SONAR is an open source quality management platform, dedicated to continuously analyze and measure source code quality, from the portfolio to the method.
Open access. The Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice.
This year's report finds that most people in England receive a good quality of care. Our ratings show that quality overall has been largely maintained from last year, and in some cases improved, despite the continuing challenges that providers face.
Yet there is growing evidence that equality and human rights for people using services and staff needs to play a central role in improving the quality of care. We are finding that some of the best providers are doing this successfully – even in times of constraint.
We have updated the good practice resource and also published:
more case studies
an online e-learning module
In a national report published today, the Care Quality Commission (CQC) found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.
Open access. Using outcome measures to advance healthcare continues to be of widespread interest. The goal is to summarize the results of studies which use outcome measures from clinical registries to implement and monitor QI initiatives. The second objective is to identify a) facilitators and/or barriers that contribute to the realization of QI efforts, and b) how outcomes are being used as a catalyst to change outcomes over time.
Open access. Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.
To obtain an overview of existing evidence regarding quality criteria, instruments and requirements for nursing documentation.. To read the full article, log in using your NHS Athens details. To access full-text: click “Log in/Register” (top right hand side). Click ‘Institutional Login’ then select 'OpenAthens Federation', then ‘NHS England’. Enter your Athens details to view the article.
To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality.. To read the full article, log in using your NHS OpenAthens details.
Editorial. Alerts have become a routine part of our daily lives—from the apps on our phones to an increasing number of ‘wearables’ (eg, fitness trackers) and household devices. Within healthcare, frontline clinicians have become all too familiar with a barrage of alerts and alarms from electronic medical records and medical devices.
Somewhat less familiar to most clinicians, however, are the alerts received by institutions from regulators and other regional or national bodies monitoring healthcare performance. After the Bristol inquiry in 2001 in the UK,1 research showed that given the available data Bristol could have been detected as an outlier and that it was not simply a matter of the low volume of cases.2 3 Had the cumulative excess mortality been monitored using these routinely collected data, then an alarm could have given for Bristol after the publication of the 1991 Cardiac Surgical Register and could have saved children’s lives.4 Similar assertions have been made about detecting problems at Mid Staffordshire National Health Service Foundation Trust—that excessively high hospital standardised mortality ratios (SMRs) pre-dated the eventual recognition of exceptionally substandard care subsequently confirmed by other means.5 6. To read the full article, log in using your NHS OpenAthens details.
Open access. Several countries have national policies and programmes requiring hospitals to use quality and safety (QS) indicators. To present an overview of these indicators, hospital-wide QS (HWQS) dashboards are designed. There is little evidence how these dashboards are developed. The challenges faced to develop these dashboards in Dutch hospitals were retrospectively studied.
We've added 10 new Be Aware updates following your suggestions:
Musculoskeletal ; Osteoporosis ; Nutrition and obesity ; Falls ; HR ; Research Methods ; Information Governance ; Bladder, bowel and pelvic healthcare ; Rheumatology ; Medicines and healthcare products regulatory agency (circulated email)
Open access. Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tips to healthcare leaders seeking to advance a culture of improvement.
Junior doctors have the highest rates of prescribing errors, yet no study has set out to understand the differences between completely novice prescribers (Foundation year one (FY1) doctors) and those who have gained some experience (Foundation year two (FY2) doctors). The objective of this study was to uncover the causes of prescribing errors made by FY2 doctors and compare them with previously collected data of the causes of errors made by FY1 doctors.. To read the full article, log in using your NHS OpenAthens details.
Middle-aged and older adults requiring skilled home healthcare (‘home health’) services following hospital discharge are at high risk of experiencing suboptimal outcomes. Information management (IM) needed to organise and communicate care plans is critical to ensure safety. Little is known about IM during this transition. A U.S. study.. To read the full article, log in using your NHS OpenAthens details.
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 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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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?
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.
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.
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.
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.
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
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.
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.
Welcome to kazukoosmith.com the place to get wholesale clothing, vintage, boho clothing and of course current clothing for women. Do a search for plus size clothing and you'll come up with some cheap dresses for women. This site is stickly for women. Includes hair products, weaves, hair accessories and a gambit of women clothing and beauty and health products for the woman. Take a look, I've worked hard to make this site special, I hope you enjoy. Come on by, http://kazukoosmith.com
Open access. Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers—particularly middle managers—also have a role to play in quality improvement.
The Committee of Public Accounts today raises new concerns about the performance of the Care Quality Commission, the independent regulator of health and adult social care in England.
We have announced today the appointment of Dame Eileen Sills, the Chief Nurse at Guy's and St Thomas' NHS Foundation Trust, as the first National Guardian for speaking up safely in the NHS.
Background: evidence from inspection programmes suggest that the quality of care provided by individual care homes for older people is very variable. Aside from periodic inspection, there is limited information that is routinely collected and can be used to monitor quality.
Objectives: to describe a method for using routine hospital data on admissions of older people as means for monitoring quality of care within a care home. To explore how this might be applied and used. Login using your SSSFT NHS OpenAthens for full text. SSOTP - request a copy of the article from the library - www.sssft.nhs.uk/library
The aim of the project is to listen to children and young people’s views on how health and care services could be improved. To do this, we worked with Youth Action Wiltshire to train 12 people, aged 16-18 years, in skills such as safeguarding, listening and communication. They can now go out into the community and speak to children and young people about their experiences.
Tara Lamont and colleagues discuss how researchers can help service leaders to evaluate rapidly changing models of care, with a range of approaches depending on needs and resources. To read the full article, log in using your NHS Athens
Over the past few weeks, concerns have been raised with CQC by some Experts by Experience in relation to moving between their current employers and Remploy Ltd, one of the two organisations awarded new contracts to deliver Experts by Experience services from 1 February.
The NHS in England faces the immense challenge of bringing about improvements in patient care at a time of growing financial and workload pressures.
In a report published today, we argue that the NHS urgently needs to adopt a quality improvement strategy if it is to rise to this challenge. All NHS organisations need to build in-house capacity for quality improvement and to commit time and resources to acquiring the necessary capabilities. They should do so by learning from the experience in trusts such as Salford, Sheffield and Wigan where quality improvement is well established.
In hospitals, breakdowns in communication has been found to be a major source of errors.1 Communication between clinicians can occur at scheduled times or rounds, through face-to-face meetings or may be facilitated through the use of communication tools such as pagers. For the latter, often urgent communication between clinicians about a patient is required. Problems in communication can result in a failure to rescue or result in poor coordination of care. To read the full article, log in using your NHS Athens
Quality improvement (QI) methods have been introduced to healthcare to support the delivery of care that is safe, timely, effective, efficient, equitable and cost effective. Of the many QI tools and methods, the Plan-Do-Study-Act (PDSA) cycle is one of the few that focuses on the crux of change, the translation of ideas and intentions into action. As such, the PDSA cycle and the concept of iterative tests of change are central to many QI approaches, including the model for improvement,1 lean,2 six sigma3 and total quality management.4
Do OD is the expert resource on Organisational Development for the NHS, delivered by NHS Employers in partnership with the NHS Leadership Academy.
The NHS OD community came together to create a new tool to support Culture Change in organisations.
To maximise access, we turned the tool into a free app for smartphones and tablets.
The app now contains two tools:
1) The OD Culture Change Tool
This tool aims to help you on your culture change journey. It will prompt thinking and action and provides support and advice on culture change. The tool asks key questions to help you to think about what you might need to do to change culture. It will help you identify areas of strengths and areas of development. It offers pointers and practice resources which provide help and advice on culture change. At the end of each section you will be given a visual representation of your responses as well as an invitation to share any thoughts that the app has sparked for you.
2) Space To Think
The Space To Think cards have been created to support you to make workforce changes to deliver better quality care for patients. We’ve put together these cards for you to use as a digital toolkit to explore your ideas. You can use them to think about how to make change happen. Follow a particular path or shuffle the cards to help you think brighter about workforce change.
NG44. This guideline covers community engagement approaches to reduce health inequalities, ensure health and wellbeing initiatives are effective and help local authorities and health bodies meet their statutory obligations.