Embedding a culture of quality improvement

"This report explores the factors that have helped organisations to launch a quality improvement strategy, and the key enablers for sustaining a focus on continuous quality improvement."

Embedding a culture of quality improvement
J Jabbal
The King's Fund
November 2017

Read more here.

Understanding quality in district nursing services

"This report investigates what ‘good’ district nursing care looks like from the perspective of people receiving this care, unpaid carers and district nursing staff and puts forward a framework for understanding the components involved. It also looks at the growing demand–capacity gap in district nursing and the worrying impact that this is having on services, the workforce and the quality and safety of patient care. The report makes recommendations to policy-makers, regulators, commissioners and provider organisations as to how to start to address these pressures."

Understanding quality in district nursing services: Learning from patients, carers and staff
J Maybin, A Charles, M Honeyman
The King's Fund
September 2016

Read more here.

The accompanying quality framework for district nursing is available here.

Prescribing safety in UK general practice

"A cross-sectional study of patients from more than 500 UK general practices found high variation in potentially high-risk prescribing and provision of monitoring tests."

Prescribing safety in UK general practice
National Institute for Health and Care Excellence
April 2016

Read more here.

Improving the quality and safety of patient care

"This brochure outlines some of the initiatives the UK is currently pursuing, and the organisations which are leading the way in standards of safety. The different sections also provide information on the partners who can best help you achieve your goal of safer, better healthcare."

Improving the quality and safety of patient care
Department of Health
March 2016

Read more here.

Reducing preventable harm in hospitals

"Sometimes small details can make a huge difference. One of the easiest ways to reduce ventilator-associated pneumonia, a major cause of death, is to put a piece of tape on the wall as a reminder to raise a patient’s bed to the correct angle."

This is part 1 of a two-part series.

Reducing preventable harm in hospitals
D Bornstein
New York Times, January 26, 2016

Read more here.

An NHS leadership team for the future

"Developing clinicians as the ‘agent for change’ has never been more important. This report seeks to evaluate how the NHS is preparing future clinical leaders for this responsibility. The NHS has access to 50,000 junior doctors who are among the highest performing young people in the country. It is an unparalleled resource in comparison to many corporations and organisations operating in the UK today."

An NHS leadership team for the future
N Ahmed, F Ahmed, H Anis, P Carr, S Gauher, F Rahman
Reform Research Trust
November 2015

Read more here.

Improving diagnosis in health care

"Despite the pervasiveness of diagnostic errors and the risk for serious patient harm, diagnostic errors have been largely unappreciated within the quality and patient safety movements in health care."

Improving diagnosis in health care
EP Balogh, BT Miller, JR Ball (eds.)
The National Academies Press
September 2015

Read more here - free registration required.

Patient safety implications of general practice workload

"The paper intends to act as a catalyst for the development of new solutions to both fatigue and workload in general practice. RCGP is asking GPs, patients, other healthcare professionals and policy makers for their views on this paper, and suggestions – at a practice, system, and national level – for how GP workload can be alleviated, therefore reducing the risk of fatigue and burnout."

Patient safety implications of general practice workload
Royal College of General Practitioners
July 2015

Read more here.

Rethinking regulation

"Health and care regulation is incoherent and expensive and there is little evidence for its effectiveness; if it was going to improve care it would have done so by now."

Rethinking regulation
Professional Standards Authority for Health and Social Care
August 2015

Read more here.

Privacy of health records

"People are often assumed to support either privacy or security, as if the choice is between one or the other. However, RAND Europe has collected evidence as part of the largest ever surveys of citizens’ views across Europe on security, surveillance and privacy issues, and the results point to the general public having a much more nuanced understanding of those issues. This brief presents people’s preferences in the context of storage of electronic health records."

Privacy of health records: Europeans' preferences on electronic health data storage and sharing
S Patil, et al.
RAND Europe
August 2015

Read more here.

Evaluation of complex health and care interventions

"As policy-makers, commissioners and providers look to innovate and develop new ways of delivering care, there is increasing recognition at both national and local levels about the importance of understanding what works, why it works, and to demonstrate impact on cost and patient outcomes. One of the recurrent problems when evaluating the impact of new care models on outcomes is how to know ‘what would have happened under a different approach to delivering care’."

Evaluation of complex health and care interventions using retrospective matched control methods: A guide for evaluators
A Davies, C Ariti, T Georghiou, M Bardsley
Nuffield Trust
August 2015

Read more here.

Perceived barriers to reporting adverse drug events in hospitals

"We believe that theoretical domains framework (TDF) is a comprehensive approach that enables us to better understand and classify barriers to behavior change in reporting ADEs. Classification of barriers based on different psychological domains could be effective in mapping suitable interventions to detected barriers."

Perceived barriers to reporting adverse drug events in hospitals: a qualitative study using theoretical domains framework approach
F Mirbaha, G Shalviri, B Yazdizadeh, K Gholami, R Majdzadeh
Implementation Science, 2015, 10:110

Read more here.

Understanding nurses’ and physicians’ fear of repercussions for reporting errors

"Although further investigation is needed to examine these and other factors in detail, supportive safety leadership appears to be central to reducing fear of reporting errors for both nurses and physicians."

Understanding nurses’ and physicians’ fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors?
ES Castel, LR Ginsburg, S Zaheer, H Tamim
BMC Health Services Research, 2015, 15:326

Read more here.

Weekend hospitalization and additional risk of death

"Admission at the weekend is associated with increased risk of subsequent death within 30 days of admission. The likelihood of death actually occurring is less on a weekend day than on a mid-week day."

Weekend hospitalization and additional risk of death: An analysis of inpatient data
N Freemantle, et al.
Journal of the Royal Society of Medicine, 2012, 105: 74-84

Read more here.

Learning not blaming

"The three reports that we are building on in developing our policy are distinct in their concerns, and this document addresses points raised in each of the three reports in turn. But there are also some common themes that run through them:

• openness, honesty and candour;
• listening to patients, families and staff;
• finding and facing the truth;
• learning from errors and failures in care;
• people and professionalism;
• the right culture from top to bottom."

Learning not blaming: The government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report 'Investigating Clinical Incidents in the NHS', and the Morecambe Bay Investigation
Department of Health
July 2015

Read more here.

People's experiences of care during a mental health crisis

"The report highlights some key lessons for the wider system, including commissioning services to meet local need, and the different agencies involved in crisis care taking a more joined-up approach."

Right here, right now: People's experiences of help, care and support during a mental health crisis
Care Quality Commission
June 2015

Read more here.

The many meanings of 'quality' in healthcare

This is a collection of articles about different perspectives of quality in healthcare.

The many meanings of 'quality' in healthcare: Interdisciplinary perspectives
D Swinglehurst (ed.)
BMC Health Services Research
2015

Access the articles here.

Choosing Wisely in the UK

"An initiative recently developed in the US and Canada called Choosing Wisely aims to change doctors’ practice to align with best practice by getting them to stop using various interventions that are not supported by evidence, free from harm, and truly necessary."

Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
A Malhotra, et al.
British Medical Journal, 2015, 350: h2308

Read more here.

The challenge of overdiagnosis begins with its definition

"If overdiagnosis is to be understood and mitigated, the broad concept should be subdivided into different problems and its ethical dimensions better acknowledged."

The challenge of overdiagnosis begins with its definition
SM Carter, W Rogers, I Heath, C Degeling, J Doust, A Barratt
BMJ, 2015, 350:h869

Read more here.

Governance challenges for providers in light of the Dalton review

"Any change in organisational structure arises from a strong business case to develop models of care for patient benefit (to improve outcomes, safety or experience), and/or to deliver a more efficient service, providing best value for the taxpayer and potentially releasing funds to reinvest in patient care."

Form follows function: Governance challenges for providers in light of the Dalton review
NHS Confederation
April 2015

Read more here.

Read related QIPP @lert post here.