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Tag Archives: NHS Micro-Climates
The Foundations for a Patient-Centred NHS Learning Culture? (Department of Health / BBC News)
Summary This “Learning Not Blaming” report presents the government’s response to (i) the Francis Freedom to Speak Up review, (ii) the Morecambe Bay Investigation, and (iii) the Public Administration Select Committee’s report on clinical incidents. The common theme for addressing … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, NHS Improvement, Non-Pharmacological Treatments, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest
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Tagged Authority Gradients vs Freedom to Speak Up, Aviation Industry, Avoidable Harm, Avoidable Mortality, Avoidable Premature Mortality, BBC Leicester News, BBC Panorama, BBC Panorama: Doctors on Trial, Capacity and Capability of Regulators, Care Quality Commission, Care Quality Commission (CQC) Inspection Regime, Care Seven Days a Week, Charlie Massey: Chief Executive of GMC, Clinical Incident Investigations, Clinical Incidents in the NHS, Clinical Risk Recognition and Planning, Comfort Seeking Organisations, Commons Public Administration Select Committee (PASC), Complaints and Raising Concerns, Complaints Handling, Complexity in the Complaints System, Consequences of the Francis Inquiry Report, Continuous Learning Culture, Corporate Self-Interest (Ahead of Patients), Cover-Ups (Attributed), Culture, Culture and Leadership, Culture Change in the NHS, Culture of Candour, Culture of Safety, Cumbria, Cumbria Partnership NHS Foundation Trust, Delayed Problem Recognition, Doctor Hadiza Bawa-Garba, Dr Bill Kirkup CBE, Dr Mike Durkin: NHS England’s Director of Patient Safety, Dr Mike Durkin: Patient Safety Investigation Service, Duty of Candour, Elevated Weekend Hospital Mortality, Five Year Forward View, Five Year Forward View (NHS England), Former Health Secretary Jeremy Hunt, Francis Freedom to Speak Up Report, Freedom to Speak Up (FTSU) Report, Freedom to Speak Up Guardian, Freedom to Speak Up Guardians, Freedom to Speak Up Report, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Freedom to Speak Up? (Whistleblowing Review), Furness General Hospital, Furness General Hospital Dementia Unit, Furness General Hospital in Cumbria, Furness General Hospital: Ramsay Unit, Health Systems in Transition (HiT), Healthwatch, Honesty and Transparency, Hospital Mortality, Hospital Mortality Rates, House of Commons Public Administration Select Committee (PASC), Implications of the Francis Inquiry Report, Improving Services For Patients: Not Defending the System, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent Patient Safety Investigation Service, Independent Patient Safety Investigation Service (IPSIS), Intelligent Transparency, IPSIS: Independent Patient Safety Investigation Service, Just Culture, Learning Culture, Learning for Improvement, Learning from Complaints, Learning From Errors and Failures in Care, Learning Not Blaming, Listening to Patients Families and Staff, Local Freedom to Speak Up Guardians, MBRRACE-UK (Mothers and Babies – Reducing Risk Through Audits and Confidential Enquiries Across the UK), Monitor, Morecambe Bay Inquiry, Morecambe Bay Investigation Report, Mortality at the Weekend, National Clinical Assessment Service (NCAS), Negative Culture, Never Events, NHS Accountability, NHS Corporate Self-Interest, NHS Culture, NHS England Never Events Taskforce, NHS Five Year Forward View (5YFV), NHS Managerial Self-Interest, NHS Micro-Climates, NHS Patient Safety Culture, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), No Harm Culture, Open and Honest Incident Reporting, Open and Supportive Culture, Openness, Over-Complexity, Over-Reliance on External Approval, Over-Reliance on External Judgments, Over-Reliance on Judgments of Others, Panorama (BBC TV), Panorama: Doctors on Trial, Parliamentary and Health Service Ombudsman, Patient Safety, Patient Safety in the NHS, Police: Complaints, Preventable Hospital Mortality, Problem Sensing, Problem Sensing Organisations (Versus Comfort Seeking Organisations), Public Administration Select Committee (PASC), Public Administration Select Committee Report into Clinical Incident Investigations, Recommendations for the University Hospitals of Morecambe Bay NHS Foundation Trust, Reducing Complexity, Reduction in Bureaucracy, Regulating Healthcare Systems, Regulating Healthcare Systems: Monitor, Regulation, Regulators, Regulators Sharing Information, Regulatory and Professional Bodies, Regulatory Gaps in Healthcare, Regulatory System, Repercussions From the Francis Inquiry Report, Report Into Maternity Care at Cumbria’s Furness General Hospital, Report of the Morecambe Bay Investigation, Reporting Culture, Reporting Mistakes, Rhona Flin: Aberdeen University, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Scrutiny of Perinatal and Maternal Deaths, Second Mid Staffs: Furness General Hospital Parallels, Serious and Untoward Incidents (SUIs), Service Redesign, Seven Day Care in England, Seven Day Services, Small Business Enterprise and Employment Act 2015 (SBEEA), Speaking Up: Resolving NHS Complaints and Preventing Problems Recurring, Surgical Never Events, Target Culture, Target-Chasing (Hitting the Target Missing the Point), Transparency, Transparency and Accountability, Transparent Learning Culture, University Hospitals of Morecambe Bay NHS Trust, Unnecessary In-Hospital Deaths, User Complaints, Valuing Complaints, Weekend Effect, Weekend Mortality Rates, Weekend Services, Weekend Working, Whistleblowing, Workplace Culture
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CQC Inspection Report Criticises Furness General Hospital Dementia Unit (BBC News)
Summary The Care Quality Commission (CQC) attributed problems in the standards of care in the Ramsay Unit at Furness General Hospital primarily to “chronic staff shortages”. New admissions to the unit were halted by the Cumbria Partnership NHS Foundation Trust briefly, after an … Continue reading →
Posted in Acute Hospitals, BBC News, CQC: Care Quality Commission, For Carers (mostly), For Nurses and Therapists (mostly), In the News, National, NHS, NHS England, Patient Care Pathway, Proposed for Next Newsletter, Quick Insights, Standards, UK, Universal Interest
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Tagged Avoidable Harm, Avoidable Mortality, Avoidable Premature Mortality, Capacity and Capability of Regulators, Care Quality Commission (CQC), Care Quality Commission Monitor and Department of Health Liaison, Central Manchester Report (December 2011), Central Manchester University Hospital Diagnostic Review (2011), Central Manchester University Hospitals NHS Foundation Trust, Centre for Maternal and Child Enquiries (CMACE), Clinical Risk Recognition and Planning, Complexity in the Complaints System, Corporate Self-Interest (Ahead of Patients), Cover-Ups (Attributed), CQC Failings, CQC Hospital Inspections, Culture, Culture Change in the NHS, Cumbria, Cumbria Partnership NHS Foundation Trust, David Behan: Chief Executive of Care Quality Commission, David Bennett: Chief Executive of Monitor, David Flory: Chief Executive of NHS Trust Development Authority, Delayed Problem Recognition, Dr Bill Kirkup CBE, Dr Mike Durkin: NHS England’s Director of Patient Safety, Dr Peter Carter: Chief Executive and General Secretary Royal College of Nursing, Failure of Communications and Inadequate Processes, False Assurance, Fielding Report, Flynn Report, Former Health Secretary Jeremy Hunt, Foundation Trust Status, Foundation Trust Status Distractions, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Furness General Hospital, Furness General Hospital Dementia Unit, Furness General Hospital in Cumbria, Furness General Hospital: Ramsay Unit, General Medical Council (GMC), Gold Command, Gold Command Process, Health and Safety Executive (HSE), Health and Social Care (Community Health and Standards) Act 2003, Health Systems in Transition (HiT), Hospital Mortality, Hospital Mortality Rates, Inspection and Regulation, Joshua Titcombe, Kirkup Recommendations for Wider NHS, Lack of Clarity About Roles, Lack of Clarity on Overall Responsibility, Local Supervising Authority, Local Supervising Authority Midwifery Officer (LSAMO), Missed Opportunities, Morecambe Bay Inquiry, Morecambe Bay Investigation Report, Negative Culture, NHS Accountability, NHS Corporate Self-Interest, NHS Culture, NHS Litigation Authority (NHSLA), NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (CNST) Reports, NHS Managerial Self-Interest, NHS Micro-Climates, NHS Regulation, NHSLA Accreditation, North West Health Authority, North West Strategic Health Authority (NW SHA), Nursing and Midwifery Council (NMC), Openness, Over-Complexity, Over-Reliance on External Approval, Over-Reliance on External Judgments, Over-Reliance on Judgments of Others, Parliamentary and Health Services Ombudsman, Patient Safety, Peter Carter: Royal College of Nursing, Preventable Hospital Mortality, PricewaterhouseCoopers (PwC) review of Trust-Wide Governance, Professor Sir Bruce Keogh, Quality Surveillance Groups, Recommendations for the University Hospitals of Morecambe Bay NHS Foundation Trust, Reducing Complexity, Regulating Healthcare Systems, Regulating Healthcare Systems: Monitor, Regulation, Regulators, Regulators Sharing Information, Regulatory and Professional Bodies, Regulatory Gaps in Healthcare, Regulatory System, Report Into Maternity Care at Cumbria’s Furness General Hospital, Report of the Morecambe Bay Investigation, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Safe Staffing Levels, Scrutiny, Scrutiny of Perinatal and Maternal Deaths, Second Mid Staffs: Furness General Hospital Parallels, Serious and Untoward Incidents (SUIs), Simon Stevens: Chief Executive of NHS England, Staffing (Hospitals), Staffing Levels, Systems Complexity, Target Culture, Target-Chasing (Hitting the Target Missing the Point), Transparency and Accountability, Una O’Brien: Department of Health, Unannounced Care Quality Commission Inspection, Unannounced Hospital Inspections, University Hospitals of Morecambe Bay NHS Trust, Unnecessary In-Hospital Deaths, Whistleblowing, Workplace Culture
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