Well spotted: but now you need to do something

Hamblin, Richard; Shuker, Carl

doi:10.1136/bmjqs-2019-010659

Cited by 4 publications

(5 citation statements)

References 11 publications

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“…To advance with a long-term perspective of QI success and cultural transformation, healthcare organisation executive boards need an organisation-wide overview that can be routinely made visible with minimal technical expertise. Setting up a routine monitoring framework can offer more timely vigilance than designing an elaborate retrospective evaluation, which some argued, is akin to attempting to "drive by looking in the rear-view mirror" (Hamblin and Shuker, 2020). Practically, routine monitoring can also improve data quality by alleviating information retrieval difficulties and ensuring systematic data accrual.…”

Section: Discussionmentioning

confidence: 99%

Evaluating quality improvement at scale: routine reporting for executive board governance in a UK National Health Service organisation

Chua

Grey

Holland

et al. 2020

Preprint

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Background The question of whether quality improvement (QI) actually improves quality in a large healthcare organisation requires overview of a diverse range of QI projects. To-date, an organisational overview remains elusive due to heterogeneity across project-specific outcomes. Where organisational-level assessments of QI success have been offered, the extent to which they could be attributed to QI activity remains unclear. Reporting on a retrospective evaluation of return on investment of QI in a UK National Health Service (NHS) Trust, we discuss the development of a reporting methodology for providing board-level insights on organisational needs and achievements in QI. Methods A researcher-in-residence worked with a resident QI team to develop and conduct a retrospective evaluation of QI projects in a large healthcare organisation in the UK that specialises in mental health. Using a survey, we assessed QI project outcomes and explored costs and benefits, as well as contextual, input and process factors that might be associated with whether QI projects led to a change in routine practice. Findings Out of 52 QI projects, 10 led to a change in routine practice. Across a diverse range of projects, time invested by staff is an opportunity cost that could serve as a common denominator for return on investment. Retrospective data accrual proved problematic for measuring benefits. Odds ratios from logistic regressions show that process factors had more apparent impact on project outcomes than contextual and input factors. Service user engagement and implementation of measurement plan showed major impact on project outcome. Of note, if QI projects had documentation for Plan-Do-Study-Act (PDSA) cycles, the odds of effecting a change in routine practice were much higher. Conclusions To inform organisational-level decision making and optimise return on investment from QI in large healthcare organisations, systematic monitoring of QI activity needs prospective data accrual, consistent measurement and coherent iterations. We recommend that this be undertaken by a resident QI unit with the data categories explored in this study. Developing a reporting methodology for routine organisational-level monitoring can be an asset for improving practice, one that is pivotal for a learning healthcare system.

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Section: Discussionmentioning

confidence: 99%

Evaluating quality improvement at scale: routine reporting for executive board governance in a UK National Health Service organisation

Chua

Grey

Holland

et al. 2020

Preprint

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“…11 12 Central regulation and performance management may have some effect on improving care, but quality improvement, leadership, public engagement, proper resourcing, education and training are needed for a safer health service. 12 In April 2016, an independent review demonstrated a lack of systematic approach and meaningful change in response to unexpected deaths at Southern Health National Health Service (NHS) Foundation Trust. 13 The Care Quality Commission (CQC), which is responsible for monitoring, inspection and regulation of healthcare services within England, conducted a wider review into the investigations of deaths.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

Brummell

Vindrola‐Padros

Braun³

et al. 2021

BMJ Open

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ObjectivesTo review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths.IntroductionPotentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on ‘LfDs’ in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and LfDs’. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths.MethodWe undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222).ResultsAll statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families.ConclusionsThe wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.

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“…[8,10] Effective organisational learning is crucial to improve patient safety and probably requires both safety-I (understanding why things go wrong) and safety-II (understanding why things go right) approaches. [11,12] In addition central regulation and performance management may have some effect on improving care, but quality improvement, leadership, public engagement, proper resourcing, education, and training are needed for a safer health service. [12] In April 2016 an independent review demonstrated a lack of systematic approach and meaningful change in response to unexpected deaths at Southern Health NHS Foundation Trust.…”

Section: Introductionmentioning

confidence: 99%

“…[11,12] In addition central regulation and performance management may have some effect on improving care, but quality improvement, leadership, public engagement, proper resourcing, education, and training are needed for a safer health service. [12] In April 2016 an independent review demonstrated a lack of systematic approach and meaningful change in response to unexpected deaths at Southern Health NHS Foundation Trust. [13] The Care Quality Commission (CQC), which is responsible for monitoring, inspection and regulation of healthcare services within England, conducted a wider review into the investigations of deaths.…”

Section: Introductionmentioning

confidence: 99%

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NHS Hospital ‘Learning from Deaths’ reports: A qualitative and quantitative analysis of the first year of a countrywide patient safety programme

Brummell

Vindrola‐Padros

Braun³

et al. 2020

Preprint

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Introduction Potentially preventable deaths occur worldwide within healthcare organisations. Organisational learning from incidents is essential to improve quality of care. In England, inconsistencies in how NHS secondary care trusts reviewed, investigated and shared learning from deaths, resulted in the introduction of national guidance on "Learning from Deaths" (LfDs) in 2017. This guidance provides a "framework for identifying, reporting, investigating and learning from deaths" Amendments to NHS Quality Account regulations, legally require NHS trusts in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended trusts would share this learning and take measurable action to prevent future deaths. Method We undertook qualitative and quantitative secondary data analysis of all NHS secondary care trust LfDs reports within their 2017/18 Quality Accounts, to review how organisations are using the LfDs programme to learn from and prevent, potentially preventable deaths. Results All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) trusts. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of trusts (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 trusts (48%) have shared or plan to share the learning within their own organisation. The majority of trusts (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 trusts (17%) mentioned involvement of bereaved families. Conclusions The wide variation in reporting demonstrates that some trusts have engaged fully with LfDs, while other trusts appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfD reports have previously been identified in national and international reports and inquiries. Further work is needed to strengthen the LfDs programme.

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Well spotted: but now you need to do something

Cited by 4 publications

References 11 publications

Evaluating quality improvement at scale: routine reporting for executive board governance in a UK National Health Service organisation

Evaluating quality improvement at scale: routine reporting for executive board governance in a UK National Health Service organisation

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

NHS Hospital ‘Learning from Deaths’ reports: A qualitative and quantitative analysis of the first year of a countrywide patient safety programme

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