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News and updates at today's Measuring & Monitoring Patient Safety conference

Following the chairs introductions, Richard Taunt Director UK Improvement Alliance opens today's conference with a focus on Measuring and Monitoring Patient Safety, covering:
• national update
• measuring and monitoring patient safety
• undertaking a baseline assessment of your service
• patient safety surveillance: what are the metrics?

Richard comments:

"How safe are we today?
How do you get an evidence based answer to this?
Adapting to different settings – different approaches to safety dependent on setting.
3 contrasting approaches to safety – ultra adaptive (embracing risk – deepsea fishing), high reliability (managing risk e.g. fire fighter), ultra safe (avoiding risk e.g. aviation industry).
In healthcare its all 3 – trauma surgery embraces risk whereas giving blood tries to be ultra safe.
Patients’ view of Harm - Seeing safety through patient’s eyes – isolated errors are less important than overall coordination of care and avoidance of major lapses.  Coordination of care acquires a much greater importance as a safety issue.  Patients with multiple problems face major challenges in coordinating their own care which can be a considerable burden and source of anxiety.
Getting the full Picture - Perils of only half the story – Must beware of hidden information
Need to look beyond the rear view mirror – indicators of past harm are helpful.
The Vincent framework – past harm, reliability, sensitivity to operations, anticipation and preparedness, integration and learning.
Powerful framework because not designed as a handbook to tell you what to do, what it is about an approach to safety, how you think about it for yourself.
How you get there, the conversations you have, are as important as theoutcome.
Recommends that people look at 2013 Framework for the measurement and monitoring of Safety – UK Improvement Alliance
Set up as a way of working with others across the UK and being more co-ordinated. "

Continuing the morning sessions is Dr Umesh Prabhu Medical Director Wrightington, Wigan and Leigh NHS Foundation Trust who will discuss 'Patient Safety Culture: surveillance and monitoring', covering: 

• how do you assess the culture of your service
• how do we change culture and values in practice?
• embedding a patient safety culture: surveillance and monitoring
• our experience in Wrightington, Wigan and Leigh

Dr Prabhu comments:

"How safe is the NHS?  It is safe statistically, given the 360 million treated – BUT one death is too many.
What does patient centred actually mean?  
What is our purpose – to provide good care which is safe and good quality, with kindness,compassionand caring
How do we do it?  By creating wonderful team where everyone respects eachother and feel valued
By creating a culture of staff happiness.  Happy staff = happy patients
Happiness – smile, polite and happy
Behaviour – enjoy work and respect each other
Engagement – feel valued and listened to
Empowerment –speak openly and know who to speak to
Well being – low sickness rates/turnover
How do you measure it?
Surveys – ask staff, ask patients
Vast majority of care is high quality, vast majority of staff are working hard to provide the best care, 
85% of mistakes are preventable.
Success is rarely due to one or two individuals but rather when the whole team works together:
Our values – no racism, no sexism, no drugs
Duty of Candour is non negotiable.
Questions asked:
Who is a good consultant?
Who is a nice human being?
Who is a good team player?
Whom do you want to see as leader and why?
HR director created a Values wheel – patients at the heart of everything we do
NHS must be for the patients with the patients and by the patients
Patients have to live with the consequences
Patient safety is not for compromises –have to own processes
Governance – is robust.
2011 Staff engagement was very poor.  Survey results big improvements year on year.
My sincere request to all of you –NHS belongs to us, it is a great institution, don’t leave it to the politicians to sort it out. 
Leadership is about action – where there is a will there is a way, where there is no will there are plenty  of excuses!"


Opening the afternoon is Helen Young Director of and Maternity and Newborn Transformation/Chief Nurse Birmingham Women’s NHS Foundation Trust, who will look at 'Patient safety and staffing: real time monitoring of patient safety risks related to staffing: Acuity, Alerts, Red Flags Events and Escalation' and will discuss:

• monitoring real time acuity of patients relative to nurse staffing and skill mix
• understanding how to set triggers for acuity alerts
• enabling frontline staff to recognise red flag events
• escalation of acuity alerts and how to manage concerns around patient to nurse ratios
• reporting, investigating and learning from incidents that have a staffing capacity or capability element 

Helen comments:

"Safe Staffing – what are you looking for?
Mobilising people to take action – be courageous and pull together in the same direction.
Hard Truths – the journey to putting patients first.
Financial and political context:
Deficit and state of NHS budget
Prime Ministers Position on Health
Performance Activity against Targets
BREXIT (procurement and work force)
Biggest risk to clinical services and transformation
Winter – can it get any worse?  Not seasonal demand any more in midwifery – its year round.
How to ensure right people, with right skills are in the right place at the right time?
Safer staffing – guide from NHS England
What is in place for 2016/17?
All organisation publishing ward level staffing information
NICE guidelines on safer staffing in nursing and midwifery
Tools available:
Safer nursing care tool
Birthrate plus
Productive Care Ward
NICE Guidelines
HE workforce planning tools and maternity care pathways
Red Flag Events:
What are they?   Categorise them by importance.
How to monitor and report?
Triangulation with what? What is the outcome of the care you are providing?  What are patient’s experiences?  Not just about data.
How do staff recognize and escalate?  What, who and how?  Escalation is the thing patients said was going wrong the most.  Policy must be clear, staff must understand it and you must audit whether staff are actually implementing it properly.
How do teams and boards learn from them?
Prevention on dumbing down
How do you know its working?
Audit and accreditation systems – CQC inspections, internal audit systems
What has worked for us?
Don’t hide your light under a bushel –get out there and spread the word.
Get in on the national agenda – speak to NHS England
Managing incidents and complaints – have changed now involve patients and families to be involved in setting the agenda of what is analysed/reported on.
Schwartz rounds – reflect on how things are being done on ward rounds
Don’t be complacent!  Keep striving to improve – you might be outstanding but you are not perfect!
To be perfect – is impossible, to make mistakes, learn and improve, that is human! "


10 March 2017


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