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Scotland Deanery

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Your Development

Safety & Improvement

 

QUALITY IMPROVEMENT

NES is committed to building capacity and capability for Quality Improvement across the public service through a range of educational programmes and resources.

NES has developed a range of training materials and tools to help individuals and organisations improve their understanding and knowledge of Quality Improvement.

Formal face-to-face Quality Improvement education programmes available include:

  • Scottish Quality & Safety Fellowship
  • Scottish Improvement Leader (ScIL) programme
  • Scottish Improvement (SIS) programme

Online resources are also available to support you on your Quality Improvement learning journey:

  • 16 e-learning modules developed specifically for NHSScotland staff
  • Quality Improvement Workforce Development Tool - an online system designed to allow individuals working in Health and Social Care Partnerships to assess their own levels of capability and confidence in a range of areas of expertise relating to QI
  • Scottish Improvement Skills Facilitator Resources - designed to be used by Improvers with experience of training and/or facilitating learning interventions

Details on our full suite of education programmes and resources are available on the Education & Learning section on the Quality Improvement Zone.

 

PATIENT SAFETY

The publication by the US-based Institute of Medicine of 'To Err is Human' in 1999 gained worldwide attention through highlighting the problem of patient safety. However, 'to err is human' describes a specific perspective of patient safety in which, at the individual level, medical practitioners are implicitly or explicitly considered to be a key 'casual factor' in why things go wrong. There is now a growing recognition that human interactions with wider systems issues frequently influenced clinical performance and outcomes, rather then just individual skill, knowledge and experience. In recent years attempts to broaden the safety focus to include wider systems issues and concerns that individual practitioners and care teams can identify and learn from have informed  both NES postgraduate educational activates as well as national improvement programmes such as the Scottish Patient Safety Programme (SPSP).

Our primary focus remains on supporting and informing education, training and life-long learning of the NHS and social care workforces in patient safety. We continue to underpin our work, where possible using core Human Factors/Ergonomic (HFE) principles.

Below we have highlighted some of our educational activities and resources. For a full range and description of these please visit the Patient Safety Zone.

 

Patient Safety Training

Ongoing work within the Patient Safety Group has resulted in a new e-learning resource on Human Factors available summer 2016. Accredited by the Chartered Institute of Ergonomics and Human Factors,this resource will offer NHS and Social Care staff in Scotland an overview of this discipline and its contribution to enhanced well-being and performance.

½ day Face to Face workshops covering areas such as “Human Factors Awareness”, “Why things go wrong (and right) in complex systems” and “How to respond when things go wrong in complex systems” will be available from June 16 onwards to consolidate and develop knowledge around Patient Safety further. Additional learning options will become available during 2016/2017. Train the Trainer/Master class sessions will also be available to help those directly involved in the education of patient safety discuss the subject in more depth and share educational strategies with colleagues. 

A prototype 'train-the-trainers' pack (based on NES enhanced Significant Event Analysis work) has been developed build capacity and capability across NHS Scotland. This work is also contributing to related national programmes on the Reporting and Management of Adverse Events and the Duty of Candour.

To register your interest in hosting a 1/2 day workshop as part of Patient Safety education in your board please contact Catrina Gordon (catrina.gordon@nes.scot.nhs.uk). Further information and workshop dates are available here

Patient Safety Tools

Structured Handover
Handover is defined as "the transfer of professional responsibility and accountability for some or all aspects of the care of a patient group of patients, to another person or professional group on a temporary or permanent basis".  Patient information that is sub-optimally communication during healthcare handover is a common cause of hospital morbidity and mortality. Dr Ailsa Howie, NHS Consultant and NES Clinical Lead for Handover has developed resources for use by local teams across NHS Scotland to improve effective handovers.

For further information, please click here

Enhanced SEA
This is a NES innovation (funded by the Health Foundation 2012 SHINE programme) which aims to guide health and care teams to apply human factors thinking when performing a significant event analysis on a patient safety incident that recognises the impact (including emotional impact) of patient safety on patients, carers and staff. This in turn can lead to a more constructive approach to learning with more meaningful improvement being implemented to minimise the risks of the event happening again. 

For further information, please click here

Adverse Events
Healthcare Improvement Scotland developed a national approach to learning from adverse events in September 2013 and refreshed the document in April 2015. This has support from NES and applies educational principles to drive learning and change from patient safety incidents. 

Trigger Review Method
The trigger review method (TRM) for primary care is a process that enables clinicians to quickly and effectively search the electronic records of specific high risk groups of patients to identify previously undetected care management hazards and patient safety incidents. Care teams then use this information to direct safety and improvement efforts. The TRM already makes a contribution as a quality improvement activity as part of medical appraisal and specialty training. However, it is perhaps better known as a core intervention in the Scottish Patient Safety Programme in Primary.

For further information, please click here

 

Patient Stories

Patient Stories - With hindsight the solutions are usually obvious, unfortunately it often takes something catastrophic to make people really accept that change is required. Patient stories are often a powerful tool in understanding the root causes of harm and are good at shaking us out of our comfort zone and making us think differently. Select to view some patient stories

 

Healthcare Associated Infection

The HAI education programme is responsible for providing educational resources to support the prevention of Healthcare Associated Infections, Decontamination and Antimicrobial Stewardship across all clinical professions and non-clinical disciplines in NHSScotland. There is strong alignment with the aims and ambitions of the Scottish Patient Safety Programme and Quality Improvement agenda using the tools, methodologies and common language to support implementation of learning. More detailed information is available here. 

 

Primary Care Safety and Improvement Resources 

  • A toolkit for delivering safe, effective and person-centred care

This 'Safety and Improvement Educational Resources' booklet brings together a range of educational and improvement interventions, which have been developed in partnership with front line primary care clinicians and their healthcare teams and senior clinical leaders in NHS Boards. The main purpose of the tools and techniques described is to support everyday performance and wellbeing within the primary care environment at work and enable delivery on patient safety and quality improvement commitments.

The toolkit can be downloaded at the Patient Safety Zone.

 

Human Factors/Ergonomics (HFE) Training

The discipline of Human Factors (Ergonomics) takes a system and design based approach to improving wellbeing and performance of people (patients, clients, relative and NHS staff) and care organisations. It is often mis-interpreted as 'factors to do with humans'. It is crucial to the understanding of why things go wrong as well as why things 'go right' educational materials and training courses can be accessed here


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