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Showing results for tags 'Transformation'.
Found 68 results
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News ArticleOrganisations 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
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Leading beyond COVID-19: transforming work and cultures
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual conference from The King's Fund will share practical ideas about transforming work and workplace cultures. It will explore how leadership and teamworking influences people’s work experiences, releasing their full potential to drive improved outcomes for patients and citizens. Discuss with other local health and care leaders how to create compassionate cultures with improved support for staff to make sure that the NHS and social care organisations are good employers and great places to work. Register -
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Why healthcare needs a people-first approach to digital transformation
Sam posted a calendar event in Community Calendar
In today’s world of multidisciplinary care, good communication between professionals and with patients makes all the difference. The digital transformation the sector was already undergoing pre-pandemic to replace postal and fax systems with email has been dramatically accelerated by COVID-19. 94% of organisations are now sending more emails due to remote working and distanced service delivery. But more email means more risk to patient data. In fact, email data breaches happen every 12 working hours. With busy clinical and administrative staff focused on delivering high-quality care, it’s time for security solutions stepped up to eradicate the everyday mistakes they make, such as attaching the wrong file to an email or adding an incorrect recipient. Join this webinar to discuss the importance of human layer security within digital transformation to ensures patient data is kept secure, while also facilitating the email communications that are fundamental to multidisciplinary care. Presenters: Clive Flashman, Chief Digital Office, Patient Safety Learning; Dr Saif F Abed, Founding Partner & Director, Cybersecurity Advisory Services, The AbedGraham Group; Sudeep Venkatesh, Chief Product Officer, Egress Register -
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The world turned upside down: Uncertainty and COVID-19
lzipperer posted an article in Letter from America
There is a lot to be uncertain about these days: school, work, health, family. However, in July one thing was certain: the streaming release of “Hamilton” in the US was going to be epic. The acclaimed musical production tells the story of a U.S. founding father Alexander Hamilton, intensely American, exploring themes of love, anger, arrogance, heroism, betrayal, mistakes, politics, policy, devotion, family, sacrifice and death. In some ways, it sounds like healthcare in the era of COVID-19. While months of the coronavirus pandemic are behind us, the uncertainties caused by the pace of change and the expected surge of further infection spread bring continued stress, fear and frustration. Disruptions to services, processes and relationships are rampant. They demand continued experimentation across healthcare to address concerns to keep patients, communities and healthcare workers safe. And the lack of a coordinated collective policy response to the crisis only perpetuates discomfort about the unreliability of actions to improve safety and the substantial costs the future holds in store. Ambiguities and dread due to the pandemic are problematic and will be for some time. Continued patient avoidance of care is evident and could be contributing to lack of timely care and diagnosis. An ImproveDx article summarises how fear is keeping patients from getting the care they need, and highlights the importance of recognising that rebuilding trust will take time. To anchor this effort, leaders must view risk as individuals see it rather than just an academic exercise to inform reentry strategies in the months to come. The unsettled nature of care and access to loved ones during COVID can make end-of-life planning particularly fraught with uncertainty. Stanford University School of Medicine has developed the GOOD framework for clarifying steps forward when working with patients and families facing palliative care decisions during the pandemic. Its four elements – Goals, Options, Opinions and Documentation – provide an effective structure for clinicians to have conversations with patients and families to address care management when the path forward is unclear. Prolonged uncertainty can degrade healthcare staff mental and physical health. In Hawaii, one health system sought to make antibody testing available to staff as a strategy to decrease anxiety and improve sensemaking around the crisis. Hawai`i Pacific Health in NEJM Catalyst explores the reasons why those who were tested opted into the programme. The authors found “curiosity” to be a primary motivator. Knowing something – whether positive or not – can reduce one aspect of uncertainty, which the article posits will help clinicians and their community think beyond the doubt to achieve a modicum of control. This single piece of stability will enable a willingness to gather information, to plan and to act. Despite the challenge uncertainty brings, there are individuals who consistently believe the future holds promise. People who are able to act and make a difference despite uncertainty. Much has been said about those in the midst of the COVID-19 crisis, but others continue to address persistent uncertainties and unreliableness of care – beyond the pressures of the pandemic. There are many whose tenacity shores up the foundations of the healthcare system to improve its safety. One such leader from the US, John Eisenberg MD, is celebrated every year through an award programme in his name. John was a founding father of patient safety in the US. Through his leadership, national research and improvement programmes were developed and funded to lead government efforts to improve quality and safety. In July for the first time, the John Eisenberg Patient Safety and Quality Awards were bestowed virtually. These awards recognise individuals, local efforts and national programmes whose work provides evidence of the value and commitment to engage in work to improve safety. This year’s recipients demonstrated values core to improvement and perseverance in their work toward achieving healthcare that is safe. The awardees have accomplishments that focused on diagnostic error and sepsis reduction. Each of these stories started in tests and trials motivated by commitment to getting healthcare to a better place. For example, Tennessee-headquartered HCA Healthcare was recognised for its SPOT (Sepsis Prediction and Optimization of Therapy) algorithm as a mechanism to identify sepsis quickly to enhance quality and patient safety. Through this enhanced use of technology, SPOT uses basic laboratory and clinical data in real time to provide teams with the information they needed to reduce sepsis mortality across their 173-hospital system. Data triggered alerts that initiated actions to decrease response times by approximately 6 hours rather than relying on shift change as the information sharing mechanism. The SPOT algorithm enhancement to the electronic medical record partnered well with existing sepsis management processes to arrive at improvements. In the climax of Hamilton’s first act, the battle of Yorktown culminates in a chorus of “the world turned upside down”, with the hope that the cacophony will ultimately result in a new country with new freedoms only imagined prior to crisis. It is certain that COVID disruptions will continue to test us all worldwide. Can we challenge ourselves, our peers and our leaders to experiment as necessary to confront COVID-19 while guaranteeing that what was learned will be used to create something better? -
Content ArticleOver the last 3 months we have seen NHS organisations work at lightning speed to adapt and serve their communities in response to the COVID-19 pandemic. With the shutting down of routine surgeries and outpatient services, care providers have adapted in an extraordinary way. Wards have been emptied as beds have been made available, while theatres and recovery rooms have been turned into intensive care beds – capable of looking after acutely unwell ‘level 3’ patients – overnight. These unprecedented changes deserve praise and commendation but, beyond this praise, what can we learn from COVID-19 and the scale of change we have seen? It was famously argued that it takes 17 years for research to impact frontline services.[1] . Due to this, immense interest has centered around how innovations, or new ideas, are diffused and how this process can be sped up.[2] Various barriers exist to the spread of new ideas and change – not limited to bureaucracy, a lack of resources to create change, and cultures – for example organisational culture. Due to these barriers the NHS and its subsequent organisations can appear as monolithic – slow to change or adapt to any innovations. But COVID-19 has turned this assumption on its head, with expansive structural and procedural overhaul seen in the last few months alone. It has led observers to ask how this has happened and, more importantly, how we can facilitate change in the future. As we reflect on these months, the psychology of a crisis can be helpful in understanding staff behaviour. There are three stages – emergency, regression and recovery.[3] In the emergency stage, energy and performance goes up as staff ‘fire fight’ in the crisis. However, the move towards the regression and recovery stage will see staff become tired and lose their sense of purpose before needing direction on how to recover and rebuild. These latter stages are symptomatic of the current state for NHS staff. Utilising theories of change, perhaps we can identify why this change happened so quickly. The impending doom felt by staff was palpable in March. The Nightingale field hospital was being built to cope with the immediate storm of COVID-19 patients needing ventilatory support and providers were told to free up beds. In business, this is coined the ‘burning platform’ and is a key driver of change. A burning platform is a term which describes the process of informing people of an impending crisis and is used to cultivate immediate change. This ‘burning platform’ is a simple analogy and based on an incident in 1988 of an oil rig worker who, when faced with an impending burning platform, jumped into freezing water. Whilst of course this sense of urgency can’t be replicated every time change needs to happen, for professionals working at the start of the pandemic, this is exactly what was replicated. Perhaps change happened so fast as professionals and staff had no other choice but to respond to the burning platform of COVID-19. Creating a sense of urgency is also argued as being integral to another organisational theory of change – Kotter’s 8 Step Process for leading change. The first stage – creating a sense of urgency – is characterised by a distinctive attitude change which leads workers to seize opportunities to make changes imminently. But NHS staff have already responded to the immediate urgency presented by COVID-19, so what happens next will be telling. Apart from creating the NHS’s own burning platform, adaptations that can be seen across the NHS are not following any other theory of change. The NHS – a highly complex and bureaucratic set of organisations – has seen providers innovate, change and adapt without the traditional ‘red tape’ of the NHS. NHS providers are no longer following a model, instead working out what is best for the patients they serve. For community providers and primary care this includes virtually treating patients to limit their risk to COVID-19. Changes that have taken years to discuss are now happening overnight – for example some hospital providers integrating IT systems to improve cohesion. With so many innovations, it is crucial that we learn from what is happening. Organisations should be supported to identify and collect information on the changes that are happening on local levels. With this wealth of information, organisations can learn what made local change possible and what the drivers of innovations were. This insight is undeniably useful as it can help us all understand the drivers of change locally and galvanise change in the future. This must be made into an organisational priority. While organisations remain in firefighting mode, now is a crucial time to take stock, capture these changes, and hold on to what is useful as the NHS – and wider society – recovers. References 1. Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011;104:510-20. 2. Turner S, D’Lima D, Hudson E, Morris S, et al. Evidence use in decision-making on introducing innovations: A systematic scoping review with stakeholder feedback. Implementation Science 2017;12. 3. Wedell-Wedellsborg M. If You Feel Like You’re Regressing, You’re Not Alone. Harvard Business Review [Internet] 2020.
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NHS X: COVID-19 Information Governance advice
Claire Cox posted an article in Good practice and useful resources
We will need to work in different ways from usual and the focus should be what information you share and who you share it with, rather than how you share it. The following advice sets out some of the tools that you can use to support individual care, share information and communicate with colleagues during this time. This includes communications tools where data is stored outside of the UK. This advice is endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital. -
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Content ArticlePart I illustrates why improving safety is so difficult and complex, and why current approaches need to change. Part II looks at some of the work being done to improve safety and offers examples and insights to support practical improvements in patient safety. Part III explains why the system needs to think differently about safety, giving policymakers an insight into how their actions can create an environment where continuous safety improvement will flourish, as well as how they can help to tackle system-wide problems that hinder local improvement.
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Content ArticleKegan proposes that there is a deep need for us to understand what it is that gets in the way of a person's genuine intention and what they can actually bring about. He looks at how we might address this gap, which he refers to as an 'Immunity to Change'.
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From Safety-I to Safety-II: A White Paper (2015)
PatientSafetyLearning Team posted an article in Organisational
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Content ArticleTopics include human factors, learning from deaths, neonatal and maternal patient safety, patient safety in primary care, medicines safety, safety in social care and patient engagement. 2. Master Slides (3).pdf AC_Salfordsafety_primary_care (1).pdf CW - Salford Apr 2019.pdf JH - Meds Safety Salford.pdf MT - Maternal and Neonatal Health Safety Collaborative Break out session.pdf Ursula Clarke PSP Patient Safety April 2019 final.pdf VC - Salford University Patient Safety Conference Glos_ Hosp_ Workshop_ 23 _April _2019.pdf
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News Article
How safe is our care?
Patient Safety Learning posted a news article in News
All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019 -
Content ArticleStill not safe: includes a critical history and examination of the patient-safety movement in American medicine attributes patient-safety initiatives to the changing (and diminished) place of doctors within the larger healthcare system at the end of the 20th century integrates three streams of thinking about healthcare mistakes: clinical reasoning; objective understanding from a safety-science perspective; patients' and families' stories of injury and suffering gives a critical and lively voice of dissent in physician-led conversations around medicine and healthcare reform and expense.
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Content ArticlePatient-Safety-Learning-Green-Paper-PDF-Online-170918.pdf
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News Article
New European study overhauling hospitals for nurse wellbeing
Patient Safety Learning posted a news article in News
Hospitals in the UK will be among 60 across Europe that will be supported to redesign their systems and ways of working to tackle nurse burnout and stress, under a ground-breaking four-year study. The first-of-its-kind project will see chosen hospitals implement the principles of the Magnet Recognition Programme, an international accreditation scheme that recognises nursing excellence in healthcare organisations. Run by the accreditation wing of the American Nurses Association, the scheme is based on research showing that creating positive work environments for nurses leads to happier and healthier staff and the delivery of safer patient care, in turn improving recruitment and retention. Among the key pillars of Magnet are transformational leadership, shared governance and staff empowerment, exemplary professional practice within nursing, strong interdisciplinary relationships and a focus on innovation. The new study – called Magnet4Europe – is being directed by world-renowned nursing professor Linda Aiken, from the University of Pennsylvania in the US, and Walter Sermeus, professor of healthcare management at Katholieke Universiteit Leuven in Belgium. Read full story Source: Nursing Times, 24 February 2020 -
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Immunity to change, a blog by Sally Howard
Sally Howard posted an article in Culture
Over the Christmas period I caught up on ‘interesting emails’, the ones with content that needs you to put thinking time aside to inwardly digest rather than cramming it in between Christmas baking. One of these was from Mike the Mentor, one of the great people who trained me as a coach a good few years ago, asking a very simple question: How is it that, despite being committed to change, we so often fail to make the changes we are committed to? He offered a great answer, taken from from Kegan and Lahey's book, Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization. If you are just following a simple recipe there’s no need for this but if you are going to take advantage of new opportunities and deliver a bigger change then this is worth a look. Just as with New Year’s resolutions, we often look at the behaviour that we want to eliminate as bad. This book is all about growing into your aspirations, knowing what makes them possible and what is getting in the way. There is a four step process to understanding the space between the change to which you are committed and actually making it happen, then a journey of a few months to make that change either with your team, with a coach or in quiet contemplation. Step one Identify your improvement goal. The thing you are really motivated to change, the one that is worth getting out of bed for, that scores five out of five, and its simply no longer tolerable to leave things as they are. For example: I am absolutely committed to improve x in our system. Step two Take an honest look at the things that you are doing or not doing that work against that goal. The more concrete you can be the better. Be honest, you don’t have to share this with anyone. But, if you can, seek out people who you trust who can add things that they see you do or don't do that are getting in the way of this being delivered. These are your hidden competing commitments. For example: I don’t actively engage. When I engage I tell people what needs to happen OR I rush through what I have to say. Step three Well done. Now confront these. What are your fears behind them? Identify that loathsome feeling lurking in the background, what would be the biggest risk for me in this? For example: I worry that people won’t take me seriously. Step four Behind step three will be one or two big assumptions that you hold to be true. These need to be identified. For example: I assume that if I don’t get this right others will reject what I hold dear because they know more than me. These steps then become the route to changing your mindset that is working against your goal. Do take a look at Kegan’s TED Talk ‘An evening with Robert Kegan and Immunity to Change’ and take a moment to reflect on the space between you deciding to do something that’s important to you now, and actually doing it. You can also go to the Harvard website where you'll find a helpful immunity mapping tool to download. Please leave a comment below or message me through the hub @Sally Howard, I'm very happy to talk further about this approach. -
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Content ArticleWhat will I learn? The report identifies 10 lessons to support providers and commissioners seeking to adopt this new approach: Start by focusing on a specific population. Involve primary care from the start. Go where the energy is. Spend time developing shared understanding of challenges. Work through and thoroughly test assumptions about how activities will achieve results. Find ways to learn from others and assess suitability of interventions. Set up an ‘engine room’ for change. Distribute decision-making roles. Invest in workforce development at all levels. Test, evaluate and adapt for continuous improvement.
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Content ArticleKey learning points The 6 most important leader competencies: Building collaborative relationships Strategic perspective Leading employees Taking initiative Participative management Change management
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EAST: Four simple ways to apply behavioural insights (2015)
Patient Safety Learning posted an article in Techniques
