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Previous Seminars

IMPLEMENTATION RESEARCH IN PATIENT SAFETY: THE NEXT FRONTIER FOR IMPROVING PATIENT CARE? Professor Nick Sevdalis, 29th March 2019

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Abstract: Patient safety has established itself as a multidisciplinary research arena for over 2 decades. During this time, a number of high profile safety-improvement interventions have been developed and evaluated, with some showing very promising results in scientific trials and other studies. Yet, descriptive evidence and anecdotal accounts from the frontline of healthcare delivery suggest that some of these interventions have struggled to gain adequate traction within routine health services – such that their expected positive impact on patient outcomes has not always been consistent.

In this seminar I will explore some of the above barriers, with specific examples from acute healthcare. I will offer an overview of the basic tenets of implementation science and reflect on their application within the current evidence base for patient safety. I will conclude the seminar with a call for reflection and debate with the audience regarding the need for further patient safety studies that evaluate clinical effectiveness, compared to studies that focus on implementation effectiveness instead – arguing that the latter are now more timely than ever.

Biography: A psychologist by training, Nick is Director of the Centre for Implementation Science at King’s College London, Academic Director of the Quality Improvement and Implementation Science Clinical Academic Group within King’s Health Partners, Chief Editor of BMJ Simulation and Technology Enhanced Learning and Associate Editor of Implementation Science. His research is situated at the interface of patient safety, improvement and implementation sciences. For the past 15 years, Nick has been studying perioperative and cancer pathways, aiming to address human factors in care delivery; to understand barriers and drivers of implementing and sustaining evidence-based improvement interventions; and to increase capacity to undertake safety and quality improvement at the frontline of healthcare delivery. His research has been disseminated in over 300 publications and chapters to-date.

Presentation slides available here

REDUCING HAZARDOUS PRESCRIBING AND IMPROVING PATIENT SAFETY IN PRIMARY CARE: Professor Darren Ashcroft, 28th February 2019

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Abstract: Improving patient safety in healthcare settings is a major concern globally. Medicines are the most commonly used clinical intervention in healthcare, and errors involving the prescribing, dispensing, administration and monitoring steps of medication use are common. Such medication errors can prolong hospital stay and lead to significant patient morbidity. Given this, the World Health Organisation has recently identified ‘Medication Without Harm’ as the priority for their third Global Patient Safety Challenge which aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years.  In primary care settings, we have been working to address these challenges focused on reducing hazardous prescribing as part of the work programme within the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC). The seminar will focus on the interventional studies underway, lessons learnt and plans for the future.

Biography: Darren holds the Foundation Professorship in Pharmacoepidemiology and is Head of the Drug Usage and Pharmacy Practice Group at the University of Manchester. He is the Deputy Director of the NIHR Greater Manchester PSTRC, in which he also leads the medication safety research theme. He is also a member of the Pharmacovigilance Expert Advisory Group (PEAG) at the Medicines and Healthcare products Regulatory Agency (MHRA).

As a pharmacist and pharmaco-epidemiologist, his major research interests and teaching include: methods to improve the appropriateness and safety of drug prescribing and drug taking, and quantification of the risks and benefits of drug therapies. He has led extensive research programmes focused on patient safety in a wide range of healthcare settings (hospitals, general practices, and pharmacies), with particular expertise in understanding and improving medication safety.

Presentation slides available here

PRACTITIONER AND PATIENT INVOLVEMENT IN THE DEVELOPMENT OF AN AUTOMATED RISK SCORE PACKAGE TO PREDICT THE RISK OF DEATH OR SEPSIS FOLLOWING EMERGENCY MEDICAL ADMISSION TO HOSPITAL: Dr Judith Dyson and Dr Claire Marsh, 24th January 2019

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Abstract: Quality and safety of care remains a priority for the NHS but approximately 5% of deaths in English hospitals are preventable, and attributed to poor quality of care.  Patients who are admitted to hospital towards the end of their lives can experience inadequate decision making, poor communication and suboptimal treatment and there is the need for clinical staff to recognise as soon as possible that a person is dying and to communicate this clearly to others.  Over a two year research study in two NHS hospitals, a suite of four automated risk scores was developed that use routinely collected electronically stored data to provide clinicians with estimates of patients’ risk of death and sepsis during their stay in hospital. These scores rely on two key clinical data sources – the patients vital signs data as defined and monitored by the National Early Warning Score (NEWS) and routine blood test results.  Staff and patient involvement has been integral to the development of the scores.  In this presentation, we outline the findings of 8 focus groups involving 11 service users and carers, and 45 health care practitioners, and explain how these have contributed to an understanding of value and potential use of the scores in practice.

Biography: Dr Judith Dyson is a registered general and mental health nurse, a health psychologist and her research focuses on the use of psychological theory in supporting practitioners in implementing best practice.

Dr Claire Marsh is a research fellow in quality, safety and patient experience and also leads patient and public engagement for the Yorkshire & Humber Improvement Academy.

Presentation slides available here

DIVERSITY IN PRACTICE LEADERSHIP – A QUESTION OF CARE, QUALITY AND SAFETY: Professor Laura Serrant, 22nd November 2018

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Abstract: Nursing and healthcare in the 21st century is charged with delivering high quality care within an increasingly diverse society. Much of the policy, practice and research drivers around cultural competence, diversity and nursing practice focuses on meeting the needs of patients, service users and the public – particularly following the findings of the Francis Report (2013). However, recent reports have highlighted that highlighting the need for compassionate care for patients often occurs in isolation from recognising the needs of the workforce or the nursing profession as a whole – in this regard we do ourselves a dis-service – and in the silent spaces between patient need and workforce responsibilities, we fail to acknowledge the importance of professional leadership as the catalyst to delivering the high quality, equitable and culturally competent care that we all hope for. This presentation will use personal and professional reflections to highlight the importance of culturally competent and compassionate leadership to truly achieving safety and quality in 21st century health care. It explores the challenges and opportunities faced at an individual and professional level in the UK. It looks back at nursing strategic drivers of the last 3 years in the UK and makes a case for centralising culturally competent, compassionate leadership in the light of the new strategic framework for nurses, midwives and care staff (2016)

Biography: Professor Laura Serrant OBE is Professor of Nursing in the Faculty of Health and Wellbeing at Sheffield Hallam University, one of the few black Professors of Nursing (out of 262) in the UK. She is one of the 2017 BBC Expert women, Chair of the Chief Nursing Officer for England’s BME Strategic Advisory group and a 2017 Florence Nightingale Scholar. She is an ambassador of the Mary Seacole Memorial Statue and the Equality Challenge Unit Race Equality Charter for Higher Education. Her work has been recognised with numerous awards and prizes, including Queens Nurse status and Fellowship of the Queens Nursing Institute to those who have shown leadership in community nursing. In 2014, she was named as one of the top 50 leaders in the UK by The Health Services Journal in three separate categories: Inspirational Women in Healthcare, BME Pioneers and Clinical Leader awards. The Powerlist 2018 lists her as the 8th most influential Black person in the UK. She was awarded an OBE in the Queen’s Birthday Honours list this year for services to Health Policy.

Presentation slides available here

LEARNING FROM NEVER EVENTS – A RESILIENT HEALTHCARE ANALYSIS: Dr Janet Anderson, 18th October 2018

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Abstract: Never Events are patient safety incidents that can cause harm or death and are so named because policy makers argue there is enough evidence available about how to prevent them, so they should never occur. Never events include wrong site surgery, wrong route drug administration, retained foreign objects and wrong implants. Between April-November 2017 332 Never Events occurred in hospitals in England, indicating that solutions to prevent them are not working. Although Resilient Healthcare is often described as a paradigm shift in safety management it is not clear how it can contribute to the investigation of adverse incidents. Root Cause Analysis (RCA) is currently used for the investigation of Never Events, but recent studies have found the recommendations to be of low quality. There is little incentive, time or resources for healthcare organisations to consider other approaches and little work has been done on how to use Resilient Healthcare insights to augment Safety I practices such as Root Cause Analysis. In this presentation the results of an analysis of 39 Never Events that occurred at one hospital over a two-year period will be discussed. The focus will be on the new insights and perspectives that Resilient Healthcare can offer to improve learning from Never Events. Recommendations for strengthening RCA and learning from Never Events will be discussed.

Biography: Janet Anderson is Director of the Centre for Applied Resilience in Healthcare and a Reader of Healthcare Improvement at King’s College London. She is a human factors psychologist. Her research draws on psychological and organisational theories and knowledge and is focused on designing systems to support safe human activity. She has specialist expertise in the theory and practice of organisational resilience, system modelling using cognitive work analysis, incident reporting and adverse event analysis, and inter professional teamwork. Board level processes and hospital wide systems for improving quality are an area of current research.

Presentation slides available here

PRIZING OPENNESS OR PRISING OPEN THE NHS? STAKEHOLDER VIEWS ON THE IMPACT OF POST-FRANCIS POLICY INTERVENTIONS: Professor Graham Martin, 20th September 2018

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Abstract: Inquiries, academic work and expert group reports on problems in the quality of care in the NHS and other healthcare systems have identified shortcomings in ‘openness’—that is, the extent to which organisations enable concerns to be raised and disclosed freely without fear—as critical to the incubation of failings in quality and safety. In response, the NHS in England has developed policy initiatives that seek to improve openness, including a statutory duty of candour when care processes give rise to harm, the introduction of ‘Freedom to Speak Up Guardians’ to facilitate staff voice about concerns, and changes to various processes, including the way serious incidents are investigated. The evidence base for many of these changes, however, is uncertain, and their impact on the quality of care unevaluated.

This paper discusses emergent findings from an ongoing evaluation of various openness initiatives in the NHS, focusing in particular on an interview-based sub-study of senior stakeholder views on the implementation and impact of these initiatives. It highlights some of the challenges involved in achieving greater openness given past experiences and deep-rooted beliefs about the (at best ambivalent, and often negative) consequences of being open, the difficulties involved in diagnosing opacity and fostering openness, and the approaches taken by senior clinicians and managers to translating policy into practice. It relates findings to current policy and wider evidence and theory on interventions to facilitate employee voice and achieve culture change.

Biography: Graham Martin is Director of Research for THIS Institute, a new unit funded by the Health Foundation at the University of Cambridge to develop the evidence base for and impact of work to improve healthcare quality and safety, and Professor of Health Organisation and Policy in the SAPPHIRE Group, University of Leicester. His research focuses on social, organisational and professional issues in healthcare system change, with a particular focus on quality improvement work and policy initiatives to address quality, safety and risk in the NHS.

SETTING AN AGENDA FOR IMPROVING PATIENT SAFETY IN MENTAL HEALTH SERVICES: Professor John Baker, 7th June 2018

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Abstract: Improving Patient Safety in Mental Health Services presents a unique set of challenges and there continues to be limited attention paid to it. This seminar will provide an insight into key issues and priorities for future research identified by staff, service users and carers. It will provide an overview of relevant work being conducted by Mental Health Research Group, School of Healthcare, University of Leeds. Examples of current work of the group include reducing restrictive interventions (restraint, seclusion and forced medication), designing safer services through improving transitions and staffing and broadening our understanding of safety incidents in inpatient mental health services.

Biography: John is the Professor of Mental Health Nursing at the University of Leeds. He leads the Mental Health Research Group in the School of Healthcare. His research focuses on the development of safe and effective mental health services and clinical interventions across secondary mental health care. He is a health services researcher who has used a variety of methods from qualitative studies to complex trials and has generated substantial research income via the NIHR including RfPB, HSDR, Programme Grants and charities such as the Health Foundation. The good practice manuals which he developed have been evaluated, cited as examples of good practice, and influenced clinical practice in the UK and abroad. The training package for patients, service users and carers to promote research awareness and understanding has been cited as an exemplar of good practice. He is also a non-executive director at Leeds and York Partnership NHS Foundation Trust.

USING DATA TO DRIVE IMPROVEMENT IN THE QUALITY AND SAFETY OF CARE: A SOCIAL SCIENCE PERSPECTIVE: Dr Jonathan Benn, 10th May 2018

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Abstract: In UK healthcare there has been continuous development in data collection to monitor the quality and safety of care, in the form of both local and national programmes for quality improvement, clinical audit, incident reporting, mortality surveillance and digital technology, amongst others.  In the past, feedback from large-scale monitoring programmes has been limited.  Recently, the promotion of quality improvement methods has given rise to new models for effective use of data and advances across a range of disciplines afford us opportunities to better understand how to make feedback more useful and actionable for clinicians, teams and organisations.  Such approaches promise to translate data into interventions that support professional behaviour change, local quality improvement and robust implementation.  In this research seminar, the challenges and opportunities for enhanced feedback and local use of data will be outlined, drawing upon experience across a range of research projects that have applied human and organisational perspectives to topics in quality improvement and patient safety.  Specific applications include quality in anaesthesia, national mortality alerting and patient safety incident reporting and learning systems.  The relative merits of a model for continuous monitoring and feedback, based upon industrial quality improvement practices, will be discussed.

Biography: Jonathan Benn is Associate Professor in Healthcare Quality and Safety at the School of Psychology at the University of Leeds.  With a background in Psychology and Human Factors, he has 13 years’ experience as a health services researcher using applied theory and methods from the social sciences to address a range of research questions at clinical and policy level.  His previous post was a Lectureship in Quality Improvement at Imperial College London and as Director of the MSc course there in Quality and Safety.  His work has been supported by the Health Foundation, NIHR CLAHRC and NIHR Health Services and Delivery Research programmes.  He is currently an Associate Editor for the Joint Commission Journal on Quality and Patient Safety, which publishes international improvement research and practical case studies to share learning across contexts.

Presentation slides available here

A ‘REAL WORLD’ TRIAL OF A STRATEGY TO PROMOTE EVIDENCE-BASED PRIMARY CARE IN WEST YORKSHIRE: Professor Robbie Foy, 18th January 2018

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Abstract: Clinical evidence that can improve patient outcomes does not reliably find its way into everyday care. The gap between evidence and practice limits the health, social and economic impacts of clinical research. Dissemination of evidence-based practice via clinical guidelines is necessary but seldom sufficient by itself to ensure implementation. Furthermore, the general practice context presents particular challenges – especially given limited practice organisational capacity, increasing workload and complexity of care, and competing priorities.

This presentation will report the key methods and findings from a major programme of work involving general practices across West Yorkshire.  We aimed to develop and evaluate an implementation package to support the uptake of a range of guideline recommendations and sustainably integrate it within general practice systems and resources.  We made our evaluation as pragmatic as possible to ensure relevance to ‘real world’ primary care.  Seminar participants can judge for themselves to what extent we met our goals.

Biography: Robbie Foy is Professor of Primary Care at the Leeds Institute of Health Sciences and a general practitioner in inner-city Leeds.  His field of work, implementation research, aims to inform policy decisions about how best to use resources to improve the uptake of research findings by evaluating approaches to change professional and organisational behaviour.  His former posts include a clinical senior lectureship at Newcastle University, and an MRC training fellowship in health services research based jointly between the Universities of Edinburgh and Aberdeen.  He is also trained as a public health physician.  He was a 2006-7 Harkness / Health Foundation Fellow in Health Care Policy, based jointly between the Veteran’s Administration and RAND in Los Angeles.  He was formerly Deputy Editor-in-Chief of the open access journal, Implementation Science.

TO IMPROVE DIAGNOSIS, INTERVENE AS SOON AS IT STARTS: Dr Olga Kostopoulou, 30th November 2017

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Abstract: The early stages of judgement are the most critical for the final outcome of the diagnostic process. I will present studies that used different methodologies to measure the influence of this early stage on the diagnostic process and outcome. I will also present the design of a computerised diagnostic support system (DSS) prototype for General Practitioners. Designed to support the early stages of the diagnostic process, the DSS prototype was recently evaluated in a study with GPs consulting with standardised patients (actors).

Biography: Olga studied Psychology at the National University of Athens, Greece, and obtained her MSc and PhD in Psychology from Cardiff University. Prior to her current position, she held academic positions at King’s College London, and the University of Birmingham. Her main research interest is the application of psychology theory and methods to the study of medical decisions. She has conducted research on medical judgement in a variety of healthcare settings, using predominantly quantitative experimental methods. She aims to understand the cognitive biases that can lead to diagnostic error and delay, and test ways of reducing bias and supporting judgement. Her research has been funded by Cancer Research UK, the EU and the DoH. She is Associate Editor of the journal Medical Decision Making, has served as elected Trustee on the Board of the Society, and has chaired the Society’s biennial European meeting in London (June 2016). She has given short courses and MSc modules on the psychology of medical decision making to UK and international audiences.