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

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

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.

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.

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