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NHS England has today published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust, and highlighted a system-wide response.
To study the effects of scale type (visual analogue scale vs. Likert), item order (systematic vs. random), item non-response and patient-related characteristics (age, gender, subjective health, need for assistance with filling out the questionnaire and length of stay) on the results of patient satisfaction surveys. Login using your SSSFT NHS OpenAthens for full text. SSOTP - request a copy of the article from the library - www.sssft.nhs.uk/library
CQC’s Chief Inspector of Hospitals, Professor Sir Mike Richards and the Chief Executive of NHS Improvement, Jim Mackey have written to all 255 NHS hospital trusts in England to ask them to consider quality and finances on equal footing in their planning decisions.
Ahead of publishing the consultation response into the functions of the office of the National Guardian, Dame Eileen Sills has set out the principles and priorities that will guide her first months in post.
Day-to-day responsibility for smooth operational running of trusts lies with their boards, and when things go wrong, formal oversight of trust boards is provided by regulators. But between those two stools is performance management; in the current system, that sits with commissioners.
We will publish two documents covering foundation trusts’ requirements for 2015/16. This consultation includes:
our proposals for indicators to be subject to assurance in our detailed guidance for external assurance on quality reports 2015/16
our proposal to clarify guidance on how auditors should report a modified conclusion on their limited assurance work
an invitation for you to comment on who should provide the external assurance on quality reports from 2016/17
We will consider all responses in finalising these documents for 2015/16.
Presentation from NHS Transformathon. This session will show how, as a nation, Scotland is seeking to achieve large scale improvement in health and care through a combination of programme-specific activities and supporting development of sustainable QI cultures within health and care organisations. They’ll do this by sharing their experience of using a range of activities to support cultural change including the Building a QI Infrastructure Programme and Board development activities. They will also share their learning and outcomes from a specific example in the care of people living with frailty and delirium.
Patient-centred care, defined as respecting and responding to the needs and preferences of patients, empowering them to make decisions that best fit their individual needs, has been identified by the Institute of Medicine as an essential element of high-quality care.1 It can be thought of as respectfully involving the patient2 in a way that helps practitioners provide care that is concordant with their patients’ values, needs and preferences while better enabling patients to actively provide input and participate in their healthcare.3 Patients are more satisfied with their care when they feel that healthcare providers are understanding their needs, carefully listening and clearly providing information4; in addition, patient-centred care has been found to be associated with improved patient outcomes.5 In order to provide exemplary patient-centred care, one needs well developed communication skills, especially in the realm of active listening and responding to patient cues. The importance of physicians mastering the art of patient-centred communication skills can be seen as a theme in the educational objectives of medical school curricula as well as in the competencies of the Accreditation Council for Graduate Medical Education. To read the full article, log in using your NHS Athens
Objectives One important component of patient-centred care is provider incorporation of patient contextual factors—life circumstances relevant to their care—in managing the patient's health. The current study uses data sets collected from direct observation of care to examine if how a provider learns contextual information influences whether the provider incorporates the information into a care plan.
Managing demand for planned health care is described in this report as a “wicked problem” – demand for healthcare is outpacing capacity to meet it.
Health economies have tried various approaches to managing demand; referral management centres, expanded roles, direct access amongst others. But the evidence base has been mixed, of variable quality and sometimes conflicting findings.
This synthesis of evidence sets out to understand what works but with a particular focus on context, to understand what works, in what settings and why.
This quality standard covers the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth). It also includes providing pre-conception support and advice for women with an existing mental health problem who might become pregnant, and the organisation of mental health services needed in pregnancy and the postnatal period.
Adherence to medicines has been identified as a key issue by the Royal Pharmaceutical Society of Great Britain,1 the WHO2 and, most recently, by the UK Academy of Medical Sciences.3 Estimates of adherence vary widely but are often reported to be as low as 50%.4 When a patient does not take their prescribed medicines as intended, they may not derive the expected outcomes. As well as implications for the individual patient, this can result in increased costs associated with patient hospitalisations or avoidable escalation in other costs of care.3 It may also result in unused medicines, the cost of which is estimated at £300 million per year in England alone.3 To read the full article, log in using your NHS OpenAthens details
PERFORMANCE: Older people’s mental health wards across Sussex require improvement, according to the Care Quality Commission. Please contact the library to receive a copy of this article - http://bit.ly/1Xyazai
Monitor requires all NHS foundation trusts to produce reports on the quality of care as part of their annual reports. Quality reports help trusts to improve public accountability for the quality of care they provide.
Prescribing errors occur in up to 15% of UK inpatient medication orders. However, junior doctors report insufficient feedback on errors. A barrier preventing feedback is that individual prescribers often cannot be clearly identified on prescribing documentation. To read the full article, log in using your NHS OpenAthens details
CQC is carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services.
This follows a request from the Secretary of State for Health, which was part of the Government’s response to a report into the deaths of people with a learning disability or mental health problem in contact with Southern Health Foundation NHS foundation Trust.
CQC’s review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home. The review will pay particular attention to how NHS trusts investigate and learn from deaths of people with a learning disability or mental health problem.
NICE has updated its guidelines pages to explain how they should be used in offering patients and service users the best care.
The new wording explains that guidelines should be taken fully into account but that the patient, or person receiving care, should be at the heart of decision-making. It also emphasises the importance of a clinician’s expertise and judgement.
The change is in response to conversations NICE has been having with people – including GPs. The new wording reflects NICE’s broader responsibilities within health and social care.
The independent Expert Advisory Group (EAG) report, advising the Secretary of State for Health on the creation of the Healthcare Safety Investigation Branch (HSIB), makes the case that there is room for improvement for investigation capability throughout the NHS.
The EAG’s advice is that HSIB should be an exemplar for the whole health system on how to undertake learning-oriented safety investigations, helping those in the system improve rather than taking on the majority of investigations itself.
Our 2016 to 2021 strategy sets out an ambitious vision: a more targeted, responsive and collaborative approach to regulation so more people get high-quality care.
Published today, the Care Quality Commission’s five year strategy, includes a greater focus on using the voices of patients, service users and their families, along with other information, to target inspections.
CQC is responsible for monitoring, inspecting and regulating health and social care in England. The new strategy sets out how CQC will combine learning from inspections with better use of intelligence from the public and others to focus inspections more tightly on where people may be at risk of poor care.
The Care Quality Commission (CQC) today publishes the findings of a short-notice, focussed inspection of Southern Health NHS Foundation Trust, conducted over four days in January 2016.
In May 2016, a new recommendation was added on providing information about olanzapine when choosing antipsychotic medication for children and young people with a first episode of psychosis.
The National Guardian Office has published a document to explain where a local guardian sits in an organisation and the principles which underpin their role to help to improve the culture around raising concerns.
The document, entitled Freedom to speak Up Guardians - Purpose and key principles of the role includes principle examples.
Hospital board members are asked to consider large amounts of quality and safety data with a duty to act on signals of poor performance. However, in order to do so it is necessary to distinguish signals from noise (chance). This article investigates whether data in English National Health Service (NHS) acute care hospital board papers are presented in a way that helps board members consider the role of chance in their decisions. You can request a copy of this article by replying to this email. Please ensure you are clear which article you requesting.
NHS Improvement has launched its single oversight framework consultation.
The framework sets out how the regulator will identify where trusts may benefit from, or require, support in key areas of performance.
We say the new framework is significant for all providers and marks a shift in the regulator's approach
Barnet, Enfield and Haringey Mental Health NHS Trust (BEH) is embarking on a new era in their quality improvement journey.
BEH is teaming up with Haelo, the Innovation and Improvement Science Centre founded at Salford Royal NHS Foundation Trust, (SRFT) as part of their world-renowned quality improvement programme.
Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) has achieved outstanding results for this year for PLACE assessments (Patient Led Assessments of the Care Environment).
Overall organisational scores exceeded the national average in all six categories, which assess how care environments support patients’ care in areas such as: cleanliness; food and hydration; privacy, dignity and wellbeing; the condition, appearance and maintenance of the dementia and disability environment.
Participation to the survey is open to all health and social care providers, is a 12 month subscription and will cost between £2,000-£4,000 dependent on the number of complaints you receive per annum.
The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO,1 the English National Health Service,2 the Institute for Healthcare Improvement,3 the Joint Commission4 and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective.5–8 Instead, it probably owes its place in the curriculum and practice of RCA to a combination of pedigree, simplicity and pedagogy...........To read the full article, log in using your NHS OpenAthens details.
Northumberland, Tyne and Wear NHS Foundation Trust and East London NHS Foundation Trust have become the first two NHS mental health trusts in England to be awarded overall ratings of outstanding, as detailed in inspection reports published today (Thursday 1 September).
The National Institute for Health and Care Excellence (NICE) has issued new guidelines on what is known as harmful sexual behaviour. As well as sexting (sending sexually explicit pictures or messages via smartphone) it also includes other age inappropriate sexual behaviour such as watching extreme pornography or making inappropriate remarks.
The Mental Health Five Year Forward View Dashboard, published in October 2016, is a response to the recommendation in the Five Year Forward View for Mental Health that NHS England create a tool “that will identify metrics for monitoring key performance and outcomes data and that that will allow us to hold national and local bodies to account for implementing this strategy.”
It includes a suite of metrics based on the proposals in the Implementation Plan and is structured around the core elements of the mental health programme
Health Education England (HEE) has worked with the National Guardian's Office to develop a new online resource for managers, to enable them to effectively deal with public interest concerns. Responding to concerns identifies appropriate ways of handling issues raised and supporting staff through the process.
It is now 15 years since Bell and Redelmeier published their landmark study demonstrating higher mortality for people admitted to hospital during weekends compared with during the week.1 Examining the records of 3.8 million patients admitted over a 10-year period to emergency departments in Ontario, Canada, this ‘weekend effect’ existed over a range of acute conditions, including 23 out of the 100 leading causes of death.
Since that paper in 2001, over 100 studies have explored the weekend effect, across a range of patient populations and health systems.2 Surprisingly, despite this large number of studies, there remains ongoing debate about whether the weekend effect exists, and if so, what causes it. For example, one recent and highly influential study found higher rates of in-hospital death following admission on Saturday or Sunday compared with Wednesday admissions (HR 1.10 for Saturday and 1.15 for Sunday).3 To read the full article, log in using your NHS OpenAthens details.
Home News Press Releases CQC calls for action to end missed opportunities to learn from patient deaths
CQC calls for action to end missed opportunities to learn from patient deaths
Published:
13 December 2016
Categories:
Media
A national review by the Care Quality Commission (CQC) has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens.
Lean, quality improvement and human factors offer proven techniques for driving efficiency, responsiveness and quality in healthcare and have been instrumental to performance improvement across a growing number of providers.
As a result, NHS organisations are now actively encouraged to adopt them to drive productivity and quality. But local adoption and ownership is essential to success.
Families with dying children must be put at the heart of care, new guidance from NICE (The National Institute for Health and Care Excellence) says.
We advise people working in health and social care to make sure mothers and fathers, brothers and sisters, get the practical and emotional support they need to care for a family member at the end of life.
As part of the consultation for our next phase of regulation, we are seeking views on draft updated guidance for providers registering to care for people with learning disabilities.
Following on from our Registering the Right Support document published in February 2016, the revised draft guidance clarifies the expectation on providers to ensure their care homes or supported living services are focussed on person-centred care and developed in-line with national policy.
We would like to hear your views on the Care Quality Commission (CQC) and NHS Improvement’s 'Consultations on the use of resources and the well-led assessments’.
The consultations will gather proposals for how NHS trusts and foundation trusts can make effective use of resources, leadership and governance enabling them to provide sustainable high quality services.
England's Chief Inspector of Hospitals has told Sussex Partnership NHS Foundation Trust that, although it has made significant progress since CQC’s last inspection, it must make further improvements to the quality of its services following an inspection by the Care Quality Commission.
The Care Quality Commission now involves ‘experts by experience’ – people who have first-hand experience of health and/or social care services – in its inspections, in training inspectors and in the broader shaping of the organisation. Utilising the 'renewable energy' of patient expertise was one of the central pillars of the NHS five year forward view (Forward View), now more than two years old.
Care Quality Commission (CQC) inspectors have updated ratings for the Tavistock and Portman NHS Foundation Trust following an inspection in November 2016, rating us as Good across all categories.
England’s Chief Inspector of Hospitals has upgraded the rating of Lancashire Care NHS Foundation Trust from Requires Improvement to Good following a comprehensive inspection by the CQC in September 2016
England’s Chief Inspector of Hospitals has upgraded the rating of Rotherham Doncaster and South Humber NHS Foundation Trust from Requires Improvement to Good following an inspection by the Care Quality Commission in October 2016.
Responding to the Care Quality Commission’s re-inspection report, Carolyn Regan, Chief Executive at West London Mental Health NHS Trust said:
“This re-inspection report clearly highlights the huge range of improvements that our staff have worked tirelessly to put in place. From our new Thames Lodge medium secure unit to improvements in staff morale, reduction and review of restrictive practices and work to improve the assessment, monitoring and treatment of our patients’ physical health.
Incident reporting is widely recognised as an important method for improving safety in healthcare, and many countries have established their own incident reporting systems.1 However, the actual value of these systems is increasingly subject to debate.2 Reporting systems, both local and national, are overwhelmed by the volume of reports and fall short in defining recommendations for improving healthcare safety: ‘We collect too much and do too little’.3 To read the full article, log in using your NHS OpenAthens details.
During the past decade, the concept of Lean has spread rapidly within the healthcare sector, but there is a lack of instruments that can measure staff’s perceptions of Lean adoption. Thus, the aim of the present study was to develop a questionnaire measuring Lean in healthcare, based on Liker’s description of Lean, by adapting an existing instrument developed for the service sector.
Our inspections of some companies providing online primary care have found significant concerns about patient safety.
Well-run services can offer a convenient and effective form of treatment, but inspectors found services that were putting patients at risk of harm by selling medicines without doing enough to check they were appropriate. We are publishing reports from two urgent inspections today - in both cases the providers have stopped providing services in England.
England’s Chief Inspector of Hospitals has rated the services provided by Northamptonshire Healthcare NHS Foundation Trust as Good following an inspection by the Care Quality Commission in January and February.
Northamptonshire Healthcare NHS Foundation Trust provides services across Northamptonshire to a population of 700,000. The trust offers a comprehensive range of physical, mental health and specialist services, many of which are provided in hospital, or from a GP surgery or clinic.
The trust was previously inspected in February 2015 when it was rated as Requires Improvement overall. Inspectors found considerable improvements had been made at the latest inspection where the care was rated as Good overall.
Die Qualitätsinitiative E-Learning in Deutschland (Q.E.D.) befasst sich mit der Qualität der Aus- und Weiterbildung unter besonderer Berücksichtigung von E-Learning. Durch die Förderung von Standards sowie deren Integration in die bestehenden Bildungs
Staff on Heather ward, based at Airedale Centre for Mental Health, which supports people with complex mental health problems ‘huddle’ twice a day so they can identify any ways they can better support people on the ward in the day ahead and keep people safe.
One of the largest providers of NHS services in Northamptonshire has been rated as Good by the Care Quality Commission (CQC) and Outstanding regarding whether services were caring.
Northamptonshire Healthcare NHS Foundation Trust (NHFT) provides a comprehensive range of physical, mental health and specialist services, many of which are provided in hospital, from a GP surgery, clinic or in the patient’s own homes.
The CQC carried out a comprehensive assessment of NHFT services in January of this year and rated the Trust overall as Good. This was an improvement on the last inspection in 2015 when the Trust was rated as Requires Improvement.
Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution. Login at top right hand side of page using your SSSFT NHS Athens for full text. SSOTP - You can request a copy of this article by replying to this email. Please ensure you are clear which article you are requesting.
Devon Partnership NHS Trust ... has been awarded an overall rating of ‘good’ by the Care Quality Commission (CQC).
The services inspected at Devon Partnership NHS Trust in December 2016 were rated as ‘good’ across the board in the five domains assessed by the CQC, these are Safe, Effective, Caring, Responsive and Well-led. Among these the Secure Service, which is based at Langdon in Dawlish, received a rating of ‘outstanding’ for its responsiveness.
A south east London trust that specialises in mental health care and community services has been rated Good overall by the Care Quality Commission.
Oxleas NHS Foundation Trust was re-inspected between 27 February and 1 March 2017, following an inspection in April 2016 when it was rated Requires Improvement.
Quality improvement (QI) offers a route to transforming care delivery at the scale and pace needed to ensure sustainability in the National Health Service. However, it is a complex endeavour with numerous challenges to consider, and it takes time. There are many ways of understanding quality and QI in healthcare, and it is important for doctors to develop knowledge of the core principles of QI, which increasingly feature in clinical settings and in training curricula for healthcare professionals. Login using your SSSFT NHS OpenAthens for full text. SSOTP - You can request a copy of this article by replying to this email. Please ensure you are clear which article you are requesting.
Leeds Teaching Hospitals NHS Trust and SFJ Awards have launched a new Level 5 Qualification to ensure staff recognise and develop the knowledge and skills required for intevestigating serious incidents in healthcare care.
Calling for the rest of the UK to follow the example of Wales and enshrine safe staffing in law, the RCN reports that a dangerous set of pressures is putting patient safety at risk.
North Cumbria University Hospitals NHS Trust has placed a quality of care board on each of its wards.
The boards are part of the Trust’s commitment to be open and transparent by allowing patients to see key information when they enter a ward such as: staffing levels on that day, hygiene scores, cleaning scores, training rates, and waiting times (for outpatient areas).
Some exciting examples of how person centred care looks in practice from around the globe, following the International Conference for Integrated Care in Dublin.