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Tag Archives: Over-Complexity
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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Dementia 2015 UK Policy Report: Improving the Quality of Life for People with Dementia (Alzheimer’s Society)
Summary The Alzheimer’s Society’s fourth annual report exploring the quality of life for people with dementia (and their families and carers) in England, Wales and Northern Ireland, is entitled “Dementia 2015: Aiming higher to transform lives is in England”. This … Continue reading →
Posted in Acute Hospitals, Alzheimer's Society, Antipsychotics, Charitable Bodies, Commissioning, Community Care, Diagnosis, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Management of Condition, Mental Health, Models of Dementia Care, National, Non-Pharmacological Treatments, Northern Ireland, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, Statistics, UK, Universal Interest, Wales
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Tagged 2015 General Election Dementia Manifesto (All Party Parliamentary Group on Dementia), Active Lifestyle, Addressing Dementia: The OECD Response (2015), All Party Parliamentary Group on Dementia Manifesto for 2015 General Election, Alternatives to Antipsychotic Medication, Alzheimer's Society Policy Reports: Dementia 20xx Series, Alzheimer's Society: Dementia Friendly Communities Programme, Alzheimer’s Society Dementia Advisers, Alzheimer’s Society National Dementia Helpline, Alzheimer’s Society Public Policy Team, Alzheimer’s Society’s Carer Information and Support Programme (CrISP), Alzheimer’s Society’s Research Network, Alzheimer’s Society’s Supporting Diagnosis Project, APPG on Dementia, APPG on Dementia Manifesto 2015, Asda, Assessment of Quality of Life, Attributable Cost of Dementia, Aviva, Awareness and Understanding, Awareness Raising, Balancing Risk and Choice, Barbara Pointon’s Web of Care, Baroness Sally Greengross (APPG on Dementia), Barriers to Involvement, Barriers to Joined-Up Care, Barriers to Support, Barriers: Discrimination, Barriers: Lack of Continuity of Care, Barriers: Lack of Support for Carers, Blackfriars Consensus Statement, Burden of Dementia (Statistics), Care and Support, Care and Support Services, Care Homes, Caregiver Support, Carer Burden in Dementia, Carer Information and Support Programme, Carer Information and Support Programme (CrISP), Carer Support, Carers’ Health and Wellbeing, Central Lancashire’s Pathway of Post-Diagnostic Support Services, Challenge on Dementia 2020, Co-Morbidities and Dementia, Commissioners of Services, Commissioning Support Services, Community Support, Community Support Services, Cracks in the Pathway (CQC), Crawley Dementia Alliance, Dementia 2015 UK Policy Report, Dementia 2015: Aiming Higher to Transform Lives, Dementia Action Alliance (DAA), Dementia Adviser Service, Dementia Advisers, Dementia Advisor Service, Dementia Advisors, Dementia Awareness, Dementia Co-Morbidities, Dementia Diagnosis and Care in England, Dementia Diagnosis Rates, Dementia Friendly Communities Champion Group, Dementia Friendly Communities Programme, Dementia Friendly Swimming Project: Amateur Swimming Association (ASA), Dementia Friends, Dementia Research, Dementia Research Funding, Dementia Research Priorities, Dementia Research: UK Impact, Dementia-Friendly Businesses, Dementia-Friendly Care Homes, Dementia-Friendly Cities, Dementia-Friendly Communities, Dementia-Friendly Health and Care Settings, Dementia-Friendly Hospitals, Dementia-Friendly Organisations, Dementia-Friendly Towns, Dementia-Friendly Workplaces, Deprivation of Liberty Safeguards (DoLS), Diagnosis and Referral, Disease-Modifying Therapies for Dementia, EasyJet, Focused Intervention Training and Support (FITS), Forget Me Not Dementia Unit (Warrington Hospital), G8 Summit, Global Alzheimer’s and Dementia Action Alliance (GADAA), Happiness and Wellbeing, Health and Quality of Life, Health and Social Care Reform, Health and Wellbeing, Health Care Support Received by People with Mental Health Problems, Health Commissioners, Health Wellbeing and Independence, Healthy Lifestyles, Home Retail Group (Argos and Homebase), Impact of Dementia (Statistics), Improving Dementia Education and Awareness, Improving the Quality of Life for People with Long Term Conditions, Inadequate Homecare Training, Increasing Wellbeing, Integrated Services in Tower Hamlets, Involvement and Participation, John's Campaign, Living Well with Dementia, Living Well with Dementia Research, Lloyds Banking Group, Loneliness and Social Isolation, Marks and Spencer, National Dementia Helpline, New Models of Care, NHS England’s Five Year Forward View, NHS England’s New Models of Care Programme, NHS Five Year Forward View (5YFV), Organisational and Cultural Barriers, Over-Complexity, Participation in Research, Patient Reported Outcome Measures (PROMs) in Dementia Study, Patient Reported Outcome Measures in Dementia, Post-Diagnosis Support, Post-Diagnostic Dementia Support, Prevalence of Dementia, Prime Minister’s Challenge On Dementia 2020, Public Health England, Quality of Care Across the Course of Dementia, Quality of Life, Quality of Life (Carers), Quality of Life for People With Dementia, Quality of Life Promotion, Quality of Life Research, Reducing Antipsychotic Prescriptions in Dementia, Reducing Complexity, Reducing Social Isolation: Side by Side, Right to Know Campaign, Risk Management, Risk Management Assessment, Risk Stratification, Social Isolation, St Gregory’s High School (Warrington), Support for New Models of Care (New Deal), Support Services, Supporting Healthy Lifestyles, Supporting People to Live Well With Dementia, Supreme Court Judgment (March 2015) on Deprivation of Liberty Safeguards (DoLS), Swimming With Dementia, Systems Complexity, Tower Hamlets, Web of Care, Workforce Development, Workforce Training, World Dementia Council
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Monitor and Trust Development Authority Under Single Leadership: Delivering Better Support to Hospitals (Department of Health / Monitor)
Summary Closer working between Monitor and the NHS Trust Development Authority (NHS TDA) should help reduce lack of standardisation and inconsistency, and help to embed hospital patient safety as an NHS priority. All NHS hospitals, whether foundation trusts or non-foundation … Continue reading →
Posted in Acute Hospitals, Commissioning, Department of Health, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Local Interest, National, NHS, Quick Insights, Standards, UK, Universal Interest
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Tagged Acute Care, Acute Care Services, Acute Hospital Care, Acute Hospital Regulatory Model, Acute Hospitals, BBC Health News, Bob Alexander: NHS Trust Development Authority (TDA), Chief Patient Officer, Claire Read: Secretary to HSJ Future of NHS Leadership Inquiry, Clinical Leaders, Clinical Leadership, Closer Working Between Monitor and NHS TDA, Commissioning Inspection and Regulation, Compassionate Care in Acute Hospital Settings, Coordinated Regulatory Action, Dame Gill Morgan DBE, Dame Gill Morgan: Chair of NHS Providers, Dame Gill Morgan: HSJ Future of NHS Leadership Inquiry, David Bennett: Chief Executive of Monitor, Dementia Care in the Acute Hospital, Denigration of NHS Leadership, Double Jeopardy Problem for Clinical Leaders, Dr David Bennett, Dr Emma Stanton: Associate Chief Medical Officer at Beacon Health Options and Chief Executive at Beacon UK, Dr Emma Stanton: HSJ Future of NHS Leadership Inquiry, End to Silo Working, Foundation Trusts, Future of NHS Leadership Inquiry (HSJ June 2015), Health Service Journal (HSJ), Hospital Patient Safety Strategies, HSJ, HSJ Future of NHS Leadership Inquiry, Identifying and Supporting Potential Leaders, Improving Patient Safety, Inspection and Regulation, Jim Mackey: Chief Executive of NHS Improvement, Jim Mackey: Former Chief Executive of Northumbria Healthcare NHS Foundation Trust, Leadership in the Clinical Curriculum, Legislation and Regulation, Management and Leadership Training, Monitor, NHS Foundation Trusts (NHSFTs), NHS Improvement: New Health Sector Regulator, NHS Leadership, NHS Leadership Academy (NHS LA), NHS Regulation, NHS TDA, NHS TDA: NHS Trust Development Authority, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), NHS Trusts and Foundation Trusts, Nicholas Timmins: HSJ Future of NHS Leadership Inquiry, Nicholas Timmins: King’s Fund, Non-Foundation Trusts, Over-Complexity, Patient Safety, Preventable Deaths in English Acute Hospitals, Priorites Within Acute Hospitals, Problems in Care in English Acute Hospitals, Professor Laura Serrant: HSJ Future of NHS Leadership Inquiry, Professor Laura Serrant: Professor of Community and Public Health Nursing at Wolverhampton University on Secondment to NHS England, Provider Appraisal And Regulation, Provider Regulation, Rationalisation of Reporting and Regulation, Reactions to the Francis Inquiry Report, Reducing Complexity, Reducing the Number of Organisations, Regulating Healthcare Systems, Regulating Healthcare Systems: Monitor, Regulation, Regulation of Governance, Regulators Sharing Information, Regulatory System, Removing Regulatory Barriers, Repercussions From the Francis Inquiry Report, Richard Lewis: EY (Ernst & Young), Richard Lewis: HSJ Future of NHS Leadership Inquiry, Rt Hon. Stephen Dorrell MP, Secondary (Acute Hospital) Care, Secondary Care, Single Regulatory Process, Sir Robert Naylor: Chief Executive of University College London Hospitals NHS Foundation Trust, Sir Robert Naylor: Health Service Journal Panel / Report on the Future of NHS Leadership, Sir Sam Everington: Chair of NHS Tower Hamlets Clinical Commissioning Group and Board Member of NHS Clinical Commissioners, Sir Sam Everington: HSJ Future of NHS Leadership Inquiry, Sir Sam Everington: Senior GP in Tower Hamlets, Stephen Dorrell: HSJ Future of NHS Leadership Inquiry, Stephen Dorrell: Senior Advisor to KPMG / Programmes Commissioned by the NHS Leadership Academy, Systems Complexity, Troubled NHS Foundation Trusts, Turnaround of Challenged and Failing Foundation Trusts
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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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NHS Reform Under the Coalition Government (King’s Fund / BBC News)
Summary Chris Ham, Chief Executive of the King’s Fund, has released an authoritative and thorough review of major reform and re-organisation within the NHS during the first three years of the coalition government. “He was agin’ it”. Mark Twain. Full … Continue reading →