scholarly journals A narrative account of the key drivers in the development of the Learning from Deaths policy

2021 ◽  
pp. 135581962110108
Author(s):  
Mirza Lalani ◽  
Helen Hogan
Keyword(s):  
Patient Safety ◽  
Policy Development ◽  
Care Quality ◽  
System Level ◽  
Structured Interviews ◽  
Policy Window ◽  
Care Quality Commission ◽  
Southern Health ◽  
National Patient ◽  
Key Drivers

Objective In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development. Methods A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon’s Multiple Streams Approach was used to frame the policymaking process. Results The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a ‘policy window.’ Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as ‘policy entrepreneurs,’ recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them. Conclusions The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.

Is patient safety in the NHS in England a postcode lottery?

2020 ◽  
Vol 29 (6) ◽  
pp. 378-379
Author(s):  
John Tingle
Keyword(s):  
Patient Safety ◽  
World Health Organization ◽  
Care Quality ◽  
Law School ◽  
World Health ◽  
The World ◽  
Care Quality Commission ◽  
Recent Patient ◽  
Health Organization

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient safety publications from the World Health Organization and the Care Quality Commission

scholarly journals “We don’t have any answers within the current framework”: tensions within cannabis policy change in Ireland

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Chris Ó. Rálaigh ◽  
Sarah Morton
Keyword(s):  
Policy Change ◽  
Policy Development ◽  
Legal Regulation ◽  
Structured Interviews ◽  
Deliberative Process ◽  
Content Type ◽  
Policy Positions ◽  
Policy Window ◽  
Progressive Policy ◽  
Cannabis Policy

Purpose International policy approaches to cannabis production and use are changing rapidly, and within the Irish context, alternatives to prohibition are being considered. This study aims to explore policymaker’s attitudes towards the decriminalisation and legal regulation of cannabis for recreational use in the midst of an unfolding policy process, examining the degree which a “policy window” might be open for the implementation of cannabis policy change. Design/methodology/approach Semi-structured interviews were held with eight key informants within the policy field in Dublin, Ireland. Kingdon’s (2014) Multiple Streams framework was used to consider whether the problems, policy and political streams were aligning to support progressive policy change. Findings Irish policymakers indicated broad support for the decriminalisation of cannabis. The legal regulation of cannabis received more qualified support. Existing policy was heavily criticised with criminalisation identified as a clear failure. Of particular interest was the willingness of policymakers to offer opinions which contrasted with the policy positions of their organisations. While a policy window did open – and close – subsequent governmental commitments to examine the issue of drugs policy in a more deliberative process in the near future highlight the incremental nature of policy change. Originality/value This study provides unique insight into the opinions of policymakers in the midst of a prolonged period of policy evolution. A latent aspiration for historical policy change was situated within the realpolitik of more traditional approaches to policy development, demonstrating that the alignment of Kingdon’s (2014) problem, policy and political streams are essential for change in cannabis policy.

scholarly journals Transforming concepts in patient safety: a progress report

2018 ◽  
Vol 27 (12) ◽  
pp. 1019-1026 ◽  
Author(s):  
Tejal K Gandhi ◽  
Gary S Kaplan ◽  
Lucian Leape ◽  
Donald M Berwick ◽  
Susan Edgman-Levitan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Education Reform ◽  
System Level ◽  
Meaning In Work ◽  
Healthcare Improvement ◽  
Medical Education Reform ◽  
Recommendations For Action ◽  
National Patient ◽  
The Usa ◽  
Multiple Challenges

In 2009, the National Patient Safety Foundation’s Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for Healthcare Improvement) assess progress made in the USA since 2009 and identify ongoing challenges.

The ENGAGED framework: a qualitative study of the current use of social media by NHS trusts (Preprint)

2020 ◽  
Author(s):  
Sonika Sethi ◽  
Sharukh Zuberi ◽  
Nishma Gokani ◽  
Rosie Bhogal ◽  
Shaneil Tanna ◽  
...  
Keyword(s):  
Social Media ◽  
Media Use ◽  
Care Quality ◽  
Theory Approach ◽  
Structured Interviews ◽  
Social Media Use ◽  
Quality Ratings ◽  
Care Quality Commission ◽  
Use Of Social Media ◽  
The Uk

BACKGROUND The number of social media users in the UK is rapidly rising. However, there is a lack on primary research as to how the National Health Service (NHS) is using social media to engage patients and the public. OBJECTIVE To understand the current methodology, implementation and strategy of social media use within NHS Trusts. METHODS A qualitative grounded theory approach was taken through semi-structured interviews with NHS Trusts. Selection was based on the Trusts quality ratings by the Care Quality Commission (CQC) in 2017, selecting the highest 15 and lowest 15 ranked trusts. Telephone interviews were conducted with a member of the communication teams and were audio recorded then transcribed. Three independent researchers thematically analysed the transcripts, to draw themes that emerged from the transcripts. RESULTS Following a pilot study, we conducted interviews with the communications team of 27 NHS trusts across the UK. Six main themes arose from the interviews: 1) The social media and communications teams; 2)The Trust; 3) The Trusts’ use of social media; 4)The Trusts’ management of their social media ; 5)The future of social media; 6)The use of social media within the NHS). These six higher themes consisted of a total of 26 subthemes. CONCLUSIONS The themes allow us to understand how social media is currently used within the NHS, as well as its potential future scope. Recognising the main areas of importance to Trusts and current difficulties they are facing, allow us to explore ways of increasing social media use by NHS Trusts. We have proposed a set of guidelines, known as the ENGAGED framework, which trusts can use to enhance social media use and enagagement. CLINICALTRIAL Nil

scholarly journals Like using a refrigerator to heat food: capacity and capability funding in primary care and the legacy of the Primary Health Organisation Performance Programme

2020 ◽  
Vol 12 (4) ◽  
pp. 345 ◽  
Author(s):  
Reuben Olugbenga Ayeleke ◽  
Timothy Tenbensel ◽  
Pushkar Raj Silwal ◽  
Lisa Walton
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Performance Management ◽  
Policy Development ◽  
Health Sector ◽  
System Level ◽  
Structured Interviews ◽  
Key Issues ◽  
General Practices ◽  
Care Improvement

ABSTRACT INTRODUCTIONIn 2016, the New Zealand Ministry of Health introduced the System Level Measures (SLM) framework as a new approach to health system improvement that emphasised quality improvement and integration. A funding stream that was a legacy of past primary care performance management was repurposed as ‘capacity and capability’ funding to support the implementation of the SLM framework. AIMThis study explored how the capacity and capability funding has been used and the issues and challenges that have arisen from the funding implementation. METHODSSemi-structured interviews with 50 key informants from 18 of New Zealand’s 20 health districts were conducted. Interview transcripts were coded using thematic analysis. RESULTSThe capacity and capability funding was used in three different ways. Approximately one-third of districts used it to actively support quality improvement and integration initiatives. Another one-third tweaked existing performance incentive schemes and in the remaining one-third, the funding was passed directly on to general practices without strings attached. Three key issues were identified related to implementation of the capacity and capability funding: lack of clear guidance regarding the use of the funding; funding perceived as a barrier to integration; and funding seen as insufficient for intended purposes. DISCUSSIONThe capacity and capability funding was intended to support collaborative integration and quality improvement between health sector organisations at the district level. However, there is a mismatch between the purpose of the capacity and capability funding and its use in practice, which is primarily a product of incremental and inconsistent policy development regarding primary care improvement.

Reflecting on the state of health and social care in England

2020 ◽  
Vol 29 (20) ◽  
pp. 1216-1217
Author(s):  
John Tingle
Keyword(s):  
Patient Safety ◽  
Annual Report ◽  
Social Care ◽  
Care Quality ◽  
The State ◽  
Law School ◽  
State Of Health ◽  
Safety Issues ◽  
Health And Social Care ◽  
Care Quality Commission

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses the latest State of Care annual report from the Care Quality Commission, which addresses some important patient safety issues

scholarly journals P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.49-e2
Author(s):  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Discharge Summary ◽  
Electronic Prescribing ◽  
List Type ◽  
Heparin Infusion ◽  
National Patient Safety Agency ◽  
High Dependency ◽  
National Patient ◽  
Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

scholarly journals Financing Long-Term Services and Supports: Opportunities for Overcoming Historical Roadblocks to Reform

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 717-717
Author(s):  
Edward Miller ◽  
Pamela Nadash ◽  
Marc Cohen
Keyword(s):  
Affordable Care Act ◽  
Policy Development ◽  
State Level ◽  
Government Action ◽  
Policy Window ◽  
Adoption And Implementation ◽  
Opportunities For Learning ◽  
State Budgets ◽  
Services And Supports

Abstract This presentation documents the continuing failure to tackle the problem of financing long-term services and supports (LTSS)—a failure most recently seen in the only national legislation ever enacted to comprehensively address LTSS costs: the Community Living Assistance Services and Supports (CLASS) Act. The CLASS Act was included in the Affordable Care Act, but was repealed in 2013. Subsequently, policy experts and some Democrats have made proposals for addressing the LTSS financing crisis. Moreover, significant government action is taking place at the state level, both to relieve financial and emotional burdens on LTSS recipients and their families and to ease pressure on state budgets. Lessons from these initiatives could serve as opportunities for learning how to overcome roadblocks to successful policy development, adoption, and implementation across states and for traversing the policy and political tradeoffs should a policy window open once again for addressing the problem of LTSS financing nationally.

scholarly journals POS0160-HPR THE CARE PROCESS OF HIP AND KNEE OSTEOARTHRITIS: GIVING AN ACCOUNT OF PATIENTS’ EXPERIENCE

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 292.2-293
Author(s):  
S. Battista ◽  
M. Manoni ◽  
A. Dell’isola ◽  
M. Englund ◽  
A. Palese ◽  
...  
Keyword(s):  
Knee Osteoarthritis ◽  
Health Professionals ◽  
Emotional Experience ◽  
Functional Limitations ◽  
Care Quality ◽  
Care Process ◽  
Exact Science ◽  
Structured Interviews ◽  
Patients Experience

Background:The care process is often a complex and intimate process experienced by patients. Osteoarthritis (OA) care is usually characterised by multimodal interventions that consider the broader array of symptoms and functional limitations and often require a high level of patients’ compliance. Despite efforts to improve the quality of care of patients suffering from OA, and the publication of state-of-the-art clinical practice guidelines [1], the quality of the care process, as experienced by patients, seems to be suboptimal [2]. Hence, it is essential to investigate how patients experience this process to highlight potential elements that can enhance or spoil it to optimise the care quality.Objectives:To explore the patients’ experience of the received OA care process.Methods:Qualitative study, 10 semi-structured interviews were performed. The interview guide was created by a pool of healthcare professionals (physiotherapists, psychologists, nurses) and expert patients. It investigated the emotional experience, beliefs, expectations, perceived barriers and facilitators towards conservative treatments perceived by patients suffering from OA. The interviews lasted approximately one hour, were transcribed verbatim and analysed independently by two authors, who labelled their core parts to find categories and subcategories. A theme-based analysis was performed following an ecological paradigm, naturalistic epistemology, philosophy of phenomenological research.Results:Our analysis revealed 7 main categories with several subcategories (Fig. 1). 1) Uncertainty as some patients perceived treatment choice not to be based on medical evidence “there is an almost religious way of thinking on how to deal with the pathology. It is not an exact science when you choose the physicians you choose the treatment”. 2) Relationship with the self and the others as some patients did not feel understood or even shameful and hopeless about their condition. 3) Patients’ and Health Professionals’ beliefs about the pathology management where common thoughts were the perceived (ab)use of passive therapies, the movement as something dangerous and that OA is “something that you try to resist to, but (surgery) is your destiny”. 4) facilitators and 5) barriers of the adherence to therapeutic exercise that revolve around the cost of the therapy, the time needed and the willingness to change life habits. 6) Patients’ attitudes towards pathology in which the oldest patients perceive OA as “something I have to accept since I am getting old” and the youngest as “Something I have to fight”. 7) Relationship with food in which diet is seen as something that “you force yourself to follow” which is useful only to lose weight and not to preserve a high health status and where overeating is used “to eat your feelings”.Figure 1.Categories and Subcategories stemmed from the analysis of the patients’ interviewsConclusion:Patients suffering from hip and knee OA seem to experience an uncertain care process. The lack of clear explanations and the attitude towards conservative treatment, which is considered as “a pastime while waiting for surgery,” fosters the importance of providing patients with adequate information about the treatment, to shift their beliefs and improve their awareness. This will enhance a patient-centred and shared decision-making treatments.References:[1]Fernandes L, Hagen KB, Bijlsma JWJ, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann. Rheum. Dis. 2013;72:1125–35.[2]Basedow M, Esterman A. Assessing appropriateness of osteoarthritis care using quality indicators: a systematic review. J Eval Clin Pract 2015;21:782–9.Acknowledgements:This work is part of the project funded by EULAR Health Professionals Research Grant 2020.Disclosure of Interests:None declared

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