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With over 135 million outpatient appointments delivered in 2023/24, outpatient care is one of the most widely used services in the NHS. Yet despite its importance, too many patients experience long waits, inconsistent communication, and a system that can feel fragmented and impersonal. As demand continues to rise, the need for a more co-ordinated, patient-centred approach has never been clearer. In this timely and forward-looking session, the Patients Association explores a bold new vision for outpatient reform: one that places patients not just at the centre of care, but in true partnership throughout it. Chaired by Sarah Tilsed, our Head of Partnerships and Involvement, you'll hear from: Irene Poku, patient advocate, Anne Kinderlerer, Digital Health Clinical Lead at the Royal College of Physicians Theresa Barnes, Associate Medical Director for Clinical Services at Countess of Chester Hospital NHS Foundation Trust. It will unpack the key themes from Prescription for outpatients: reimagining planned specialist care, a joint report from the Patients Association and the Royal College of Physicians. This roadmap for reform proposes five ambitions and eight transformational shifts to create outpatient services that are timely, equitable, and genuinely collaborative. As the NHS looks to the future through the lens of the 10-Year Health Plan, this is a chance to be part of the conversation about what outpatient care should look like and how we can get there. Register- Posted
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untilJoin Aqua for their national event, ‘Transforming Tomorrow Through Leadership and Improvement Today’ to connect, learn, and shape the future of health and care through co-production and partnership working. It will be bringing together healthcare leaders, innovators, and change-makers for an afternoon of insightful discussion and meaningful connections as we mark 15 years of the Advancing Quality Alliance being the leading improvement partners. With an exciting line-up of speakers and time for discussion and networking, this event is an opportunity for you to gain fresh perspectives and reconnect with peers. Register- Posted
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The first of four webinars co-hosted by the WHO Department of Integrated Health Services (IHS) and the Global Health Partnerships (GHP) (formerly THET) to explore the transformative potential of relationality in community engagement and how it can be leveraged for people-led change. It’s part of a series being run by WHO and the Global Health Partnerships (GHP) (formerly THET), building on last year’s policy report on this issue launched at the World Innovation Summit for Health (WISH) https://wish.org.qa/wp-content/uploads/2024/09/Relationality-in-Community-Engagement.pdf Register -
News Article
Zero tolerance ‘won’t fix sexual harassment of staff’
Patient Safety Learning posted a news article in News
“Cultural transformation” rather than “zero tolerance” is required to overcome widespread sexual harassment by ambulance service staff and patients, according to the person leading national efforts to make improvements. The comments to HSJ from Bron Biddle, the lead for reducing misogyny and improving sexual safety at the Association of Ambulance Chief Executives, follow the publication of the 2024 NHS staff survey results. These found 1 in 12 reported unwanted sexual behaviour from colleagues or other staff in the past year – more than double the figure across all sectors and a slight increase on 2023. When reporting unwanted sexual behaviour at work from patients, relatives or the public, the figure totals a huge 29% of ambulance staff nationally — slightly higher than 2023 and massively above the national average for all NHS staff of under 9%. Despite the huge issue, HR specialist Ms Biddle, who has been running a programmme to tackle the problem for several years, said rooting it out required a “reset” of cultural norms, as well as social change. “If we just reinforce things like zero tolerance and stamping it out, we are missing the nuance of why this is happening in the first place,” she told HSJ. “It is easy for us to think of someone as a bad apple, but are they bad apples, or are we complicit in the environment they are operating in? And this is why wider culture transformation is so important if we want to prevent sexualised behaviours in the first place.” It means action taken against perpetrators should be “proportionate” rather than always hard-line, she said, and drew a distinction between predatory and exploitative behaviour, and that exhibited by someone who is capable of adapting their behaviour. Read full story (paywalled) Source: HSJ, 28 March 2025- Posted
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News Article
Failed CQC transformation cost £99m
Patient Safety Learning posted a news article in News
The Care Quality Commission spent £99m on a transformation programme that failed to achieve most of the promised benefits, a highly critical independent report has revealed. In 2021, the regulator launched its transformation programme under the oversight of former chief executive Ian Trenholm, which it said would simplify the assessment process for health and social care providers. It entailed major changes to the organisation and operations of the CQC’s inspection regime, but also the introduction of new IT, including a “regulatory platform and provider portal”. An independent review by IT expert Peter Gill and published after a CQC board meeting yesterday found the transformation programme was to blame for widespread IT failures that have caused “significant organisational disruption”. “The vast majority of the benefits expected to be delivered have not yet been achieved,” it said. Read full story (paywalled) Source: HSJ, 27 March 2025- Posted
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The Independent IT Review (IIR) was commissioned following the Penny Dash report, which highlighted issues with poorly performing IT systems hampering the Care Quality Commission (CQC)’s ability to roll out the Single Assessment Framework (SAF). That report made seven recommendations, including the need to rapidly improve operational performance, fix the Provider Portal (PP) and Regulatory Platform (RP), and improve the quality of reports. This review addresses the following questions: How and why did the reach a point where its IT solutions caused significant organisational disruption? Is the IT solution salvageable, based on the current contractual relationship with suppliers and subcontractors? If so, what needs to be done to make the IT solutions, the overall operating model, the programme management and contractual controls fit for purpose? If not, how should the CQC proceed to build or buy and implement an IT solution that is fit for purpose in the shortest possible time?- Posted
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Following Lord Darzi’s investigation in 2024 and a ‘national conversation’ on how to fix our ‘broken’ NHS, a new 10 Year Health Plan charged with setting out government plans to deliver its three shifts – from hospital to community, analogue to digital and sickness to prevention – will publish in the spring. The spending review, which will set out government spending plans for the next three years, and the publication of a revised long-term workforce plan, are also expected over the coming months. About the event This King's Fund conference will explore how implementation of the three shifts can deliver improved care, outcomes and experience for the public, while ensuring our health and care system is compassionate, equitable and sustainable. Our expert speakers will outline the actions and decisions needed to transform the health service into a prevention-focused service by 2035. Conference sessions will provide practical guidance on: how the 10 Year Health Plan can support the government’s overall health mission the impact of the comprehensive spending review and radical options for how funding is allocated and flows through the system how the plan can only be delivered successfully if there is similar attention and support for adult social care managing the trade-offs, including implementing the changes and shifts over the long term while prioritising resources on current pressures building on the approach in the development of the plan to work differently with people (patients, staff and communities) and ensure services are co-designed to meet needs and deliver care that is truly patient-centred how to achieve a managed shift in resources and power away from the acute sector towards primary, community and preventive services creating digitally enabled services that are inclusive and trusted by engaging with people and communities. Register- Posted
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This article, co-authored by IHI President Emeritus and Senior Fellow Don Berwick, highlights how healthcare in the US is failing patients and presents a vision of a system that better supports the nation’s needs.- Posted
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Published every 4 years to coincide with federal leadership transitions, the National Academy of Medicine’s Vital Directions for Health and Health Care series analyses the top health policy needs for the nation. The 2025 edition, published in Health Affairs, presents an expert overview of six key priorities: transforming health care payment and delivery; integrating AI into health care; modernising public health; addressing the health impacts of climate change; improving women’s health; and advancing the biomedical research enterprise. As leaders inside and outside government navigate complex challenges, the Vital Directions series provides actionable, evidence-based guidance. From Laggard To Leader: Why Health Care In The United States Is Failing, And How To Fix It Artificial Intelligence In Health And Health Care: Priorities For Action Four Opportunities To Revitalize The US Biomedical Research Enterprise Updating US Public Health For Healthier Communities Critical Steps To Address Climate, Health, And Equity New Directions For Women’s Health: Expanding Understanding, Improving Research, Addressing Workforce Limitation -
News Article
‘Complacent’ health chiefs in England lack drive to transform NHS, say MPs
Patient Safety Learning posted a news article in News
Plans to radically reform the health service are at risk because senior leaders of both NHS England and the Department of Health and Social Care (DHSC) are “complacent” and lack dynamism, MPs have said. In a report the public accounts committee (PAC) warns that officials in England have neither the ideas nor the drive to implement the health service transformation required by Keir Starmer and Wes Streeting. The influential cross-party Commons committee did not identify individuals by name. But it reached its conclusions after questioning in November five top-level civil servants including Amanda Pritchard, NHS England’s chief executive, and Sir Chris Wormald, the DHSC’s then permanent secretary, who has since become the new cabinet secretary. “The scale of government’s ambitions is great but senior officials do not seem to have ideas, or the drive, to match the level of change required, despite this being precisely the moment where such thinking is vital,” the PAC said in its report on the health service’s financial sustainability. Their lack of energy and urgency risks wasting “a golden opportunity” to modernise how the NHS works and thus improve the country’s health, the MPs said. Read full story Source: The Guardian, 29 January 2025- Posted
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News Article
Martha’s rule having ‘transformative effect’, NHS England data shows
Patient Safety Learning posted a news article in News
Patients have been moved to intensive care or received potentially life-saving treatment such as oxygen as a direct result of hospitals adopting Martha’s rule, NHS data shows. Doctors and nurses have changed how they care for dozens of very sick patients since its introduction in many parts of the NHS in England during the course of 2024. Martha’s rule, named after Martha Mills, who died in 2021 aged 13, gives patients and their loved ones the right to request an urgent review of the person in hospital’s treatment. That triggers their care being looked at urgently by a team of specialists, who offer a second opinion. Prof Sir Stephen Powis, NHS England’s national medical director, said: “The introduction of Martha’s rule represents one of the most important changes to patient care in recent years, and we are really encouraged to see the impact it is already having for patients in this first phase.” The new patient safety procedure has led to 573 calls, across the 143 hospitals using it, in which someone has sought an urgent review. About half (286) have prompted an urgent review by critical care staff. And about one in five of those reviews – 57 cases – has led to the person’s care being escalated, for example by being given potentially life-saving antibiotics or other drugs. Martha's mother, Merope Mills, told the Today programme: “It’s clear to me that if we implement Martha’s rule nationally, we can confidently say that it would greatly improve care, change the culture, and save lives.” She continued: “Any doctors who still have doubts about the value of Martha’s rule, I’d love them to realise a bit of humility and being open to the opinions of the family and patients makes for the best and safest medicine. Read full story Source: The Guardian, 17 December 2024- Posted
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The Patient Information Forum (PIF TICK) criteria have been updated after consultation with the PIF TICK Steering Group. The update takes in new developments including artificial intelligence and health information translation. This webinar explains the changes in the criteria, the timetable for implementation and how PIF will support members through the change. To support members with the responsible use of AI, a Framework for Policy Creation on the Use of AI in Health Information was also launched at the event. Speakers from PIF and Prostate Cancer Research introduced the new criteria and showcased examples of how AI can be used for good in health information. Related reading: Balancing the risks and benefits of AI in the production of health information- Posted
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News Article
Brain op failings made patients' lives 'hell'
Patient Safety Learning posted a news article in News
Patients who had probes located in the wrong part of their brain due to failings at an NHS trust suffered unnecessarily for years, a damning report has found. The leaked report into deep brain stimulation (DBS) surgery at University Hospitals Birmingham NHS Foundation Trust, seen by the BBC, also shows a whistleblower was ignored, intimidated and disciplined. Wendy Swain, who had electrodes in the wrong place for 11 years, leading to difficulty walking and a facial twitch, said: “They’ve made my life hell.” The trust, already under fire following an inquiry that exposed a culture of bullying and a lack of openness, said it was "truly sorry" for the mistakes and felt "deep regret". Dr Chris Clough, former chair of the National Clinical Advisory Team who oversaw the final report into the brain surgery failings, said he did not believe the trust was learning lessons. “I am begging them to get this report out and be open and fair with patients,” he said. “There’s suffering that has gone on here and they need to let people know what went on.” Read full story Source: BBC News, 6 December 2024- Posted
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Remove barriers on NHS data access to save patient lives
Patient Safety Learning posted a news article in News
Barriers on NHS data access should be removed so it can be used to improve patient care and allow crucial research into diseases like dementia, cancer and heart disease, a review has urged. Patients and their families are being let down because policymakers and healthcare leaders are not maximising the benefits of the rich abundance of health data in the UK, Professor Cathie Sudlow OBE, who led the independent review, said. The UK is unique because its population of 68 million people are largely seen by the NHS, with health data going back decades, the report commissioned by top government health officials said. But access to this existing health data is difficult or slow and can take many months or even years – impeding its use to improve people’s health and lives, the Sudlow Review found. Prof Sudlow said: “Research about health conditions affecting millions of people across the UK is far too often prevented or delayed by the complexity of our systems for managing and accessing data.” She added: “This review shows that getting this right holds a great prize for our own care and for an effective healthcare system for everyone. “We need to recognise our national health data for what they are: critical national infrastructure that can underpin the health of the nation.” Read full story Source: The Guardian, 8 November 2024- Posted
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Professor Cathie Sudlow OBE was commissioned to lead the independent review by the Chief Medical Officer for England, NHS England’s National Director for Transformation, and the UK National Statistician. Scientists often have to wait months or even years to securely access health data before they can carry out crucial research into conditions like dementia, cancer, and heart disease. The Sudlow Review is a call to action for policymakers and healthcare leaders, and emphasises that health data should be seen as critical national infrastructure requiring careful leadership and vital investment. The review includes five recommendations that highlight the need to remove barriers, streamline processes, and enable safe and secure data use across the UK. Five recommendations The Sudlow Review’s recommendations provide a pathway to establishing a secure and trusted health data system for the UK: Major national public bodies with responsibility for or interest in health data should agree a coordinated joint strategy to recognise England’s health data for what they are: a critical national infrastructure. Key government health, care and research bodies should establish a national health data service in England with accountable senior leadership. The Department of Health and Social Care should oversee and commission ongoing, coordinated, engagement with patients, public, health professionals, policymakers and politicians. The health and social care departments in the four UK nations should set a UK-wide approach to streamline data access processes and foster proportionate, trustworthy data governance. National health data organisations and statistical authorities in the four UK nations should develop a UK-wide system for standards and accreditation of secure data environments (SDEs) holding data from the health and care system. -
Content Article
New research has revealed what is hampering digital adoption across the NHS, as leaders look to unlock the full potential of technology and usher in the digital revolution. A survey, conducted by NHS Providers, indicates that everything from financial constraints, day-to-day pressures, and obsolete IT infrastructure are hamstringing the health service. This blog from the National Health Executive looks at the barriers, the current digital capability and the next steps.- Posted
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untilIntegrated care systems (ICSs) have the potential to radically transform health and care through collaboration, long-term thinking, and by pushing the boundaries of what is possible. In this summit, we give voice to innovative thinking and practices by hearing from senior leaders and partners from both within and outside of the health and care service, who have found ways to create meaningful impact by doing things differently. Be inspired by leaders who despite challenging circumstances and a backdrop of a 30% reduction in running costs have carved out opportunities for collaboration to create transformational change. Join us at this event to be at the forefront of discussions and debate on how ICSs can work differently to meet the needs of their local populations and fulfil their original purpose. Through keynote speeches, panel debates, case studies and interactive workshops, this summit will explore: how we meet the potential of ICSs to transform health and care the importance of focusing on prevention as a way of sustainably meeting the needs of local populations, and the role data has in it how provider collaboratives and Integrated Care Boards (ICBs) can work together differently and effectively to deliver integrated care services how reconvening community services so that care is moved closer to home can potentially transform the health and care system the value of working with patients and communities to provide better services how system-wide solutions can be utilised to tackle the workforce crisis what leading in uncertainty feels like and what can be learnt from it. Register- Posted
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untilPatient Safety Movement Foundation invites you to the 11th World Patient Safety, Science & Technology Summit. Patient safety thought leaders and advocates from around the globe will come together to share their expertise and develop transformative solutions to enhance safety and outcomes of care for patients worldwide. Register- Posted
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?- Posted
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Content Article
The USA President’s Council of Advisors on Science and Technology have released their report to the US President, Joe Biden, on patient safety. The report contains recommendations aimed at dramatically improving patient safety in Amercia. Recommendation 1: Establish and maintain Federal leadership for the improvement of Patient Safety as a national priority. 1A - Appoint a Patient Safety Coordinator reporting to the President on efforts to transform Patient Safety among all relevant Government Agencies. 1B - Establish a multidisciplinary National Patient Safety Team (NPST) and ensure inclusion of persons from populations most affected. Recommendation 2: Ensure that patients receive evidence-based practices for preventing harm and addressing risks. 2A - Identify and address high-priority harms and promote patient safety though incentivizing the adoption of evidence-based solutions and requiring annual public reporting immediately and quarterly public reporting within 5 years. 2B - Create a learning ecosystem and shared accountability system to ensure that evidence-based practices are implemented and goals for reduced harms and risks of harm for every American are realized. 2C - Advance interoperability of healthcare data and assure access to the tracking of harms and use of evidence-based solutions. 2D - Improve safety for all healthcare workers and their patients through supporting a just culture of patient and clinician safety in healthcare systems. Recommendation 3: Partner with patients and reduce disparities in medical errors and adverse outcomes. 3A - Implement a “whole of society approach” in the transformational effort on patient safety. 3B - Improve data and transparency to reduce disparities. Recommendation 4: Accelerate research and deployment of practices, technologies, and exemplar systems of safe care. 4A - Develop a national patient safety research agenda. 4B - Harness revolutionary advances in information technologies. 4C - Develop federal healthcare delivery systems’ capacities and showcase results as exemplars for safer healthcare.- Posted
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A Kind Life website
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A Kind Life works with NHS organisations to help them shape a culture that cultivates kindness and nurtures high performance. The company offers a range of training courses and programmes focused on areas such as recruitment, leadership, feedback and conflict resolution.- Posted
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Key to the success of the Patient Safety Incident Response Framework (PSIRF) is working collaboratively across organisations utilising the skills of colleagues from different departments This podcast, hosted by Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England, aims to further progress the conversation with special guests: Liz Maddocks-Brown, formerly NHS Horizons Claire Cox, Andy Wilmer and Lorraine Catt from Kings College Hospital Stefan Cantore from Sheffield University Management School.- Posted
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This free eGuide will aid your strategic communications design, and show you how you can develop strategic communications that support and educate populations and patients to make better lifestyle decisions and live healthier lives. In the eGuide, you’ll discover: Why is behavioural change critical for prevention? What are the fundamental elements of strategic healthcare communications. How to develop your vision for patient activation communications to become a reality. The guide is free, but you will need to submit your details download the Apteco guide from their website.- Posted
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In this report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report, which can be read in full here or from downloading the attachment below. Action is needed to ensure that ICSs are not ‘patient safety free zones’, says Patient Safety Learning. A year on from ICSs being placed on a statutory footing, a new report, The elephant in the room: Patient Safety and Integrated Care Systems, argues that there needs to be a greater focus on the role that they play in patient safety. The report sets out what we mean by avoidable harm in healthcare, outlining the scale of this problem and the need for a transformation in approach to improving patient safety. It also looks at the landscape of different coordinating groups and organisations in England that have roles and responsibilities to improve patient safety and reduce avoidable harm. What is revealed is a complex and fragmented environment, lacking strong measures for cross-organisational thinking and coordination to address complex systemic threats to patient safety. Considering the creation and initial development of ICSs, the report highlights how there has been little mention of their role in, or impact on, patient safety. It illustrates that although patient safety has not been set as explicit priority for ICSs, the delivery of safe care runs implicitly through each of their main aims. It goes on to consider the potential role that ICSs can potentially play in helping to embed and improve patient safety. Recommendations Considering the steps that could be taken to address the current gap that exists between patient safety and ICSs, and the wider fragmentation of the patient safety landscape in which they operate within, the report makes the following recommendations: The Department of Health and Social Care and NHS England should consider introducing a fifth aim for ICSs making explicit their role in helping to improve patient safety and reduce avoidable harm. NHS England should update the NHS Patient Safety Strategy to account for ICSs being placed on a statutory footing in July 2022 and set out their roles and responsibilities in relation to this. The Department of Health and Social Care and NHS England should consider revising the remit of the National Patient Safety Committee to take on a greater role in coordinating and joining-up the existing patient safety landscape in England. The National Patient Safety Committee should regularly publish agendas, papers and the minutes of its meetings to help inform all bodies that may be impacted by this, such as ICSs and individual healthcare providers, and also patients and the wider public. Patient Safety Learning comment: Patient Safety Learning Chief Executive Helen Hughes said: “ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, we think patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Currently there is not clear guidance or support to ensure that ICSs treat patient safety as a core purpose of healthcare. We believe they need to have specific aims for reducing avoidable harm and improving patient safety. There also needs to be clarity on where the patient safety role of ICSs fits into the wider healthcare system. The landscape of organisations with patient safety roles and responsibilities in England is fragmented and lacks coordination, often ill-suited to tackling complex systemic challenges to patient safety. We believe that the Department of Health and Social Care and NHS England need to consider how to better join-up this system, to promote cross-organisational working, coordination and ultimately reduce avoidable harm.”- Posted
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Authors of this article argue that: "...navigating the pandemic asked a lot of employees - and while they delivered, it came at a cost. Relentless sprinting means many employees are running on fumes. To create more sustainable change efforts, leaders must prioritise change initiatives, showing employees where to invest their energies. They also must manage change fatigue by building in periods of proactive rest, involving employees in change plans, and challenging managers to help build team resilience."- Posted
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