Learning is a life-changing opportunity - and a great education should have a measurable, proven impact on learners’ lives. That’s what Pearson’s efficacy programme and tools are all about.
Our strategy for 2016 to 2021 set out an ambitious vision for a more targeted, responsive and collaborative approach to regulation. Our business plan sets out the areas we will focus on over the coming year, as we adapt to a challenging and changing environment.
This quality standard covers community engagement approaches to improve health and wellbeing and reduce health inequalities, and initiatives to change behaviours that harm people’s health. This includes building on the strengths and capabilities of communities, helping them to identify their needs and working with them to design and deliver initiatives and improve equity.
England’s Chief Inspector of Hospitals told Tees, Esk and Wear Valleys NHS Foundation Trust that although the overall trust is doing well, it must make improvements to the safety of two core services after its latest inspection by the CQC.
Consultant liaison psychiatrist Alex Thomson and colleagues James Hughes and Genevieve Holt, from CNWL discuss how a focus on outcomes allows its staff and patients to work together to improve services.
Many healthcare systems recommend root-cause analysis (RCA) as a key method for investigating critical incidents and developing recommendations for preventing future events. In practice, however, RCAs vary widely in terms of their conduct and the utility of the recommendations they produce.1 ,2 RCAs often fail to explore deep system problems that contributed to safety events3 due to the limited methods used, constrained time and meagre financial/human resources to conduct RCAs.4 Furthermore, healthcare organisations often lack the mandate and authority required to develop and implement sophisticated and effective corrective actions.4 Consequently, corrective actions primarily aim at changing human behaviour rather than system-based changes.5 ,6
In this issue of BMJ Quality and Safety, Kellogg et al7 confirm these concerns about RCAs. Reviewing 302 RCAs conducted over an 8-year period at a US academic medical centre, the authors report the most common solution types as training, process change and policy reinforcement. Serious events (eg, retained surgical sponges) recurred repeatedly despite conducting RCAs. These findings highlight the long overdue need to enhance the effectiveness of RCAs. To read the full article, log in using your NHS OpenAthens details.
The CQC will begin roll-out of its new inspection approach from April 2017.
The CQC’s new regulation regime is intended to offer a more targeted and tailored approach to inspections, with previous ratings helping to determine how often trusts are re-inspected.
The guide, Better Questions, Safer Care, builds on our work for the Measuring and Monitoring of Safety Framework with The Health Foundation, and contains a range of useful resources to help health and care professionals to take a more holistic approach when looking at the safety of care.
This guideline covers assessment, treatment, monitoring and inpatient care for children, young people and adults with eating disorders. It aims to improve the care people receive by detailing the most effective treatments for anorexia nervosa, binge eating disorder and bulimia nervosa.
The Care Quality Commission has rated wards for people with learning disabilities or autism provided by Central and North West London NHS Foundation Trusts as Outstanding following its latest inspection.
Acute wards and psychiatric intensive care units (PICUs) at a south London NHS trust have improved since September 2015 but have still been rated Requires Improvement by the Care Quality Commission.
Today we have published a new report detailing the findings from our comprehensive inspections of specialist mental health services over the last three years.
A ‘Trigger Tool’ is used around the world to identify case-notes that warrant further search for adverse events. This paper shows we can get rid of Trigger Tools and just review random notes – we will find just as many adverse events. If we want a ‘canary in the mineshaft’ then we should examine adverse events in case-notes of patients who have died – they have a much higher than random adverse event rate.
The Shrewsbury and Telford Hospital NHS Trust (SaTH) has been working to improve care for patients who suffer Sepsis and has been using techniques learnt from the Virginia Mason Institute (VMI) in Seattle, as part of a five-year partnership.
This quality standard covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older, and how to identify those at risk of a decline. It describes high-quality care in priority areas for improvement. It does not cover the mental wellbeing and independence of people who live in a care home or attend one on a day-only basis.
A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust, we look at how acute, community and mental health trusts across the country investigate and learn from deaths of people who have been in their care.
In response to the data, Dr Paul Lelliott, deputy chief inspector of hospitals (lead for mental health), said:
“It is concerning to see that more people are being detained under the Mental Health Act than in previous years, when there is a national commitment to reduce this number.
As hospitals, health systems and other providers navigate changes in health care, volunteers stand out as key contributors in the success of pursuing the Triple Aim, a framework developed by the Institute for Healthcare Improvement that outlines an approach for maximizing the performance of the health care system
Open access. Quality improvement (QI) projects have been shown to positively influence patient care. They provide opportunities for trainees to present and publish their work locally and nationally, and to gain valuable leadership and management experience. We describe a pilot project to engage in QI trainees across a National Health Service trust and a school of psychiatry. After the first year of this programme over half of psychiatry trainees in the school (58% of core trainees and 47% of advanced trainees) are participating in 28 individual QI projects and QI project methodology is to become embedded in the core psychiatry training course. Specialty doctors, consultants, foundation doctors, general practitioner trainees, medical students and the wider multidisciplinary team have all become engaged alongside trainees, working with patients and their families to identify problems to tackle and ideas to test.
Communication between involved parties is essential to ensure coordinated and safe health care delivery. However, existing literature reveals that the information relayed in the referral process is seen as insufficient by the receivers. It is unknown how this insufficiency affects the quality of care, and valid performance measures to explore it are lacking. The aim of the present study was to develop quality indicators to detect the impact that the quality of referral letters from primary care to specialised mental health care has on the quality of mental health services.
Lean healthcare is claimed to contribute to improved patient satisfaction, but there is limited evidence to support this notion. This study investigates how primary-care centres working with Lean define and improve value from the patient's perspective, and how the application of Lean healthcare influences patient satisfaction based on results from the Swedish National Patient Survey. To read the full article, log in using your NHS OpenAthens details.
This quality standard covers the prevention, assessment and management of mental health problems in people with learning disabilities in all settings (including health, social care, education, and forensic and criminal justice). It also covers family members, carers and care workers
A new agreement has been formalised between the Care Quality Commission (CQC) and HM Inspectorate of Prisons (HMi prisons), to help facilitate how we will continue to work together to inspect health and care services in prisons.
We have responsibilities to inspect and regulate health and social care in the criminal justice system this including prisons, youth offending institutions, police stations and immigration removal centres.
Experts acknowledge that mental health problems may be more difficult to diagnose for people with learning disabilities. This is because it can be harder for the person to explain how they are feeling and what help they would like.
Open access. Just over 50 years ago, Avedis Donabedian published his seminal paper, which sought to define and specify the ‘quality of health care’, articulating the now paradigmatic triad of structure, process and outcome for measuring healthcare quality.1 In recent years, we have seen the rapid expansion of increasingly inexpensive information technology capability and capacity, facilitating the collection and analysis of large healthcare data sets. These technological advances fuel the current proliferation of performance measurement in healthcare
As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement. To read the full article, log in using your NHS OpenAthens details.
There have been improvements to the care provided to patients at Broadmoor Hospital - the Care Quality Commission has found.
CQC inspected the high security psychiatric hospital in Berkshire in July 2017 after inspectors previously found breaches in the care provided at Broadmoor by West London Mental Health NHS Trust.
CQC, alongside a number of partners, has today published a new good practice resource, Equally Outstanding, exploring how a focus on equality and human rights can help to improve quality of care.
This programme of work has seen the development of new national guidance from the National Quality Board, of which CQC is a member. For NHS trusts the guidance sets out the actions they must take when someone in their care dies and clear reporting expectations requiring trusts to collect and publish specific information on patient deaths on a quarterly basis. Work to produce guidance for families and carers on what to expect from the investigation process is also underway.
Handoff communication errors are a leading source of sentinel events. We sought to determine the impact of a handoff improvement programme for nurses. To read the full article, log in using your NHS OpenAthens details.
As part of her improvement project exploring how to increase capability to deliver continuous quality improvement, she shares her thoughts Sweden's approach to health and care systems.
England’s Chief Inspector of Hospitals has found improvement in the quality of services for patients during the latest inspection of Sussex Partnership NHS Foundation Trust.
As a result of the inspection, Sussex Partnership NHS Foundation Trust is now rated as Good.
North Staffordshire Combined Healthcare NHS Trust has today welcomed the publication of its latest CQC inspection, which - for the first time in the Trust's history - rates every Combined Service as "Good" or "Outstanding". The Trust's overall rating is "Good".
The results mean that Combined Healthcare is the best rated mental health trust across the whole of the Midlands and East of England and third highest in the whole country - only 1 of 3 with every service rated at least Good and at least two Outstanding.
For better or worse, the EHR has become an integral part of medical care. For every hour we spend on direct patient care, we spend another two with the EHR.5 Even when interacting with patients, our focus is on computer screens up to 80% of the time.6
Given this degree of attention, it is not surprising that the EHR influences physician behaviour, especially the overuse of low-value medical care. For example, an unchecked box on an order set provides a powerful stimulus to order a test, regardless of clinical utility.7 Displaying brand name instead of generic options leads to more expensive prescribing.8 Allowing labs to be ordered recurrently increases unnecessary phlebotomy.9 Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.10. To read the full article, log in using your NHS OpenAthens details.
Frank discussions, prompted by the improvement work SaTH are doing through its partnership with the Virginia Mason Institute in Seattle, has resulted in defects in C. diff being reduced by 13 per cent in just one month.
This guideline covers care and support for adults with learning disabilities as they grow older. It covers identifying changing needs, planning for the future, and delivering services including health, social care and housing. It aims to support people to access the services they need as they get older.
CQC inspectors visited The Priory in January 2018 to check on the safety of patients receiving treatment for drug and alcohol use on West Wing. Previously the service was in breach of regulations around substance misuse and detoxification.
The CQC has published a focused report on the safety of one ward at South West Yorkshire Partnership NHS Foundation Trust following an inspection in December 2017.
Picker has published a report which outlines the key learnings from NHS trusts involved in the scale-up and spread of Always Events.
Always Events are aspects of the patient experience that are so important to patients and family members that health care providers must aim to perform them consistently for every individual, every time.
A team of inspectors visited Northumberland Tyne and Wear NHS Foundation Trust in April and May. It was rated Good for safety, and Outstanding for caring, effectiveness, responsiveness and well-led. Overall, the trust rating has remained Outstanding - the same rating that it achieved when it was last inspected, in June 2016.
The Care Quality Commission has found further improvements Berkshire Healthcare NHS Foundation Trust
A team of CQC inspectors visited the trust during June and July 2018 to check four of the trusts ten mental health services and three of its community services. CQC also looked specifically at management and leadership to answer the key question: Is the trust well led?
The artists and Hospital Rooms have worked in partnership with the patients and staff on ES1 PICU to improve the quality of care for patients, change the physical environment and produce innovative permanent artworks. The award highlights how a physical environment on a ward can have a big impact on the quality of care which patients receive.
The independent homicide review report identifies a number of areas for improvement in the care we provided and these largely mirror the findings of the Trust’s own investigation in 2015. Since that time we have implemented a number of significant changes and improvements to our mental health services in Southampton and are in the process of putting in place the additional recommendations highlighted in this report.
Independent research carried out by AvMA shows that the Care Quality Commission (CQC) “requires improvement” in how it regulates the statutory duty of candour. This is despite significant improvements since AvMA’s previous report in 2016.
Open access. Emergency hospital admission on weekends is associated with an increased risk of mortality. Previous studies have been limited to examining single years and assessing day—not time—of admission. We used an enhanced longitudinal data set to estimate the ‘weekend effect’ over time and the effect of night-time admission on all-cause mortality rates.
To determine whether patients treated in hospital on the weekend report different experiences of care compared with those treated on weekdays.. To read the full article, log in using your NHS OpenAthens details.
Editorial. More than 50 years of health services research has driven home a core lesson: unintended and inappropriate variations in care are common.1 2 Identification of such variation in obstetrics was the impetus for Archie Cochrane to start his work.3 In this issue of BMJ Quality & Safety, Weiss and colleagues report an intervention developed to address inappropriate variation in aspects of maternal newborn care across Ontario, Canada’s most populous province.4 The intervention involved systematic collection and analysis of administrative data to assess key quality indicators for all hospital births in the province and provision of this data in a ‘dashboard’ back to hospitals.. To read the full article, log in using your NHS OpenAthens details.
England’s Chief Inspector of Hospitals has rated the services provided by Leeds and York Partnership NHS Foundation Trust as Requires Improvement following inspections by the Care Quality Commission.
The present study investigates the suitability of various treatment outcome indicators to evaluate performance of mental health institutions that provide care to patients with severe mental illness. Several categorical approaches are compared to a reference indicator (continuous outcome) using pretest-posttest data of the Health of Nation Outcome Scales (HoNOS).
Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.. To read the full article, log in using your NHS OpenAthens details.
This guideline covers ways to reduce suicide and help people bereaved or affected by suicides. It aims to:
help local services work more effectively together to prevent suicide
identify and help people at risk
prevent suicide in places where it is currently more likely.
Performance measurement (PM) and management for quality have become ubiquitous in 21st-century healthcare. Numerous entities have independently developed measures for assessing mortality, quality of chronic-disease care, access and patient satisfaction. Consequently, measures have mushroomed; for example, the National Clearinghouse for Quality Measures houses nearly 1100 active measures.1 Despite this proliferation, those whose performance is being measured have had little input in measure development. Research consistently shows when performance measurement systems are implemented by leadership divorced of the evidence-based motivational component that induces goal commitment and facilitates behaviour change, these do not accelerate performance improvement.2 3. To read the full article, log in using your NHS OpenAthens details.
We have seen variation in how trusts are implementing the new guidance. While awareness of the guidance is high, some trusts are finding it more difficult than others to make the changes they need.
There is some, limited evidence that suggests the guidance is better suited to acute trusts than mental health or community trusts.
The streamlining programme’s aim is for BOB [Buckinghamshire, Oxfordshire and Berkshire West] as a healthcare system, is to work collaboratively to achieve improvements in quality, staff health, wellbeing and make financial savings by realising the potential value of the healthcare workforce deployed across the region. Six NHS trusts, four key HR workstreams, over 24 managers all producing a maze with multiple processes to support their recruitment and staff experience.
There has been an increasing interest in the concept of value-based health care and how resources are allocated to improve outcomes. However, measuring outcomes in mental health services is often complex and fraught with difficulty, with professionals and service users often having very different perspectives on the nature of mental illness and the role of services in addressing it.
UHDB is celebrating a year of embarking on an improvement practice this month. On 12 April 2018, we were chosen as one of seven trusts nationally to take part in a programme which draws on learning from an American hospital to enable staff in a new improvement method which delivers results that patients will see and feel.
The Care Quality Commission has rated LANCuk Heywood, an assessment and treatment service for children and adults with Attention Deficit Hyperactivity Disorder and Autism, as Requires Improvement following an inspection in January 2019.
The Care Quality Commission’s Chief Executive, Ian Trenholm and Dr Paul Lelliott, Deputy Chief Inspector (Mental Health) will give evidence to the UK Parliament Human Rights Committee in early June.
To offer a better experience to service users on their ward, the team at Horizon Centre in Wakefield have introduced new ways of collecting patient feedback in order to see what they’re doing well and where they could make improvements.
The NHS has today announced that an additional £5 million will fund reviews to improve care for people with a learning disability and committed to renewed national action to tackle serious conditions.
The world’s first programme to review the deaths of everyone with a learning disability is being expanded to speed up the spread of best practice.
Thousands more reviews will be carried out over the next 12 months, driving local improvements to help save and improve lives.
The Care Quality Commission (CQC) is calling for an independent review of every person who is being held in segregation in mental health wards for children and young people and wards for people with a learning disability or autism. These reviews should examine the quality of care, the safeguards to protect the person and the plans for discharge.
Open access. The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method.
Free access. Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. The purpose of all safety measures is to improve care and prevent safety events; this can be achieved by different means. If the overall goal of measuring patient safety is to capture the universe of safety events that occur, then broader measures encompassing large populations, such as those based on administrative data, may be preferable. Acknowledging the trade-off between comprehensiveness and accuracy, such measures may be better suited for surveillance and quality improvement (QI), rather than public reporting/reimbursement. Conversely, using measures for public reporting and pay-for-performance requires more narrowly focused measures that favour accuracy over comprehensiveness, such as those with restricted denominators or those based on medical record review.
In this update for 2018, we report on:
the increase in opioid prescribing across the UK
measures put in place following the Gosport Independent Panel report
our continuing concerns regarding lower schedule controlled drugs
the introduction of legislation for cannabis based medicinal products.
Our update shares the key issues raised by NHS England controlled drug accountable officers and their unaccounted-for losses of controlled drugs by NHS England area. We also give examples of issues raised and followed up through the local area networks.
This is an important judgement as it further clarifies what is an acceptable care setting. The appearance of the proposed service did not match with the residential area it was located within and was too big - there was a supported living service on the same site. This did not promote integration with the local community.
A Pre-admission Suite (PAS) at a south London mental and community health trust has now closed, following a Care Quality Commission focused inspection in August 2019.
CQC undertook the inspection following concerns received about the length of
time patients stayed in Oxleas NHS Foundation Trust’s PAS and complaints from patients and relatives.
The Care Quality Commission (CQC) has rated the services provided by South West Yorkshire Partnership NHS Foundation Trust as Good following an inspection in May and June. This represents an improvement on their last inspection in March and April 2018 when the trust was rated as Requires Improvement.
Book review. Writing to Improve Healthcare, edited and authored by David P. Stevens, is a timely and important book that is designed to help quality improvers publish their quality improvement (QI) work. (Dr Stevens was the previous Editor-in-Chief of this journal, when it was called Quality & Safety in Healthcare.) The book is unique in that it applies a healthcare improvement perspective to the traditional manuscript preparation and publication process. This is useful for the novice writer and for authors accustomed to writing more traditional clinical research studies or writing for other biomedical fields. Indeed, while some prospective authors of QI work may not be first-time writers, this may be the …...To read the full article, log in using your MPFT NHS OpenAthens details. To read a copy of the book in this review, please contact the library
This guideline covers identifying and managing depression in children and young people aged 5 to 18 years. Based on the stepped-care model, it aims to improve recognition and assessment and promote effective treatments for mild and moderate to severe depression.
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B. Yu, and M. Singh. Cooperative Information Agents IV - The Future of Information Agents in Cyberspace, volume 1860 of Lecture Notes in Computer Science, Springer, Berlin/Heidelberg, (2000)