Calculates various metrics for projects, packages and compilation units. Includes both simple counts like lines of code as well as more complex metrics such as the McCabe cyclomatic complexity.
We must optimize stent deployment & maintain a registry of how well (or poorly) we use drug-eluting stents. Instead of asking “Which stent?” or “How much anti-platelet therapy?” we must ask “How effectively are we deploying our stents?”
Design of Clinical Trials for Treatment of Pain, Development of Clinical Trials, Selected Qualitative Methods, Within-Patient Studies: Cross-over Trials & n-of-1 Studies, Clinical Economics, etc.
SONAR is a code quality management platform, dedicated to continuously analyze and measure technical quality, from the projects portfolio to the class method.
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
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.
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.
This article, part two, explores the wider involvement of individuals, organisations and nurse education in preventing care erosion, with a particular focus on reflection; mastery of nursing skills and care; supporting nursing values; and addressing denial and trivialisation of, and justifications for, substandard care. To read the full article, log in using your NHS OpenAthens details.
These Specialised Services Quality Dashboards (SSQD) are designed to provide assurance on the quality of care by collecting information about outcomes from healthcare providers. SSQDs are a key tool in monitoring the quality of services, enabling comparison between service providers and supporting improvements over time in the outcomes of services commissioned by NHS England.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
Some exciting examples of how person centred care looks in practice from around the globe, following the International Conference for Integrated Care in Dublin.
The Care Quality Commission (CQC) has today (Friday, June 2) published its report on the trust, which provides mental health services in Sussex and specialist community mental health services for children and young people in Hampshire and Kent and Medway. These include two adult social care services and primary medical services for HMP Lewes and HMP Ford.
The Shrewsbury and Telford Hospital NHS Trust (SaTH) is one of five hospital trusts in the UK taking part in an exciting partnership with VMI and last week it held a Regional Sharing Event to celebrate some of the significant improvements to patient care which have been made since this began.
The Care Quality Commission (CQC) has announced the reappointments of Sir Robert Francis QC and Paul Rew as non-executive directors for a second three-year term.
Find out about the progress made by trusts to date in relation to the appointment of Freedom to Speak Up (FTSU) guardians and how Dr Hughes and her office are supporting guardians to improve the culture of speaking up safely.
Inspectors found many examples of excellent care – but they also found too much poor care and far too much variation in both quality and access across different services. This is particularly concerning given the increasing demand for mental health services, meaning that more people risk receiving care that is not good enough – or no care at all.
A safety organisation drawing on lessons from the airline industry will have new legal powers to investigate serious patient safety incidents in the NHS in England, under plans laid before parliament today (14 September 2017).
service is under intense pressure to innovate given the ever increasing demands placed upon it. Whilst many studies have looked at diffusion of innovation from an organisational perspective, few have sought to understand how individuals working in healthcare innovate successfully. We took a positive deviance approach to understand how innovations are achieved by individuals working in the NHS.
We conducted in depth interviews in 2015 with 15 individuals who had received a national award for being a successful UK innovator in healthcare. We invited only those people who were currently (or had recently) worked in the NHS and whose innovation focused on improving patient safety or quality. Thematic analysis was used.
This consultation is targeted at providers of health and social care services registered with CQC. It seeks your views as to whether it is appropriate for CQC to extend performance assessment and ratings to include independent community health services and independent doctors.
just a phenomenon embraced by the young—31% of all seniors are on Facebook.2 With growing engagement across demographics, social media networks offer new platforms of digital interaction at a scale that is hard to comprehend—313 million active Twitter users sending half a billion tweets and 1.9 billion Facebook accounts uploading 350 million photos every day. SnapChat has created some of the country's youngest billionaires. All these activities, driven by the public's desire to curate and share life experiences, provide new opportunities to observe and understand lived reality in greater detail and closer to real time than ever before. To read the full article, log in using your NHS OpenAthens details.
Open access. Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.
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.
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
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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 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.
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.
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.