Prospective Hazard Analysis (PHA) Proactive risk assessment Looking for Trouble
|
|
|
- Paul Glenn
- 8 years ago
- Views:
Transcription
1 Prospective Hazard Analysis (PHA) Proactive risk assessment Looking for Trouble James Ward
2 Views on risk assessment? 2
3 Outline 1. Good practice in risk assessment 2. The PHA Toolkit 3. Case studies using the PHA Toolkit 4. Feedback on the PHA Toolkit 5. PHA future 6. Conclusions A taster of what PHA looks like 3
4 Retrospective vs. Prospective risk management A shift in the balance? Retrospective 1 9 Prospective Limitations 4
5 Risk assessment 5
6 Risk assessment An evidence-based decision making process Universal: All decision making, whatever the level of importance and significance, involves the explicit consideration of risks and the application of risk management to some appropriate degree. (BS ISO 31000: 2009) Versatile: Can be applied to work processes, and strategies and decisions, operations, processes, functions, projects, products, services and assets and to any type of risk (BS ISO 31000: 2009) Part of a design process: It is essential that risks are identified systematically from the early stages of planning a project. A system of risk management should be introduced that works effectively alongside the creative work. (BS :2008) 6
7 Risk management and Design for Patient Safety BUILD KNOWLEDGE BASE PROVIDE SAFE MEDICAL CARE DEFINE THE REQUIREMENTS EVALUATE THE MEDICAL SYSTEM DESIGN THE PRODUCT(S) DESIGN THE MEDICAL SYSTEM DELIVER THE MEDICAL SYSTEM MANAGE RISK 7
8 PHA Toolkit outline 8
9 Some aims / features of the PHA Toolkit Aim: distil good risk practice down into a Toolkit for NHS use: 1. Proactive 2. Holistic 3. Systematic 4. Flexible 5. Self-documenting 6. 9
10 The PHA Toolkit 10
11 PHA Toolkit Some questions it asks 1) Trigger: why undertake a review? 2) Articulate purpose: what is the purpose of the review? 3) Define requirements: who, what, when? 4) Describe system: what is to be assessed? 5) Identify hazards: what could go wrong? 6) Assess risks: will it go wrong? 7) Propose actions: what actions are required? 8) Review process: what next? 11
12 PHA Toolkit A template 12
13 PHA Toolkit A table for decision making A customisable table for risk-based decision making: Components Deviations Risks Etc. id. Component Deviation Concern Hazard Defence(s) Like Imp Z A B C D E F Infusion pump Elevated flow Yes Overdosing Check setting 3 5 Referral / patient told Referral made Discharge letter Discharge summary Letter taken to tray Patient not told Referral not drafted or drafted incorrectly Letter ambiguous or incomplete Letter does not get to GP Not done or incomplete Letter not put in tray Yes Yes Yes Yes Yes Yes Patient not told Referral not drafted Letter ambiguous Letter lost Summary incomplete Letter not in tray Induction, supervision, routine practice Routine practice, alert consultant / GP Routine practice, admin provide advice Routine practice, GP returns patient Ward clerk checks, cannot obtain drugs Routine practice, patient safety alert Risk Risk Action(s) Like Imp Risk 15 Overdose Check bloods Patient unaware, does not expect referral No appointment GP does not know about cancer GP does not know about cancer GP does not know about cancer No referral made Patient told verbally and in writing Checklist for clinicians - - Checklist, senior review Immediate handover, CDU tray, checklist
14 PHA Toolkit three key points 1) Trigger: why undertake a review? 2) Articulate purpose: what is the purpose of the review? 3) Define requirements: who, what, when? 4) Describe system: what is to be assessed? 5) Identify hazards: what could go wrong? 6) Assess risks: will it go wrong? 7) Propose actions: what actions are required? 8) Review process: what next? A Describing systems C Risk Ass t Techniques B Linking 14
15 A) Describing systems 15
16 Describing systems engineered systems How do you describe a system? Fly For Fun Boeing
17 Describing systems healthcare work systems? People Objects Places Tasks Timing Environment Culture and norms Information 17
18 Describing systems healthcare work systems? John John Varied smoker Fire setter Sectioned New admission Drug-induced psychosis, florid V, caring parents Against smoking 18
19 B) Linking systems descriptions to risk assessment techniques 19
20 Preliminary Risk Review / Linking diagrams and the risks Sources of harm provide an information feed to help systematically assess the risks 20 id. Component Deviation Concern Hazard Defence(s) Like Imp Z A B C D E F Infusion pump Elevated flow Yes Overdosing Check setting 3 5 Referral / patient told Referral made Discharge letter Discharge summary Letter taken to tray Patient not told Referral not drafted or drafted incorrectly Letter ambiguous or incomplete Letter does not get to GP Not done or incomplete Letter not put in tray Yes Yes Yes Yes Yes Yes Patient not told Referral not drafted Letter ambiguous Letter lost Summary incomplete Letter not in tray Induction, supervision, routine practice Routine practice, alert consultant / GP Routine practice, admin provide advice Routine practice, GP returns patient Ward clerk checks, cannot obtain drugs Routine practice, patient safety alert Risk Risk Action(s) Like Imp Risk 15 Overdose Check bloods Patient unaware, does not expect referral No appointment GP does not know about cancer GP does not know about cancer GP does not know about cancer No referral made Patient told verbally and in writing Checklist for clinicians - - Checklist, senior review Immediate handover, CDU tray, checklist
21 C) Risk assessment techniques 21
22 Many risk assessment techniques! Just a few of them: FMEA HFMEA THERP SLIM-MAUD FMECA HRMS HEART PHA APJ HACCP CREAM FTA HAZOP ST-PRA SWIFT SHERPA ETA TRACEr PRA JHEDI ATHEANA 22
23 Types of technique Checklists and standards Inductive What happens if? Deductive How could x happen? (Sherlock Holmes) Guidewords Human error (Human Reliability Assessment) PHA Toolkit selected a nominal 10 techniques with potential in the NHS 23
24 Human Reliability Assessment techniques it is important that due recognition is given to human and organizational factors when identifying risk. (BS EN ISO 31010: 2010) THERP SLIM-MAUD HRMS HEART SHERPA APJ 24 CREAM ATHEANA JHEDI THEA TRACEr
25 Systematic Human Error Reduction and Prediction Approach 1) Describe the tasks (Hierarchical Task Analysis) 2) Classify the tasks (Action / Retrieval / Checking / Selection / Information communication) 3) Consider the error modes (Guidewords: e.g. too long / wrong operation on right object) 4) Consider and rate the probability of occurrencee 5) Consider and rate the consequences 6) Consider the opportunities for error recovery 7) Consider remedial measures Linking Wrong information communicated Hospitals prescribe things they are not supposed to Budget consequences you get into trouble with PCT for prescribing certain drugs stressful for GP No M H More meetings between GP and hospital doctors Lyons, M.N., Ward, J.R., Barclay, S., Anderson, J., Buckle, P. And Clarkson, P.J. (2007) 'The feasibility of applying a systematic human error reduction and prediction approach (SHERPA) in healthcare: a case study of repeat prescribing in primary care' in Patient Safety Research Shaping the European Agenda, Porto, Portugal 25
26 PHAs done / ongoing 26
27 PHAs done and ongoing A = Acute, M = Mental Health, C = Community Medication (A) Violence (M) Ward closure (A) Perioperative Information (A) New screening process (A/C) Clinical documentation (A) Smoking (M) Door security (M) Physical journeys through a building (M) Urgent referral process (A) Admission of patients (M) Active Shooter response (A) Trauma Network (A/C) 27
28 PHA Feedback 28
29 Results Selected comments You talk about attitudes and I think that s the main thing that I ve suddenly had a change in! Actually this is quite important, and not because somebody s asked me to do it. [Junior Doc] These sessions are hugely beneficial; I ve learned so much. [But] speaking to people throughout the week that I ve been trying to explain it to them, they have gone rather glassy-eyed and [there s] jaw-dropping, and I ve said well it s not as bad as it sounds. [Nurse] The feedback has been unanimously positive in supporting the use of the tool as it has enabled the team to have confidence around each issue we have explored in depth and arrive at the correct decision. [Senior manager] [This has] saved money & significant clinical time, risk. [Senior manager] The idea of PHA within the NHS is clearly laudable. Anything that moves our view of medicines risks from reactive "why things went wrong" to proactive "how we can ensure a safe proactive environment" is to be applauded - but requires a major cultural change! [Senior Manager] 29
30 Some limitations 30
31 Limitations of PHA Clearly the profile and level of the risk in healthcare is generally different to that in e.g. nuclear power, where single incidents can cause major losses Resources and the opportunity cost System change and system diversity Quality of the data The counterfactuals Training staff and facilitators Culture of openness and analysis? Need for continuous process 31
32 What next with PHA? 32
33 PHA future 1. Developing the Toolkit 2. PHA evidence is it worth it 3. PHA training course 4. PHA marketing? 33
34 Conclusions 1. PHA readdress the reactive / proactive balance in risk management. 2. Extremely broad applicability supports decision making. 3. Appropriate? Tricky balancing act: e.g. limited resources vs. comprehensiveness and assurance 4. Positive feedback and effects (e.g. culture), but still much to do! 34
35 Thank you greenstreet berman James Ward Engineering Design Centre Department of Engineering University of Cambridge 35
36 Report and early version of the Toolkit: Google: PHA PSRP Or: 36
How To Improve Safety In The Nhs
PS035 Original research completed in 2010 Briefing Paper Introduction: Principal Investigator: Professor John Clarkson Should the NHS adopt a new system for predicting possible risks to patient safety?
BRITISH DERMATOLOGICAL NURSING GROUP
Nurse Led systemic monitoring clinics guidance on setting up this service Introduction Nurse led systemic monitoring clinics are an innovative approach to improving care delivery and maintaining both a
Quality Risk Management Tools Quality Risk Management Tool Selection When to Select FMEA: QRM Tool Selection Matrix
Quality Risk Management Tools Quality Risk Management Tool Selection When to Select FMEA: QRM Tool Selection Matrix 26 Quality Risk Management Tools The ICH Q9 guideline, Quality Risk Management, provides
Root Cause Analysis Investigation Tools. Concise RCA investigation report examples
Root Cause Analysis Investigation Tools Concise RCA investigation report examples www.npsa.nhs.uk/nrls Acute service example Mental health example Ambulance service example Primary care example Acute service
Information Governance. A Clinician s Guide to Record Standards Part 1: Why standardise the structure and content of medical records?
Information Governance A Clinician s Guide to Record Standards Part 1: Why standardise the structure and content of medical records? Contents Page 3 A guide for clinicians Pages 4 and 5 Why have standards
Guide for Clinical Audit Leads
Guide for Clinical Audit Leads Nancy Dixon and Mary Pearce Healthcare Quality Quest March 2011 Clinical audit tool to promote quality for better health services Contents 1 Introduction 1 1.1 Who this
Standard 5. Patient Identification and Procedure Matching. Safety and Quality Improvement Guide
Standard 5 Patient Identification and Procedure Matching Safety and Quality Improvement Guide 5 5 5October 5 2012 ISBN: Print: 978-1-921983-35-1 Electronic: 978-1-921983-36-8 Suggested citation: Australian
Agreed Job Description and Person Specification
Agreed Job Description and Person Specification Job Title: Line Manager: Professionally accountable to: Job Purpose Registered Nurse Lead Nurse Inpatient Unit Clinical Director Provide specialist palliative
Learning when things go wrong. Marg Way Director, Clinical Governance Alfred Health, Melbourne
Learning when things go wrong Marg Way Director, Clinical Governance Alfred Health, Melbourne Safety and Quality Management in hospitals Things have changed a lot over the last 10 years.. HOSPITAL catastrophes
Australian Safety and Quality Framework for Health Care
Activities for MANAGERS Australian Safety and Quality Framework for Health Care Putting the Framework into action: Getting started Contents Principle: Consumer centred Area for action: 1.1 Develop methods
Guidance on Lone Working in the Healthcare Sector
Guidance on Lone Working in the Healthcare Sector Our vision: A national culture where all commit to safe and healthy workplaces and the safe and sustainable management of chemicals Contents 1. Introduction
7/24/2015. Disclosure. Preventing Medication Errors in a Just Culture Environment. Blame Free Culture. Objectives.
49th Annual Meeting Preventing Medication Errors in a Just Culture Environment Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or
Process for reporting and learning from serious incidents requiring investigation
Process for reporting and learning from serious incidents requiring investigation Date: 9 March 2012 NHS South of England Process for reporting and learning from serious incidents requiring investigation
ST LUKE S HOSPICE CLINICAL NURSE PRACTITIONER HEAD OF CARE SERVICES SUZANNE SALES CLINICAL NURSING SERVICES MANAGER
ST LUKE S HOSPICE JOB DESCRIPTION: DAY HOSPICE LEAD/ CLINICAL NURSE PRACTITIONER DATE: MARCH 2015 WRITER: DEB HICKEY HEAD OF CARE SERVICES SUZANNE SALES CLINICAL NURSING SERVICES MANAGER TOTAL NUMBER 11
3.0 Risk Assessment and Analysis Techniques and Tools
3.0 Risk Assessment and Analysis Techniques and Tools Risks are determined in terms of the likelihood that an uncontrolled event will occur and the consequences of that event occurring. Risk = Likelihood
Guide for general practice staff on reporting patient safety incidents to the National Reporting and Learning System
Guide for general practice staff on reporting patient safety incidents to the National Reporting and Learning System NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients
Risk Assessment and Management. Allen L. Burgenson Manager, Regulatory Affairs Lonza Walkersville Inc.
Risk Assessment and Management Allen L. Burgenson Manager, Regulatory Affairs Lonza Walkersville Inc. Standard Disclaimer Standard Disclaimer: This presentation is the opinion of the presenter, and does
GUIDANCE AND TEMPLATE
GUIDANCE AND TEMPLATE The care pathway mapping tool is designed to be used as part of the map the care pathway stage of the eight stage workforce planning approach. The output of the tool will be the creation
Medicines reconciliation on admission and discharge from hospital policy April 2013. WHSCT medicines reconciliation policy 1
Medicines reconciliation on admission and discharge from hospital policy April 2013 WHSCT medicines reconciliation policy 1 Policy Title Policy Reference Number Medicines reconciliation on admission and
High Integrity Systems in Health Environment. Mark Nicholson
High Integrity Systems in Health Environment Mark Nicholson Introduction National Patient Safety Agency (NPSA - 2003) has described patient safety as process by which an organisation makes patient care
Development of a patient satisfaction survey for Acute Medicine. Liz Lees Consultant Nurse & Clinical Dean Acute Medicine
Development of a patient satisfaction survey for Acute Medicine Liz Lees Consultant Nurse & Clinical Dean Acute Medicine 4 th International Conference, Society for Acute Medicine, Edinburgh 7-8 October
JOB DESCRIPTION. Advanced Nurse Practitioner Professional Lead
JOB DESCRIPTION JOB TITLE: RESPONSIBLE TO: LOCATION(S): JOB PROFILE: Advanced Nurse Practitioner Advanced Nurse Practitioner Professional Lead North Bristol Trust Southmead Hospital This role is to work
INVESTIGATION The care and treatment of Ms FG
INVESTIGATION Our aim We aim to ensure that care, treatment and support are lawful and respect the rights and promote the welfare of individuals with mental illness, learning disability and related conditions.
Keeping patients safe when they transfer between care providers getting the medicines right
PART 1 Keeping patients safe when they transfer between care providers getting the medicines right Good practice guidance for healthcare professions July 2011 Endorsed by: Foreword Taking a medicine is
Guide to the National Safety and Quality Health Service Standards for health service organisation boards
Guide to the National Safety and Quality Health Service Standards for health service organisation boards April 2015 ISBN Print: 978-1-925224-10-8 Electronic: 978-1-925224-11-5 Suggested citation: Australian
QUALITY RISK MANAGEMENT (QRM): A REVIEW
Lotlikar et al Journal of Drug Delivery & Therapeutics; 2013, 3(2), 149-154 149 Available online at http://jddtonline.info REVIEW ARTICLE QUALITY RISK MANAGEMENT (QRM): A REVIEW Lotlikar MV Head Corporate
RECORD KEEPING IN HEALTHCARE RECORDS POLICY
RECORD KEEPING IN HEALTHCARE RECORDS POLICY Version 6.0 Key Points The Policy provides a framework for the quality of the clinical record facilitates high quality, safe patient care and that subsequently
A&E Recovery & Improvement Plan
Engagement and Patient Experience Committee (A Sub-Committee of NHS Southwark CCG Governing Body) ENCLOSURE B A&E Recovery & Improvement Plan DATE OF MEETING: September 2013 CCG DIRECTOR RESPONSIBLE: Tamsin
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST HEALTHCARE GOVERNANCE COMMITTEE
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST HEALTHCARE GOVERNANCE COMMITTEE I TO BE HELD ON MONDAY 26 NOVEMBER 2012 Subject: Supporting Director: Author: Status
Proactive Risk Assessment: Using FMEA in Healthcare. Shelly Jeffcott PhD Senior Research Fellow
Proactive Risk Assessment: Using FMEA in Healthcare Shelly Jeffcott PhD Senior Research Fellow Opening Thoughts Focus on retrospective analysis of error But what about near misses Adapting tools from other
This guide was published in 2011 and will be reviewed in 2012. The latest version will always be available online at www.1000livesplus.wales.nhs.
Acknowledgements This guide has been produced by Julie Parry. We would particularly like to thank healthcare organisations in Wales and their teams for their work in implementing this intervention and
DH Review of NHS Complaint Handling Submission by the Foundation Trust Network (FTN)
DH Review of NHS Complaint Handling Submission by the Foundation Trust Network (FTN) 1. Introduction 1.1 The Foundation Trust Network (FTN) is the membership organisation for the NHS acute hospitals and
We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.
Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Royal Free Hospital Urgent Care Centre Royal Free Hospital,
Australian Safety and Quality Framework for Health Care
Activities for the HEALTHCARE TEAM Australian Safety and Quality Framework for Health Care Putting the Framework into action: Getting started Contents Principle: Consumer centred Areas for action: 1.2
INDICATIVE ROLE SPECIFICATION FOR A MACMILLAN CANCER SUPPORT WORKER - CARE COORDINATION
INDICATIVE ROLE SPECIFICATION FOR A MACMILLAN CANCER SUPPORT WORKER - CARE COORDINATION August 2011 Introduction and context Macmillan has been working with the Department of Health in England (DHE) and
National Clinical Programmes
National Clinical Programmes Section 3 Background information on the National Clinical Programmes Mission, Vision and Objectives July 2011 V0. 6_ 4 th July, 2011 1 National Clinical Programmes: Mission
Harness Care Cooperative Ltd Quality primary care services provided through local cooperation Company registration: 06584450
Harness Care Cooperative Ltd Quality primary care services provided through local cooperation Company registration: 06584450 Job Description Job title: Nurse Practitioner /Lead Nurse ACCOUNTIBILITY The
Acute care toolkit 2
Acute care toolkit 2 High-quality acute care October 2011 Consultant physicians are at the forefront of delivering care to patients presenting to hospital with medical emergencies. Delivering this care
ACUTE CARE PATHWAY AND ALTERNATIVES TO ADMISSION
ACUTE CARE PATHWAY AND ALTERNATIVES TO ADMISSION Sarah Biggs and Helen Dudeney - Crisis Assessment & Treatment Team Services Manager s Mary Dolan and Michelle Howitt Overview of Acute Services North West
Risk management for external beam radiotherapy Recommendations (draft)
Patient safety in external beam radiotherapy - Guidelines on risk assessment and analysis of adverse events and near misses. Risk management for external beam radiotherapy Recommendations (draft) Jean-Luc
Aspirations Support Bristol Limited
Aspirations Support Bristol Limited Aspirations Support Bristol Inspection report Design House 26 South View Staple Hill Bristol BS16 5PJ Tel: : 0117 965 1447 Website: www.aspirations-support.co.uk Date
The Marlborough Medical Practice Patient Participation Group (PPG) Survey 2015 RESULTS
The Marlborough Medical Practice Patient Participation Group (PPG) Survey 2015 RESULTS Introduction The PPG Survey was carried out to allow patients and their carers to feedback on key aspects of the service
Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide
Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide (Adapted from Suicide Prevention Resource Center (SPRC) & American Association of
Arrangements have been made for the following fire service training course:-
Fire Service Central Training Programme Course: Fire Service Instructor Newbridge Fire Station (13 th of March, 23 rd to the 27 th of March, 2015) 7 th of January, 2015 To Each Director of Services (Fire)
Managing the boundaries of NHS and privately funded healthcare Policy on the separation of private and NHS treatments
South Central Priorities Committees (Oxfordshire PCT) Policy Statement 67a: Managing the boundaries of NHS and privately-funded healthcare Clinical Executive decision: September 2009 Date of Issue: April
Defining the boundaries between NHS and Private Healthcare
West Midlands Strategic Commissioning Group Commissioning Policy (WM/13) Defining the boundaries between NHS and Private Healthcare Version 1 April 2010 1. Definitions Private patients are patients who
SER Family Support Network. Involving family members and carers in treatment services. (adapted from the NHS, A Guide for commissioners & Services)
SER Family Support Network Involving family members and carers in treatment services (adapted from the NHS, A Guide for commissioners & Services) 1 The SER Family Support Network asks that all the lead
Mental Health. Bulletin. Introduction. Physical healthcare. September 2015
Mental Health September 2015 Bulletin Introduction Welcome to the second edition of the Mental Health Bulletin. In this issue we again look at some of the themes from recent inspections, as well as share
AVOIDING UNPLANNED ADMISSIONS ENHANCED SERVICE: PROACTIVE CASE FINDING AND CARE REVIEW FOR VULNERABLE PEOPLE GUIDANCE AND AUDIT REQUIREMENTS
April 2014 AVOIDING UNPLANNED ADMISSIONS ENHANCED SERVICE: PROACTIVE CASE FINDING AND CARE REVIEW FOR VULNERABLE PEOPLE GUIDANCE AND AUDIT REQUIREMENTS A programme of action for general practice and clinical
Board of Directors Meeting
Board of Directors Meeting 23 rd July 2014 (BDA/14/26) part Performance Report Monitor Key Indicators Status: A Paper for Information History: Amanda Pritchard Chief Operating Officer Page 1 of 10 Performance
NHS Lanarkshire Information Governance Committee
INFORMATION GOVERNANCE COMMITTEE DRAFT TERMS OF REFERENCE Name Purpose NHS Lanarkshire Information Governance Committee To provide direction of and oversee the development of NHS Lanarkshire Information
Case study: Pennine MSK Partnership
Case study: Pennine MSK Partnership Dr Alan Nye is a GP in Oldham, GPSI in Rheumatology, Director of Pennine MSK Partnership, Associate Medical Director of NHS Direct and Associate Medical Director of
Date of birth Gender NHS number (if known) Town/Country of birth. Home Telephone no. Work Telephone no.
ADULT - FEB 15 Office use only Staff initials Date ID seen Welcome to Wokingham Medical Centre Thank you for completing this registration form. When registering in person at the surgery please supply two
Coventry and Warwickshire Repatriation Programme
NHS Arden Commissioning Support Unit Coventry and Warwickshire Repatriation Programme Large-scale service redesign and innovation to benefit patients Arden Commissioning Support Unit worked with Coventry
Standards of proficiency. Operating department practitioners
Standards of proficiency Operating department practitioners Contents Foreword 1 Introduction 3 Standards of proficiency 7 Foreword We are pleased to present the Health and Care Professions Council s standards
ELECTRONIC MEDICAL RECORDS (EMR)
ELECTRONIC MEDICAL RECORDS (EMR) SAUDI BOARD FOR COMMUNITY MEDICINE FIRST PART - FIRST SEMESTER (FALL 2010) COURSE SBCM 002: MEDICAL INFORMATICS Osama Alswailem MD MA Medical Record function 1. It s a
Executive Summary and Recommendations: National Audit of Learning Disabilities Feasibility Study
Executive Summary and Recommendations: National Audit of Learning Disabilities Feasibility Study Contents page Executive Summary 1 Rationale and potential impact of a future audit 2 Recommendations Standards
National Clinical Programme in Surgery (NCPS) Care Pathway for the Management of Day Case Laparoscopic Cholecystectomy
National Clinical Programme in Surgery (NCPS) Care Pathway for the Management of Day Case Consultant Surgeon DRAFT VERSION 0.5 090415 Table of Contents 1.0 Purpose... 3 2.0 Scope... 3 3.0 Responsibility...
The Administrator s Guide to the Quality Strategy & Quality Improvement. Version 1 - December 2011
The Administrator s Guide to the Quality Strategy & Quality Improvement Version 1 - December 2011 Contents NHS Education for Scotland 2011. You can copy or reproduce the information in this document for
Level 8 - Job description for an advanced nurse practitioner in general practice
Level 8 - Job description for an advanced nurse practitioner in general practice Title: Advanced nurse practitioner in general practice Agenda for Change (AfC) banding: 8 Hours of duty: Responsible to:
The CCG Assurance Framework: 2014/15 Operational Guidance. Delivery Dashboard Technical Appendix DRAFT
The CCG Assurance Framework: 2014/15 Operational Guidance Delivery Dashboard Technical Appendix DRAFT 1 NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing
Snapshot. Co-creating Health. Building new relationships between people with long-term conditions and a supportive health service
Snapshot Co-creating Health Building new relationships between people with long-term conditions and a supportive health service Identify Innovate Demonstrate Encourage What are we doing? We know that people
Integrated drug treatment system Treatment plan 2009/10. Part 1: Strategic summary, needs assessment and key priorities
Establishment: HMP Belmarsh Drugs partnership: Greenwich Primary Care Trust: Greenwich Integrated drug treatment system Treatment plan 2009/10 Part 1: Strategic summary, needs assessment and key priorities
SCR Expert Advisory Committee
SCR Expert Advisory Committee Terms of Reference Judith Brodie, Chair August 2015 1 Copyright 2015, Health and Social Care Information Centre. Contents Contents 2 1. Background and Strategic Justification
DRAFT. Report to Governors on the Quality Report 2015/16. Royal United Hospitals Bath NHS Foundation Trust] Year ended 31 March 2016 16 May 2016
![DRAFT. Report to Governors on the Quality Report 2015/16. Royal United Hospitals Bath NHS Foundation Trust] Year ended 31 March 2016 16 May 2016](/thumbs/39/18643345.jpg "DRAFT. Report to Governors on the Quality Report 2015/16. Royal United Hospitals Bath NHS Foundation Trust] Year ended 31 March 2016 16 May 2016")
Report to Governors on the Quality Report 2015/16 This version of the report is a draft. Its contents and subject matter remain under review and its contents may change and be expanded as part of the finalisation
Electronic Prescriptions, Dashboards and MyHealth @ University Hospital Birmingham
Electronic Prescriptions, Dashboards and MyHealth @ University Hospital Birmingham Thursday 25 th July 2013 Digital Health: design: develop: deploy: evaluate Electronic Prescribing & Medication Administration
Appendix 3 INDIVIDUAL PATIENT DRUG TREATMENT. POLICY AND PROCESS FOR DECISION MAKING September 2007
Appendix 3 INDIVIDUAL PATIENT DRUG TREATMENT POLICY AND PROCESS FOR DECISION MAKING September 2007 Approved by Board: 6 th September 2007 Date Implemented: 1 st October 2007 Review Date: September 2008
6. Risk management plans for high risk activities and special events
6. Risk management plans for high risk activities and special events What is a high risk activity or special event? The answer to this question will be different for every organisation. A high risk activity
Risk Assessment of Pediatric Emergency Transfers
Risk Assessment of Pediatric Emergency Transfers Toolkit: AHRQ P20 HS017125 For further questions, please contact: Jane Holl, MD, MPH (j holl@northwestern.edu) Table of Contents Pages FMEA Prep Checklist
Intro Who should read this document 2 Key Messages 2 Background 2
Classification: Policy Lead Author: Nathan Griffiths, Consultant Nurse Paediatric Emergency Medicine Additional author(s): N/A Authors Division: Salford Healthcare Unique ID: DDCPan04(14) Issue number:
webgp: the virtual general practice
webgp: the virtual general practice 1 Executive summary Over the course of 6 months, the Hurley Group piloted a suite of online patient services to 20 London GP practices (including 5 non-hurley Group
Future hospital: Caring for medical patients. Extract: Recommendations
Future hospital: Caring for medical patients Extract: Recommendations Future hospital: caring for medical patients Achieving the future hospital vision 50 recommendations The recommendations from Future
How To Write A Nursing Home Self Assessment Survey On Patient Transitions And Family Caregivers
How Are We Doing? A Nursing Home Self Assessment Survey on Patient Transitions and Family Caregivers Well-planned and managed transitions are essential for high quality care and patient safety. Transitions
How Good is Our Council?
A guide to evaluating Council Services using quality indicators Securing the future... l Improving services l Enhancing quality of life l Making the best use of public resources Foreword Perth & Kinross
Improving the Rehabilitation and Recovery Service Model in Leeds
Improving the Rehabilitation and Recovery Service Model in Leeds Presenters: Emma Brown (Care Coordinator) James Byrne (Recovery Worker Leeds Mind) Nigel Whelan (Care Coordinator) Introduction Provide
MENTAL HEALTH ACT - SECTION 5(2)
Psychiatry > Scenario 11 MENTAL HEALTH ACT - SECTION 5(2) MODULE: MHA ASSESSMENT FOR SECTION 5(2) TARGET: PSYCHIATRY TRAINEES ST4-6 BACKGROUND: Trainees are often asked to assess voluntary patients who
Learning Disabilities Nursing: Field Specific Competencies
Learning Disabilities Nursing: Field Specific Competencies Page 7 Learning Disabilities Nursing: Field Specific Competencies Competency (Learning disabilities) and application Domain and ESC Suitable items
How Are We Doing? A Home Health Agency Self Assessment Survey on Patient Transitions and Family Caregivers
How Are We Doing? A on Well-planned and managed transitions are essential for high quality care and patient safety. Transitions occur when patients are admitted and discharged, when they move from one
Risk Management Strategy
Risk Management Strategy A Summary for Patients & Visitors This leaflet has been designed to provide information on the Trust s Risk Management Strategy and how we involve patients and the public in reducing
The SAOR Model for Screening and Initial Assessment
The SAOR Model for Screening and Initial Assessment The key components of the SAOR model are outlined below: Support Ask & Assess Offer Assistance Refer The support aspect of the intervention is guided
The Recovery Pathway Service forms a key component of the Sunderland Integrated Substance Misuse Service, as illustrated below:
SERVICE SPECIFICATION LOT 1 RECOVERY PATHWAY 1.0 SERVICE MODEL The Recovery Pathway Service forms a key component of the Sunderland Integrated Substance Misuse Service, as illustrated below: Recovery Outcomes
A Route Map to the 2020 Vision for Health and Social Care
A Route Map to the 2020 Vision for Health and Social Care 02 A Route Map to the 2020 Vision for Health and Social Care Introduction This paper sets out a new and accelerated focus on a number of priority
JOB TITLE: Data Quality/IT Manager
JOB DESCRIPTION JOB TITLE: Data Quality/IT Manager RESPONSIBLE TO: PRACTICE MANAGER PARTNERS SALARY: Starting From 25000 HOURS: 35 Hours The post-holder will need to become familiar with all functions
Code of Practice for Records Management NHSLA Risk Management Standards Contributes to Care Quality Commission: Outcome 4
Cardiac Nurse Practitioner Clinical Operational Policy Policy Register No: 09143 Public Developed in response to: Information Governance Toolkit Code of Practice for Records Management NHSLA Risk Management
Criteria Led Discharge
Criteria Led Discharge Everything you need to know, but may never have asked about criteria led discharge from hospital Liz Lees Consultant Nurse & Clinical Academic Doctoral Research Fellow The University
Changing health and care in West Cheshire The West Cheshire Way
Changing health and care in West Cheshire The West Cheshire Way Why does the NHS need to change? The NHS is a hugely important service to patients and is highly regarded by the public. It does however
Ambulance Services Commissioning Update
Joint Health Overview and Scrutiny Committee Great Western Ambulance Service 29 February 2008 Ambulance Services Commissioning Update 1. Purpose To update the Joint Health Overview and Scrutiny Committee
Review of compliance. Great North Air Ambulance Service Great North Air Ambulance Service. North East. Region:
Review of compliance Great North Air Ambulance Service Great North Air Ambulance Service Region: Location address: Type of service: North East The Imperial Centre Grange Road Darlington Co Durham DL1 5NQ
Making the components of inpatient care fit
Making the components of inpatient care fit Named nurse roles and responsibillities booklet RDaSH Adult Mental Health Services Contents 1 Introduction 3 2 Admission 3 3 Risk Assessment / Risk Management
Online Supplement to Clinical Peer Review Programs Impact on Quality and Safety in U.S. Hospitals, by Marc T. Edwards, MD
Online Supplement to Clinical Peer Review Programs Impact on Quality and Safety in U.S. Hospitals, by Marc T. Edwards, MD Journal of Healthcare Management 58(5), September/October 2013 Tabulated Survey
NSQHS Standard 1 Governance
NSQHS Standard 1 Governance Definitions sheet Governance Audit Tools Definitions Contents 1. Open Disclosure Program Page 1 2. ACUTE Clinical Record Audit Tools Page 2 -----------------------------------------------------------------------------------
A breath of fresh air Our vision for smoke-free hospital sites
A breath of fresh air Our vision for smoke-free hospital sites Have your say on our smoke-free vision 1 Our responsibility We are a large acute trust serving a population of 700,000 people, with over 6,000
Managing Clinical Trial Risk: It's a Tough Job, But One Person Has To Do It
Managing Clinical Trial Risk: It's a Tough Job, But One Person Has To Do It Michael Macri, Director, Strategic Services, inventiv Health Clinical Sherry Merrifield, Director, Clinical Monitoring, inventiv
3.4.4 Description of risk management plan Unofficial Translation Only the Thai version of the text is legally binding.
- 1 - Regulation of Department of Industrial Works Re: Criteria for hazard identification, risk assessment, and establishment of risk management plan B.E. 2543 (2000) ---------------------------- Pursuant
A developmental framework for pharmacists progressing to advanced levels of practice
ACLF Advanced to Consultant level Framework A developmental framework for pharmacists progressing to advanced levels of practice Version 2009(a) CoDEG www.codeg.org ADVANCED AND CONSULTANT LEVEL COMPETENCY
LKS Library and Knowledge Services
LKS Library and Knowledge Services Evidence into Action Project Background Inpatient psychiatric units offer assessment and treatment to acutely unwell individuals. Multidisciplinary teams work collaboratively
Wiltshire Wide Capacity Management and System Resilience 2015/16 Briefing for Wiltshire Health and Wellbeing Board November 2015
Wiltshire Wide Capacity Management and System Resilience 2015/16 Briefing for Wiltshire Health and Wellbeing Board November 2015 1.0 Overview The aim of the document is to provide an update on the approaches
How To Prevent Suicide
ZERO SUICIDE WORK PLAN TEMPLATE This template should be used by an implementation team after completing the Zero Suicide Organizational Self-Study. It is organized by element of the Zero Suicide model