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Previous seminars

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.