipation and preparedness: the ability to anticipate, and be prepared for, problems. Integration and learning: the ability to respond to, and improve from, safety information.

The new framework aims to: make things simpler. better reflect how care is actually delivered by different types of service as well as across a local area. connect CQC registration activity to its assessments of quality. The CQC will continue to use its existing quality ratings and five key questions, but this framework replaces the existing key lines of enquiry (KLOEs) and prompts with new ‘quality statements’, also known as 'we statements'. For each quality statement, the CQC will state which evidence it will always need to collect and look at, which will vary depending on the type of service,

By creating a book with broad scope and clear descriptions of the key concepts and thinking in patient safety, the authors have aimed to connect with a much wider readership than those with a professional or academic interest in the subject. They have not limited themselves to theoretical models or risk management methodologies. They have aimed to address safety in various medical specialties. For example, there is a discussion of the causation and solutions in conditions such as infantile cerebral palsy; today in many health systems this has a high human and economic cost, some of which are preventable. They have also dealt with how the structure, culture and leadership of healthcare organisations can determine how many patients suffer avoidable harm and how safe they and their families should feel when putting their trust in local services. Safety problems relating to non-technical skills are also discussed; this is a topic of great importance but under-represented in medical and nursing educational and training curricula.

Mrs Trellis of North Wales writes: Q: Why is there no mention in your blogs about "motivation, personality, team building, and alike"? A: Well that’s not human factors. That’s another branch of psychology called occupational psychology. These people are trained – BSc then MSc and then often four years of supervised work. Usefully for the medical profession they are registered by the Health and Care Professional Council (HCPC). If you are interested in these matters, ensure they have at least the postgraduate qualifications. The most important bit is that they abide by a code of ethics. Ignore the "I do team talks and motivational stuff" go for MSc in the subject. If they say I’m a Human Factors person who does team talks, then sigh. It’s like a GP saying they also will have a go at dentistry/carpentry/service your car. Q: How do I select a Human Factors person? A: Do they have a doctorate (DPhil preferred!) in the domain and, as it's research, have they published in peer reviewed journals, or has their work been reviewed by other PhD types? They should have a minimum of an MSc and tell you they abide by a code of ethics. As this is still a new area of science go for a postgraduate qualification in the core areas of engineering or cognitive psychology from a university you recognise. There are international protocols about how humans should be treated, and they should be able to say they meet them (NHS Research Ethics Committee is cool). The organisation should have an ethics committee and that should contain lay members and professorial level scientists. Q: Do I need a research ethics committee to do an investigation? A: If its collecting novel data and people are put in a place where their wellbeing (psychological and physiological) may be affected – then YES. The NHS has a network of ethics committees and you will have one (https://www.hra.nhs.uk/about-us/committees-and-services/res-and-recs/). I was recently asked to take part in a questionnaire study about ‘cover ups’ in hospitals. Question one was about whistleblowing and I needed to give my name. I asked about ethics permission and I was told its not needed and they (the university) would not grant it anyway. I asked if reliving a traumatic event caused me some anxiety would they offer me support? The answer was “it’s just a research project looking at deaths – why would you need that”. Your duty as a researcher is to protect the person giving the answers. Q: There is someone into my hospital who tells me they can help with Human Factors, how do I know they are fit and proper? A: Well that’s what the Disclosure and Barring System (DBS) is about. Ask that they have a minimum of an enhanced DBS check or alternatively, with Human Factor types, security clearance (SC & DV). With DBS the nature of their originating organisation often determines the frequency required by them to renew it (sometimes just once). Check that their organisation stores and handles data safely and securely. This is not GDPR. Ask how they store it and if they meet a recognised standard. Financial health is important and such ‘numbers stuff’ is on companies house. Look for three years of accounts. Many look for five but companies have to start somewhere. Q: Is healthcare all about process and not about outcomes? A: True, but it does not have to be. It is easy to solve the problem. Q: Are non-technical skills (NTS) and neuro linguistic programming (NLP) real science? A: NTS is a system that claims you can measure ‘attentiveness’ and ‘conciseness', and, in investigations, these factors are the cause of accidents. In humans there are ‘hidden’ cognitive processes so NTS people say, for example, ‘situational awareness’ and ‘attention to detail’, which are overtly manifested as behavioural markers. NLP makes claims about modelling exceptional people and being a cure for the common cold. Neither have any scientific validation, sound theoretical stance or pretty much any sort of evidence to support the concepts. In essence they are pseudoscience A useful link to Professor Wiki again (https://en.wikipedia.org/wiki/Neuro-linguistic_programming) Those proposing this pseudoscience also say there are overt NTS behavioural markers, that to the trained observer (you need normally need to pay and go on a course), can easily be measured. What a behavioural marker looks like that shows higher or lower attention to detail we are never informed. All these markers are, of course, they claim a-cultural, universal, and innate. There are some ideas that really stretch credibility – even to the untrained, including that during certain hours of the day you can’t see below your knee, which if true would mean any invading army only needs to sneak in just below knee height. One proponent said you can do this pseudoscience after a fatality – but when questioned how you communicate with the dead, they became vague as to the precise methodology. Q: I’ve hired someone who works in ‘other high risk or high-performance industries’ and if it works aboard ship/chemical plant/airside it's fine for medicine. Comments? A: Well no. Sadly Human Factors is not widespread in healthcare and healthcare is totally unique. Despite my experience in rail, aviation, marine, road and security, I have found healthcare to be very different. Human Factors types have not had much involvement in medicine (sorry). Each discipline in medicine is vastly different to each other. My first time in the Emergency Department was a shock, and I thought, naively, I could generalise that knowledge to paramedics and vans with flashing lights. Even comparison between theatres (in the same trust) where I thought I knew what each team did was foolhardy. Each discipline is unique and whoever works with you needs to spend a lot of time understanding what happens (see part 4 of my blog). Orthopaedics is very unique; strangely I like doing work there. A big thank you to many Royal colleges and every scrub nurse and operating department practitioner, oh and anaesthetist – whose battle with even the room is amazing. Q: We have investigated an event like this before. Why do we need to do it again? A: In the 600 investigations I’ve done, not one is the same. Indeed, I’ve not known the cause at the beginning of any investigation. We described that there are over 1000 variables (blog part 1) that come together, in one moment of time, and it's often four or more coming together to cause the incident in a domain like transport. As my American colleagues say – “Do the Math” – all incidents are unique. Q: Should we only investigate major incidents (multiple deaths) and not be distracted by all the rest? A: Sigh. How do you know if they are major unless you investigate? If you don’t investigate, how do you stop them from happening again, and how disrespectful to the family of the person who was injured or died. An example of good and bad outcomes: Good example of best practice We believe the fatality occurred because the high viz uniform is not effective during rain, the lighting caused glare on the windscreen that meant there was not much light hitting the retina of the person trying to detect your late partner. So, the evidence suggested your partner was not detected by them. I’m sorry for your loss but this is the new uniform, and this is how we have reduced the lighting to stop glare. Simply this will not happen again, no other family will suffer such a loss. Bad example Alternatively – Meh – others have died in the same way and well your loss is in the ‘all the rest’ pile. Do we want the latter in our society? Q: All this investigation work tells us nothing we did not know before the incident occurred. Comment? A: You are doing the investigation wrongly. It’s a worry, if you knew it was going to occur again then you are not dealing with an accident, but you are looking at a crime scene. Remember an accident is a rare random event (see blog part 1) that’s not foreseeable. Q: How many of the 600 odd cases did you not find the cause? A: One – still a total mystery as to its cause. A vehicle after 60 miles of perfect driving where a driver diverts across three lanes of the motorway and hits the only vehicle parked on the hard shoulder for nearly 30 miles. If anyone has a thought – please share. Q: There are courses on Human Factors methods like hierarchical task analysis (you mention Task Analysis in your blogs) and Control charts, aka Shewhart charts. Is that what we need? A: Your training in medicine is what to focus on. Let Human Factors people do Human Factors stuff. Keeping up to date in your chosen field and looking after patients is enough. No society should expect you to become an expert in everything. Q: Our 40-stage model of investigation process …. Is the way forward? Rest withheld A Process is not outcomes. Start with a blank sheet of paper. Collect data. Its fine to allocate tasks to the investigation team members – but in healthcare – its just you, and perhaps a friend. When I say friend – someone from the ward below – or someone who still makes eye contact after the last one! Q: Why should I report – nothing happens for months and when it does nothing changes; I’ve reported the same type of incident three times in 2 years. I’ve not been interviewed, or a statement taken. A: I always use an analogy in industries where reporting is critical. The analogy refers to any relationship where information needs to be two way. The analogy: imagine you come home each night and say to your partner – “I love you”, and there is no response. How long will you say that to them? An example from security. It's important that all members of a security team report to the control room what they see, then to the police. Our extensive research showed that people stopped reporting when they had no feedback. Simple remedy – give feedback. In counter terrorism work the feedback sometimes can’t be that detailed, but what we found is – thanks that’s useful – is often enough. The feedback needs to be within 24 hours (see the When to investigate blog) and it needs to be personal. Hopefully if you are on a train, see something, say it, you should get the immediate feedback – it's sorted. Happy days testing that audio on the rail network! Encouraging reporting is the next step. If it's quiet and you are getting nothing – raise the issues with everyone, immediately. My colleague had a super way of getting security teams to communicate during a major event. The ‘broadcast all’ button on their radio was hit and all got a message – it’s a bit quiet. Long story but reports started coming in within seconds, the team (about 200 of them) became chatty and two of those reports were useful. Yes, feedback was given aided by tea and biscuits. Q: My report is downgraded – although the person died. How can that be? A: Let’s look at the NHS Improvement's Serious Incident Framework guidance and think of an event that did not happen – a near miss. The guide says of near misses: “It may be appropriate for a ‘near miss’ to be a classed as a serious incident because the outcome of an incident does not always reflect the potential severity of harm that could be caused should the incident (or a similar incident) occur again. Deciding whether or not a ‘near miss’ should be classified as a serious incident should therefore be based on an assessment of risk that considers: The likelihood of the incident occurring again if current systems/process remain unchanged; and The potential for harm to staff, patients, and the organisation should the incident occur again“ It's clear it's not the severity but the potential severity and the potential to occur again. I do wonder if investigation teams understand that we investigate to stop it occurring again. It's not about getting to the bottom of the pile of reports or getting ready for court. It's about prevention. As Metallica say "Nothing else matters" and NHS improvement are correct. (see blog part 1). Q: Do you think only those with medical training should investigate incidents (see Who should investigate blog)? A: It’s a team effort. There now appears to be some universities doing investigation training. This appears to be about creating a process of investigating. I would ask them how many investigations they have done, the outcomes, and evidence that the proposed process gets to the proximate cause. Q: Why is a postgraduate qualification is suggested in this area. A: Well, It’s a new area of science – that’s what a post doc or MSc is about. Its research – it being a new area of science – so a research qualification is ideal. Ethics forms a major area of postgraduate training in psychology Ethics is vital in medicine and its cornerstone is informed consent. Well if I go to my GP, I would like to know they have a Dr title. This is in the area of medicine. Having spent many hours talking about science, ethics, forensics, and psychology in assorted village halls and drafty council offices on behalf of HM Government. l’ll be delighted to address any club or institute about these matters. All I can ask the tea is strong, the cake light and fluffy. Q: As an experienced investigator, I think I’ve been taught very little about investigations, Human Factors, philosophy, logic, statistics and cognitive psychology. Where do I learn or even should I? A: I know truly little about medicine. I spent thirty years learning the list above. I think those with an expertise in medicine should do medicine. The beauty comes when we work together, each asking questions with the Socratic method (blog part 6). If you really want to know more, a degree in psychology or engineering/computer science is good. Avoid a standalone MSc from a university you have never heard of. A PhD or posh DPhil from one of the few universities that offer it, is a must. Training by a police force as a Senior Investigating Officer is cool. There are some organisations offering investigation training – ask how many have you done, who commissioned you and how have you become an expert in this? My editor adds “and how long did they spend in the witness box answering questions.” Q: We have now got walkie talkies to communicate. Are they a good idea? A: Oh dear – technology mediated communications needs a lot of thought and training. In the military and in the police, you are trained to use a radio – I’ve done the police course twice due to me forgetting the radio was live when describing someone on a beach! What you are communicating, if you know and trust the person, how the information is displayed (vertically ships/horizontally submarines), even if there is a 20 millisecond delay in the comms – all affect reliability and, importantly, trust. Q: What is the single most important “bit of science/philosophy in investigations?” A: Occam’s Razor. Thanks to our new MSc student – why do new people make us oldies look dim. I’ll cover that in my next blog. Willian of Occam (1287 – 1347) kind of set the scene – which for followers of these blogs updates us from the normal Greek learning (500 BC) we talk about. In a few years together we can chat about the 1930s! Q: So, in blog part 6 you set a challenge about a train station and incidents – what’s the answer? A: The passenger information system was underneath a glass canopy, and this is where all the incidents occurred. Hence, I say everyone knew the train times and would not be running. As you get older you may often need to get closer to text to read it. You also have issues with glare and contrast. All fine for being older – but put a change in platform surface at the same point as arms are raised to stop the glare in the eyes through the glass canopy – well you see why those fell. Information sign moved slightly, and no incidents. A big thanks to my science editors, Profs Alex and Graham, and soon to be PhDs Lara and Emma. Thanks to the hub editor (Sam) who I know groans when another blog arrives to have the bad jokes removed. Yes, dear reader, they start off far worse than the ones you read... Oh, look our doormat is festooned with another letter from a Mrs Trellis – she writes... Read the other blogs in this series Why investigate? Part 1. A series of blogs from Dr Martin Langham Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 9: Making wrong decisions when we think they are the right decisions Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

The aim of this framework, produced by the Royal College of Midwives, is to help Local Maternity Systems and the Maternity Transformation Programme to measure, consistently, the level of continuity of carer being provided over time, not only to monitor delivery, but also to help evaluate the extent to which particular models realise the benefits set out in evidence. This document summarises the policy expectations and then suggests a measurement framework that draws on existing data, or that can be incorporated into other existing data collection thus imposing minimal burden on health care organisations and staff. It provides clarity in terms of how continuity of carer is to be defined and measured, and benchmark data upon which improvement can be measured.

Key highlights Empirical description of safety case development at service level in healthcare. Safety cases can support adoption of proactive and rigorous safety management. Adaptation to purpose and use of safety cases might be required in healthcare. Education should be provided to practitioners and regulators.

Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, informed, calm approach in the way we respond to individuals that have unique needs during a crisis and A better form of multi-skilled, personalised support after the crisis event is over. So in July 2013 the Serenity Integrated Mentoring (SIM) model of care was proposed. This is how it works: SIM brings together all the key urgent care agencies involved in responding to high-intensity crisis service users around the table, once a month. This multi-agency panel selects each individual based on demand/risk data and professional referrals. They use a national 5-point assessment process to ensure that the right clients are chosen and in a way where we can ensure a delicate balance between their rights as an individual but our need to safeguard. Selected individuals are then allocated to a SIM intervention team. The SIM team is led principally by a mental health professional (who leads clinically) and a police officer (who leads on behaviour, community safety, risk and impact). The team supports each patient, to better understand their crises and to identify healthier and safer ways to cope. In the most intensive, harmful or impactive cases, the team also does everything it can to prevent the need for criminal justice intervention. Together, the mental health clinician, the police officer and the service user together create a safer crisis plan that 999 responders can find and use 24 hours day. The crisis plan is then disseminated across the emergency services. The SIM team reinforces these plans by training, briefing and advising front line responders in how to use the plans and how to make confident, consistent, higher quality decisions. What are the benefits and risks of this approach? Benefits: It is claimed that this is a more integrated, calm and informed approach to responding to individuals in crisis and the HIN provides "better multi-skilled, personalised support after a crisis event was over". The HIN website states: "Across the UK, emergency and healthcare services respond every minute to people in mental health crisis and calls of this nature are increasing each year. But did you know that as much as 70% of this demand is caused by a small number of ‘high-intensity users’ who struggle with complex trauma and behavioural disorders? These disorders often expose the patient to higher levels of risk and harm and can simultaneously cause intensive demand on police, ambulance, A&E departments, and mental health crisis teams." Risks: This approach has been subject to strong criticism from some users of mental health services, mental health clinicians and mental health support organisations. Concerns have been raised about whether the HIN/SIM approach is safe, effective or appropriate. I believe we need an open and inclusive discussion about High Intensity Networks, with users of mental services leading the debate. As a former mental health nurse in an Assertive Outreach team I'm keen to learn: How users of services were involved in the initial development of the model? What are the similarities and differences between High Intensity Networks and an Assertive Outreach model? How this approach compares with approaches in other countries? How users of services are involved in evaluating and adapting the model? What the specific benefits are for users of services and are there any risks to this approach? Does this lead to a long term improvements for users of services? I hope people will feel able to contribute openly to this discussion, so we can learn together. #HighIntensityNetwork #mentalhealth

These guidelines by the Association of Anaesthetists are a concise document designed to help peri-operative physicians and allied health professionals provide multidisciplinary, peri-operative care for people with dementia and mild cognitive impairment. They include information on: involving carers and relatives in all stages of the peri-operative process administering anaesthesia with the aim of minimising peri-operative cognitive changes training in the assessment and treatment of pain in people with cognitive impairment.