Goodbye 2017, hello 2018!

Drawing on lessons from our Patient Safety team’s recent away day, Nathalie Delaney shares a few creative and collaborative ideas to review what you’ve achieved as a team in the past year and how this might inform your plans for the coming year.

At the end of the year, it can be a good time to reflect on the achievements and learning of the past year and make intentional plans for a successful year ahead.

The West of England AHSN’s Patient Safety team met at the end of 2017 to do this together, and I thought I’d share our process here as you may want to reflect on this yourself or with your own team.

Goodbye 2017

As an icebreaker, we looked at the strengths of our team using the 16 personality types. Who’s in your team? What are your strengths? Then we looked back to celebrate the past year and asked ourselves:

  • What were our successes and achievements in the past 12 months?
  • What have we learned about ourselves and our members this year?
  • What were our biggest lessons this year?
  • Was there anything that surprised us?

If you are doing this as an individual, you may want to start by reviewing your calendar for the past year to identify key milestones and achievements. Alternatively you could create a shared timeline as a team. The Sign Up to Safety Kitchen Table Scribble Sheet has some other prompts that may help you do a freeform download of what’s on your mind.

Based on this we made a list of: what might we change or maintain in our work in 2018?

Looking ahead

We then had a presentation from our Managing Director, Deborah Evans, and Chief Operating Officer, Tasha Swinscoe, on the ‘big picture’ for the year ahead, both nationally and locally. From these, we identified what opportunities and challenges might arise in the year ahead?

Each member of the team was asked to nominate their theme song before the workshop. We held a short quiz to try to guess which song belongs to each team member, based on 20-second snippets from Spotify. As a team, we were surprisingly bad at this and it was a good way to find out something new about colleagues we work with. In case you’re interested, mine was ELO’s Mr Blue Sky.

Hello 2018!

The afternoon was spent creating a shared vision for 2018. We split this into aspects about how we, the team worked, and also our projects.

For our team we asked:

  • What should we stop this year?
  • What should we continue this year?
  • What should we start this year?

You can download a template to use with your team or consider the questions individually.

After a quick cake break, we discussed our projects and objectives, using the MoSCoW framework to identify our key aspirations and the impact we wanted to see:

  • Must do
  • Should do
  • Could do
  • Won’t do.

Our next steps are to identify what results we want to see and break these down into our large goals and smaller steps as driver diagrams using Quality Improvement methodology. As a team, we are moving to using Verto to manage our programme in the New Year. If you prefer paper to digital, you can print out our handy calendar for 2018 and add in your own goals and actions.

Over to you…

How can we in the West of England AHSN help you reach your goals in 2018? There are plenty of opportunities for support whatever your aspirations.

If your goal is to learn more about Quality Improvement, why not sign up to study the Quality Improvement in Healthcare MOOC starting in February 2018. This is a free six week course delivered online. You can also sign up for a free account for LifeQI which is a web-based platform designed to assist frontline staff running Quality and Safety improvement. The LifeQI system has recently been majorly upgraded and is free to access for West of England AHSN members.

Opportunities to join the Q community, an initiative connecting people with improvement expertise across the UK will re-open in 2018. Register your interest to be notified when applications are open.

If you are working in primary care, recruitment will open soon for Cohort Three of our successful primary care collaborative. Find out more and register your interest.

If your goal is to share learning from an innovative, measurable solution to a patient safety issue then why not enter the National Patient Safety and Quality Improvement Poster competition. Enter online by 16 March 2018. Short-listed entries will be invited to present a poster at the Bristol Patient Safety Conference on 16 May 2018.

If you are working in business check out our business support video which includes an introduction to our work with businesses and innovators and sign up for our newsletters including our funding finder which provides regular up-to-date funding opportunities for health innovators. This includes opportunities from Innovate UK, Department of Business, Innovation & Skills, Horizon 2020, The National Institute for Health Research and NHS England.

If you want to meet and share ideas with others who share your passion about improving and innovating healthcare, then you need to sign up for hyvr, our new social network for citizens, innovators, healthcare professionals – and well anyone really!

And if you would like to know more about evidence and evaluation or involving public contributors we have a range of toolkits to help you with practical steps in your day-to-day work. NIHR CLAHRC West provide a range of excellent training courses aimed at developing of skills in understanding, using and producing evidence for the health, public health and commissioning workforce, and patients and members of the public. You can also join our evaluation online network, a virtual peer to peer support group for all things evaluation related.

Evidence Works – an evidence-informed commissioning toolkit

Evaluation Works – a service evaluation toolkit.

Working Together – A toolkit for health professionals on how to involve the public

All the best wishes for a fantastic 2018!

“So what do you do?”

Nathalie Delaney, Improvement Lead in our Patient Safety team, shares her experiences of trying to explain what she does at work and, trickier still, what on earth is human factors…

“So, what do you do?” It’s the question we all get asked at parties.

Explaining Academic Health Science Networks is hard enough to people inside the NHS so I usually go with: “I work for the NHS,” as my opening line. Generally in my social circle there’s a one-in-four chance that I’m speaking to a fellow NHSian so we move onto “Where do you work?” and try and figure out people we both know.

“As a nurse?”

This is the usual follow-up question the other three times. Not sure why people’s minds jump to this conclusion – there are hundreds of job roles in the NHS, all working as part of the team. (If you want to take a test to find out what role you are suited for, Step into the NHS is great fun.) Anyway, I go on to explain that I work in projects in the patient safety team to get us on more familiar ground.

“Ok, what are you working on at the moment?”

So I explain I’ve been working with community providers in the region on training staff in human factors, and we’re now expanding this into GP practices and giving talks as part of the local maternity network too.

“Human factors? What’s that?”

Now human factors is a difficult topic to define, I usually start my sessions with a prompt question – “What makes your working day easier or harder?” and from there gather a variety of human factors that can affect us, ranging from physical things (like being hungry or tired), emotional things (stressful situations), the environment and design of our kit (frustration with computers is a really common issue people raise). But essentially my cocktail party definition is that “human factors are what mean we can’t be replaced by robots – but also mean that we are fallible and can make mistakes.” Sometimes I’ll give a few examples of human factors in practice.

“Surely that’s just common sense… the NHS needs people to train them in this?!”

Well, yes and no. A lot of human factors are common sense, but often our systems are designed for people who think like robots, rather than individuals with all our quirks and eccentricities.

For example, we all know what we need to do to keep healthy, but who can honestly say they do exercise for 30 minutes, drink eight glasses of water, eat five pieces of fruit and get enough sleep every day? (Maybe that is you, in which case, well done and keep going!) An awareness of human factors can help you notice where you might be at risk of making an error, or why the design of a task is frustrating you, and from there you can start to change it.

Recently the University Hospitals of Leicester launched an excellent series of videos was raising awareness of human factors in maternity care, “The Little Voice Inside”, and the original human factors video “Just a Routine Operation” still has much to teach us today.

“I don’t agree with this – if someone makes an error then they just need to be trained to do the right thing next time.”

That’s the old way of thinking, and the NHS has made a massive culture change over the last decade or so to turn this around into understanding that often it is the system around people that creates the conditions for error. The old way of thinking is about giving people remedial training, or even worse, putting signs on everything. Because, of course, that works…

As an aside, I love spotting signs that people have added onto things. Usually it is because of some previous behaviour that they want to change or poor design (as in the image at the top of this post). Signs are a really good way of finding where your system can be improved. I also like to spot “emotionally intelligent” signs which use an understanding of human factors to get a better result.

Another question I ask participants is, “What workarounds do you use at work to get things done?”

“Ok, so you just systemise everything and then it will be fine.”

Well, if we could do that, then we could replace everyone with robots. And as I’ve explained, frustration with technology is a big issue for people, so I don’t think it’s the best solution at the moment (although my colleagues in the Enterprise team may have a better idea about the future of technology – I’ve heard intriguing things about robot trousers being developed at the University of Bristol).

And actually the special thing about healthcare is the human connection – the compassion of staff caring for patients and each other. As Helen Bevan tweeted the other day, “Kindness is a superpower.” Human factors is about the people within the system too, and there are some brilliant movements in the NHS which are appreciating this, starting with Kate Granger’s #hellomynameis campaign, Sign Up To Safety, Civility Saves Lives, and the Circle of Care video.

Organisations are starting to move away from focusing on safety by avoiding harm to looking at excellent practice and where we can learn from what goes well too, for example Learning from Excellence, which our colleagues at the West Midlands AHSN helped to develop and which won an HSJ Patient Safety award in 2017 or the #MatExp movement (read this great blog post from Florence Wilcock).

As Suzette Woodward has said, it is about “noticing, understanding and learning from small moments of organisational life.”

“This all sounds very fluffy. Where’s the evidence?”

The two best sources are the Clinical Human Factors Group and the Chartered Institute of Ergonomics and Human Factors who have lots of case studies, resources and research evidence on their websites. It’s an academic subject; some people do PhD studies in human factors, and I don’t claim to be an academic expert – only as lived experience in being human and not a robot. Bleep bloop!

For more information on our human factors project, including a step-by-step guide to implementing in your own organisation, please visit


Image sources:

Things come together – a blog about my mum

Our Managing Director, Deborah Evans shares a candid insight into the final moments with her mother…

I’ve always been struck by the title of Chinua Achebe’s novel Things Fall Apart.

My mum died recently and in her case it was much more like Things Come Together.  Mum lived in a brilliant Brunel Care home called Saffron Gardens. The care home is an amazing place where people, like my mum, with dementia are cared for by first class staff.

Right up until January, Mum was able to visit us at home and enjoy our company. However, in more recent weeks she stopped eating. She would hold my hand and gaze up at me, or touch a colourful scarf I wore.

As her body became weaker, infections would start to impinge on her health. The staff and I would try to discover what was wrong with her. We used all our foibles to try to give her medication or take her pulse, temperature and, most challengingly, her blood pressure. She was highly resistant, not understanding the strange sensations. It’s one thing to let your daughter put a temperature probe in your ear, but another when she starts squeezing your arm! We had a secret weapon; a kind-hearted Polish team leader from the other unit would come over and give my mum a big hug and tell her that he loved her – and then quickly slip her liquid medicine down her throat.

This kind of deterioration isn’t rare, which is why colleagues in Kent Surrey and Sussex AHSN have a ‘test bed’, which aims to harness technology to address some of the most complex issues facing patients and the health service and help support people with dementia at home.

Our team in the West of England are also working on how to take a complete set of vital signs and calculate a National Early Warning Score (NEWS) from a person who doesn’t easily comply with examinations and tests. We are also looking at ‘wearable’ devices, which can take and relay vital signs from people in their own homes to staff working in rapid response teams, out of hour’s services, GP surgeries and ambulance services. This would greatly help the GP, paramedic, out-of-hours and nursing home staff to understand how best to help a person who can’t describe and can’t comply with care.

At a time when the NHS is so stretched, I was so proud that her GP practice at Lawrence Hill Health Centre, BrisDoc, and the South Western Ambulance Trust fielded skillful and clinically astute staff to support us in helping my mum die at home surrounded by her family.

The evening before she died, we sat around her bed and sang songs they would sing at ‘Singing for the Brain’ and Mum would lift her arm as she recognised them.

The love and care of women of every colour and nationality at Saffron Gardens care home, and of committed NHS professionals, meant that everything came together for my mum at the end of her life.

We can and we should adopt NEWS

Steven West, Chair of the West of England AHSN and Vice-Chancellor of the University of the West of England, explores how we can come together to create solutions that are sustainable, affordable and acceptable to all NHS stakeholders?

Our NHS and social care system are one of the country’s greatest assets. They are a fantastic gift that we give to each other and one that is envied across the globe.

However, the world is changing and the need for us to continue to review, reset and reinvent our health and social care system has never been greater. The demands we are placing on it are huge and it is beginning to fail.

Whilst this is, in part, a reflection of us all living longer and increased potential through new technologies and new drugs to diagnose and treat more and more conditions and diseases, we have to face up to the challenges that this brings. More people are accessing services and there is often greater demand than we are currently able to meet.

The creation of Academic Health Science Networks by NHS England back in 2013 was an attempt to create partnerships to help us to better collaborate, innovate, disseminate and spread learning and best practice. It was done at a critical time as much of the infrastructure that had formerly been in place to facilitate this kind of learning and sharing had been dismantled in successive reorganisations. The uncomfortable truth was that the system had become fragmented, staff and expertise had been lost, resulting in us facing significant financial, social and staffing challenges.

Recent media reports have highlighted yet again just how fragile our health and social care eco-system is. It is difficult to ignore the reports when so many dedicated staff who have committed their whole lives to the service are signalling we have a problem. For those of us in the system it is heart-breaking to watch. We are working hard yet no matter how hard we try we are not gaining enough ground.

This is made worse when you listen to reports that seek to apportion blame in one direction or another. We are one NHS. The problems we face are not just about the funding – it is also about the structures, the interfaces, the mechanisms for collaboration, and the relationship between the government, the professionals and importantly the citizens. We all have a stake in this and it is important that we seek a collective solution to create the integrated and joined-up services that are required 365 days a year, 24 hours a day.

So how can we help, how can we get beyond the current ‘blame, denial and shouting’ culture that is so evident at the moment? How do we come together to really create solutions that are sustainable, affordable and acceptable to all the stakeholders? One of the answers is to look at what currently works. Where have we cracked some of this and can learn and spread this knowledge?

The West of England Academic Health Science Network (AHSN) is one of 15 AHSNs across England that has been innovating and spreading best practice. Each AHSN will have examples of best practice and innovation that have improved services locally. Our challenge now is spreading these beyond our local geography and partnerships.

Recently I read with sadness and frustration reports of critically ill patients dying on trolleys in over-crowded Emergency Departments. Sadly this is not new. But there are things we can, and have done, that is reducing the risks and has even eliminated the problem in some of our hospitals.

I want to shout about the National Early Warning Score (NEWS), which the West of England AHSN is supporting all our healthcare providers in the region to adopt and spread.

I urge our political and clinical leaders to stop arguing and blaming each other, and to wake up and work with us to spread this approach to every Emergency Department, every Ambulance Service, and every Community and Primary Care setting across the country. No more ‘lost’ critically ill patients need to die on trolleys for lack of basic care.

In the Emergency Departments in the West of England we now use NEWS alongside an Emergency Department safety checklist which should be universally adopted too.

This means care can be monitored across every handover throughout the system. This will ensure time is not wasted, and instead we are saving lives.

We have saved lives! We have a sound evidence base, training materials, toolkits and are happy to share and spread. Let’s not waste time and see more patients die needlessly. We can and we should adopt this approach and show we can spread best practice quickly, efficiently and safely.

Yes we can, yes we should, yes we have!


Thinking outside the STP box

Our Patient and Public Involvement Manager, Hildegard Dumper looks back to our annual conference and the delights of playing Partneropoly…

If you happened to be walking through the corridors of the Swindon Hilton back in October, might have been surprised to find yourself in a room of shoeless health professionals screeching at each other in competitive excitement. You’d have seen the entire floor covered by a vast colourful quilt, which, when your eyes adjusted you would have recognised as rather like a Monopoly board.

This was the Partneropoly workshop at the West of England AHSN’s annual conference, which was given over to the theme of Sustainability and Transformation Partnerships (STPs) and brought together all those involved in delivering the three STPs in our area (Gloucestershire; Bristol, North Somerset & South Gloucestershire; and Bath, Swindon & Wiltshire).

The Partneropoly workshop was an interactive approach to getting the different stakeholders in the STPs to think ‘outside the box’ and see how they could share resources and expertise to make their plans more effective. Inspired by that well-known game Monopoly, Partneropoly was the brilliant brain child of Jan Cobbett at Bristol Health Partners, originally designed to encourage their Health Integration Teams to work more collaboratively across their ‘silos’.

In our workshops, we divided participants into teams based on their STP footprint. Each team could be made up of any combination of people from all kinds of organisations: commissioning, trusts, public contributors, industry, education, and voluntary sector. Just like in the traditional game, teams got to choose their playing piece – there was a boot, iron, top hat, car and so on – the only difference being these were huge! They threw the two massive dice and picked up their boot, iron, car or whatever and physically walked it around the board. Instead of landing on real estate like Mayfair, Oxford Street and the like, our teams landed on a possible partner organisation. This could be the AHSN, your local trust, clinical commission group, housing, police, education or just about any other potential partner. On picking a Chance card they’d be asked to think through how their STP might work with that specific stakeholder organisation on a specific area of work, such as equalities, patient safety or making better use of estates or workforce development.

I was fascinated to observe individuals being made to leap (in stockinged feet) well out of their comfort zone and interact with people they would not normally have reason to talk to. Then to top it all, they were actually having to listen to each other. I watched one group being dominated by two commissioners who were assuming they had to have all the answers. Eventually the penny dropped when they realised they had a valuable resource in their voluntary sector team member.

Afterwards, several people said it made them realise that there is a wide range of organisations out there that might play a meaningful role in delivering the vision of our STPs. Someone from a large trust told me they really had no idea there were so many organisations that could be working with. Those from industry said it had helped them understand what STPs are all about and how they could work more effectively with the health sector.

We are planning to use the game as a tool to get people from all disciplines interacting with each other. One of its next ‘outings’ will be with our Patient and Public Leads in the region to see how it can be of benefit to them.


Making every day a good NEWS day

Whenever I reflect on my role as a Patient Safety Improvement Lead here at the West of England AHSN I consider myself a very privileged person.

My day to day working life involves interacting with inspirational clinicians and patient safety leads from NHS and provider organisations across the region. Our little team encourages and supports them to work with us and collaborate across geographical and sector boundaries on programmes to improve healthcare safety for our population.

We ask busy people to be even busier and I am constantly humbled by the effort and goodwill we receive in response.

The success of our AHSN-led regional patient safety programmes relies heavily on organisations at the coal face doing the work for us. As improvement leads we don’t deliver patient safety improvements to patients; we only encourage and support them.

Last week I found myself in the unusual position of being the ‘deliverer’ – not directly to patients I hasten to add (with no clinical qualifications to speak of, that would clearly be bad for patient safety!) – but delivering presentations on two of our programmes that are attracting attention from health professionals across the country. The first of these is our fantastic cross-system work to roll out the National Early Warning Score (NEWS) across the West of England, and then there’s our support of the adoption and spread of the Emergency Department (ED) Safety Checklist; an elegantly simple but brilliantly effective patient safety intervention now in use in six out of seven of our EDs.


Anne Pullyblank is Clinical Director for Patient Safety at the West of England AHSN and Colorectal Surgeon at North Bristol NHS Trust. Anne and I were asked to talk at a national Deteriorating Patient conference and were joined by delegates from as far afield as Fyfe and the Channel Islands.

People were keen to hear about our ‘Share the NEWS’ concept, which sets out to improve the communication of NEWS at the interfaces of care, in particular the lessons we have learnt from our patient safety collaborative.

We looked back at our achievements since the launch of the West of England’s Deteriorating Patient programme in March 2015.


  • All six of our acute trusts have standardised to NEWS across all services, including ED, and this includes NEWS on patient transfers within hospital and in transfers between acute trusts.
  • The ambulance trust now has NEWS embedded into its electronic Patient Care Record, which automatically calculates NEWS from the vital signs monitoring equipment in the response vehicles and is handed over with the patient to the receiving department.
  • All our regional community service organisations are using NEWS to assess cohorts of patients and as a trigger to escalate to either primary or acute care.
  • Both our mental health trusts have improved the accuracy of NEWS calculation on their inpatient wards and are working collaboratively on non-contact physical observation policies and improved communication on transfer to acute trusts.
  • All GP out of hours providers are routinely using NEWS when referring patients to Urgent Care. With the support of the Clinical Commissioning Groups through direct seminars, contractual incentives (primary care offers and CQUINS), far more in-hours GPs are now using NEWS to assess the acuity of patients, specifically when referring patients to hospital.

This is excellent progress in such a short time and we were able to explore our strategies for engaging our cross-system stakeholders. We adopted a hybrid of the Institute for Healthcare Improvement (IHI) model for improvement and standard project management methodology, using six monthly regional learning set events to focus on specific cross-sector themes to support the use of NEWS within organisations and the communication of NEWS at the interfaces of care, combined with regular meetings of sub-regional cross-sector groups to drive this work forward.

Delegates seemed impressed by our achievements and were very interested in the resources we’ve developed (implementation toolkits, information sheets, videos and blog posts – all available on the West of England AHSN website) to support our work. It was great to feel that our region is pushing the envelope in collaborating across systems for common outcomes, and that on a national stage we are one of the pioneers in using NEWS across sectors and at the points of handover of care to ensure patients are seen at the right time, in the right place by the right clinician.

In the same week, I was invited to present our work on the adoption and spread of the ED Safety Checklist to representatives from EDs across the Wessex AHSN region, along with my colleague Emma Redfern who is Associate Director for Patient Safety at the West of England AHSN and ED Consultant at University Hospitals Bristol NHS Foundation Trust (UHB).

Emma Redfern photo
Emma Redfern, Associate Director for Patient Safety

Impressed with the West of England ED Collaborative’s approach, which regularly brings together representatives from all our regional EDs and the ambulance trust to share patient safety innovations and strategies, Wessex AHSN was keen to understand if there was an appetite within their region to adopt a similar model.

To demonstrate the impact of the West of England ED Collaborative, Emma and I presented our work on the adoption and spread of the UHB piloted ED Safety Checklist. We started with why the concept of the ED Safety Checklist had been developed in the first place: to address the issue of consistent crowding in ED leading to poor standards in basic clinical care and avoidable harm. We explained what the ED Safety Checklist is and how it had been developed through a review of baseline data to assess the performance of ED in the delivery of basic clinical care and patient comfort, a review of serious incidents and the employment of quality improvement methodology to rapidly test the use of a systematic hour-by-hour checklist when caring for patients in ED.

We then took delegates through how we rolled out the piloted concept to other EDs in the region, describing the toolkit we have developed which gives top tips on what to do and what not to do when introducing the ED Safety Checklist, and the benefits of the ED Collaborative as a network for sharing good practice. It was good to be able to show the impact of this work to date, which clearly shows an improving trend in the key performance indicators for standard clinical care such as NEWS and pain score at triage to ED, and timely instigation of appropriate investigations across the region (measured as an average across our implementation sites).

Again, the quality of our collaborative patient safety work was recognised, which is all about the sharing of good practice and the clear impact this is having on patient safety in a constantly pressured and stressed NHS department.

When reflecting on my experiences last week, I have to say it felt good to be a ‘deliverer’. I am honoured to have had the opportunity to represent our region and our fantastic stakeholders, and to promote our collaborative achievements. My hope is that we have inspired others to follow our lead; to breakdown geographical and sectoral boundaries within heath communities, to work together to achieve common aims and ultimately deliver safer standards of care to every patient.

I may not be a direct ‘deliverer’ of patient safety improvements, but I really am privileged to work with inspirational individuals and organisations that do.

Don’t let the carers of today become the patients of tomorrow

In his latest blog post Dr Hein Le Roux reflects on the danger of making assumptions and how to turn negative experiences into positive ones.

Carers play a crucial role in our society and it is important that they continue to be recognised and valued.

Practice colleagues at Minchinhampton Surgery have been working on a quality improvement (QI) project which builds on the great work many practices are already doing to better identify carers, raise their profile and signpost them to carer support organisations such as Carers Gloucestershire.

The project came about when a carer (John) approached our practice manager (Wendy) to tell us that he felt there were gaps in how our practice dealt with him, and by inference the other 200 carers on our register.

Wendy had the foresight to turn John’s negative experience into something very positive both for all the carers registered at our practice as well as our practice team, and John agreed to work with us as an equal partner (Patients as partners – Kings Fund) to improve on a quality improvement project.

As a practice, we realised that it can be easy to become defensive, assuming that patients always want a Rolls Royce. However, by listening, we realised that often all they want is a bicycle that works.

By listening to John, we were able to better understand his frustrations. Surprisingly, despite being a full time carer to his wife, he had never heard of Carers Gloucestershire. As a practice, we realised that it can be easy to become defensive, assuming that patients always want a Rolls Royce. However, by listening, we realised that often all they want is a bicycle that works. In other words, simple improvements can really make a big difference to people’s lives.

We contacted Carers Gloucestershire who shared their best practice guide for GP practices. They suggested that we approach Locking Hill Practice, which is seen as a beacon carer practice, having previously worked with Carers Gloucestershire and their PPG to develop a highly regarded Carers scheme.

Their practice manager (Jenny Valleley) was inspirational and happy to share their experience, learning and documents with us. In a world where there can be both implicit and explicit competition between us all, this collaborative and open approach was really refreshing and made a tangible difference to patient care. Instead of reinventing the wheel, we have then adapted their resources to inform our own local project that is bespoke to our situation.

The project has led to four specific actions being taken at Minchinhampton surgery, which other practices may find useful:

  • A member of staff has been appointed as Carer Administrative Lead.
  • In collaboration with John and the local PPG, the practice has developed a carers pack containing useful information, including details about Carers Gloucestershire. This is given to existing and new carers registering at the practice. We measure how many packs we give out to track our progress.
  • The practice has built a good relationship with the local PPG, gaining their support in raising the profile of carers in the local community, many of whom are socially isolated and lonely. Some of our PPG members are also carers, so this project resonates with them and we have certainly valued their interest and contribution.
  • A practice learning event was held – John and Carers Gloucestershire spoke about what it means to be a carer and what practical help practice teams could offer to support.  Like your teams, our practice team is already very empathetic to our patients and having this learning event has enabled us to combine their intrinsic kindness with new practical skills to help improve our carers wellbeing.

The links below may be of interest for improving your carers’ experiences. We are very open to your feedback and are always keen to improve what we do.

  1. Carers in Gloucestershire (Tim Poole, Chief Executive of Carers Gloucestershire)
  2. A Carer’s Perspective (John)
  3. A Carer’s Perspective (Gerald)
  4. Carer Project (Jenny Vallely, Practice Manager at Locking Hill)
  5. Supporting Carers (Kerry Renowden)
  6. King’s Fund paper on ‘Patients as Partners’
  7. Quality improvement resource

Patient Safety Collaboratives: heartening, ambitious and innovative

What do you get when you cross an urgent care system under tremendous pressure with a newly formed Patient Safety Collaborative looking for a flagship project? asks Managing Director Deborah Evans ahead of our session at Patient First on 22 November.

Against all expectations, we found that our proposition to embed the National Early Warning Score  (NEWS) across the entire urgent care system in the West of England has captured the imagination of clinicians in primary care, acute hospitals, mental health, community services and the ambulance service.

Our clinical director Anne Pullyblank showed a short film at one of our conferences and a few months later 130 people turned up at an engagement event.  The very next day, we started getting phone calls from clinical teams saying they were starting to use NEWS in areas that had never used it before.

We have been living with the consequences ever since. How do you get a good baseline when blessed with clinicians who Just Do It? How do you set a measurement strategy for whole system change? How do you attribute causes when so much is being changed right across the urgent care system all the time?

Our NEWS journey will be the subject of our session in the Best Practice Theatre at Patient First later this month, “The deteriorating patient – what about Bobby?” which will highlight the huge potential NEWS has when used across the entire system at every handover of care.

We’re now 18 months into this journey and have been reflecting a great deal about the role that Patient Safety Collaboratives can play.

We are one of 15 Academic Health Science Networks, comprising the AHSN Network which covers the whole geography of England. Each AHSN coordinates the Patient Safety Collaborative covering the same patch.

The AHSN model of a network of member organisations gives us a strong basis for engagement and grassroots support. We thrive where clinicians and their organisations commit their discretionary effort. We have a system wide perspective because we include CCGs, NHS trusts and other providers of health care, and can draw in statutory and non-statutory partners. We are independent and are seen as such; we are not part of the performance management system experienced by so many. We work in partnership with Sign Up to Safety, the Health Foundation, NHS Improvement and many, many others.

In a landscape of overlaps and gaps we are giving many clinicians an opportunity to work together, rather than in competition.

Patient Safety Collaboratives are now in their third year of operation and all over the country there are heartening, ambitious and innovative projects in play.

We share and learn together and have developed a ‘logic model’ to provide a conceptual framework. We build capability with our member organisations and have developed a software platform ( Seedata Life system) which is already the repository for hundreds of quality improvement (QI) projects – offering all the tools to run QI work and share the learning.

Already we have some ambitious and large scale programmes. The Emergency Laparotomy Collaborative is a shared project across 25 acute hospitals in the West of England, Kent, Surrey and Sussex, and Wessex – we are improving the quality of care together and using a shared national set of metrics to review and learn. The South of England Mental Health Collaborative embraces 16 mental health trusts and offers inspiring learning sets on an ‘all share, all learn’ basis. This is parity for mental health services beginning to move from words to commitment.

We will have a strong presence at this year’s Patient First. Visit our Patient Safety stand to find out more about us and our work. Talk to people from your area. Make connections. Attend our Best Practice Theatre. Feel the energy.

The West of England AHSN’s performance of “The deteriorating patient – what about Bobby?” will take place on Tuesday 22 November at 14:30 in the Best Practice Theatre at Patient First.

Download the full programme here and register for a fully-subsidised place at using the code AHSN46.

Just ask: “Could it be sepsis?”

Over recent years, the awareness, detection, and prevention of sepsis has increasingly moved up the NHS agenda, and in 2015/16 the management of sepsis was made part of the Commission for Quality and Innovation (CQUIN) goal.

More recently the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) released their  ‘Just Say Sepsis’ paper providing 21 recommendations for hospitals and primary care providers, and in light of this new information the National Institute of Health and Care Excellence (NICE) released new guidance on 14 July 2016, encouraging clinicians to consider sepsis early on with the same level of urgency as heart attacks.

Jeremy Hunt, Secretary of State for Health, subsequently met with UK Sepsis Trust Chief Executive, Dr Ron Daniels and mother Melissa Mead, whose son William died of sepsis in 2014, to announce that an awareness campaign would be launched to raise the profile of this devastating condition in the run up to World Sepsis Day on 13 September 2016.

We have been helping to raise awareness of sepsis across the West of England region through a series of sepsis masterclasses, as well as our Deteriorating Patient events.  In February 2016, we had the honor of Dr Ron Daniels speak at our Sepsis masterclass who was also joined by Susanna Morrish, a mother who lost her precious son Sam to sepsis in 2010.

Through these events we have helped lay a foundation for some great awareness work around sepsis by bringing together clinicians, patients, and healthcare staff from a wide variety of areas.  The topics covered have included the detection and management of sepsis across a range of settings including paediatrics, maternity, and community care, although we understand that more needs to be done.

Moving this forward locally is a regional sepsis group chaired by Dr Lesley Jordan at the Royal United Hospital in Bath, and on the 25 July 2016 they recently launched a 60 day campaign across our acute care providers to raise awareness of sepsis amongst staff and the general public.  The aim of this programme is to train over 3,000 staff in sepsis awareness and management across the West of England region using training sessions, training tools, presentations, and other promotional material. The idea is based upon the same model that the RUH used two years ago in which 700 members of staff were trained and made aware of sepsis, which led to the team’s awareness campaign being shortlisted at this year’s Patient Safety Care Awards.

Meanwhile, we at the West of England AHSN have been working to improve sepsis care for patients across the West of England through its ties to our Safer Care through Early Warning Scores project.

The new NICE guidelines encourage clinicians to consider using an early warning score to assess people with suspected sepsis in acute hospital settings, and encourage primary and community care workers in cases where sepsis is suspected to make a definitive decision as to whether a patient should be referred to hospital or make a definitive diagnosis.  The link between implementing the sepsis six and using the early warning score has, therefore, been something that we have been exploring over the past year, and is something that we will be exploring further in September.

For our Deteriorating Patient event on 15 September 2016 in Bristol, we will be once again looking at many of these topics, including;

  • a session on sepsis run by Dr Lesley Jordan and Dr Alison Tavare looking at what the new NICE guidelines mean to us
  • an in depth look at how the National Early Warning Score is being used in the community
  • and a look at how structured communication across various healthcare settings can improve patient care

If you have been fortunate enough to secure yourself a place at this popular event, we look forward to seeing you there, alternatively look out for the 60 day sepsis awareness campaign taking place across our acute care providers.

Otherwise, here is a round-up of all the recently published guidance on sepsis:


Updated 19 December 2016

Recent news articles on sepsis:

Patient Safety Collaboratives – delivering on a promise

Dr Rosie Benneyworth is AHSN Network Lead for Patient Safety Collaboratives. In this special guest blog post, she celebrates the achievements of the Collaboratives in their first two years.

It has been two years since Patient Safety Collaboratives were set up in response to the Berwick Report, A promise to learn – a commitment to act.

Professor Don Berwick wrote:

“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

The Patient Safety Collaboratives, the largest patient safety initiative in the history of the NHS, are run by England’s 15 Academic Health Science Networks and funded by NHS Improvement. They were the key recommendation in the Berwick Report to spread best practice and build skills and capabilities in patient safety and improvement science.

So what’s happened since then? Here are ten highlights of the work of Patient Safety Collaboratives, as showcased in their first collective report, Making care safer for all, launched at Patient Safety Congress last week.

  1. Mortality after emergency laparotomies (major stomach surgery) reduced by 42% over an eight-month period in 24 NHS acute trusts – led by Patient Safety Collaboratives Kent, Surrey, Sussex; West of England; and Wessex.
  2. A cluster of nine Patient Safety Collaboratives are working together to create a common process and outcome measurement for people with acute kidney injury. This will be reported by the UK Renal Registry and rolled out nationally to improve safety and quality of care.
  3. A 50 per cent increase in service users returning to mental health wards on time was achieved by Oxford Patient Safety Collaborative working with three NHS providers of mental health and community services, reducing the risk of self harm, self neglect and suicide when service users abscond from a mental health ward.
  4. Inpatient medication errors across six NHS trusts were reduced from 11 per cent to nine per cent, after Imperial College Health Partners Patient Safety Collaborative worked with ten organisations in North West London.
  5. Safety ‘huddles’ that led to a reduction of 60 per cent in falls by inpatients, as a result of Yorkshire and Humber Patient Safety Collaborative working with more than 66 frontline teams across 18 organisations, including two nursing homes and two GP teams. One ward moved from an average of one fall a week to repeatedly achieving no falls for more than 30 days.
  6. Twelve Patient Safety Collaboratives, led by the Innovation Agency in the North West Coast, are working with the National Board for Sepsis on earlier identification and treatment of people with sepsis and the deterioration that sometimes arises as a result of the condition.
  7. Six Patient Safety Collaboratives, led by East Midlands, are working together on safer discharge of patients and transfer of care.
  8. Ten Patient Safety Collaboratives have adopted a web-based platform which provides the tools needed for quality improvement projects, including sharing data and plotting results in run charts, developed by South West AHSN.
  9. The Collaboratives have created clusters around specific themes and health issues, to facilitate learning and adoption of innovation. The current priority areas include deterioration and sepsis; safer discharge; acute kidney injury; medicines optimisation; and mental health.
  10. Acknowledgement from Dr Mike Durkin, NHS National Director of Patient Safety, who said:“The Patient Safety Collaboratives have played a critical role in delivering changes in the culture of patient safety across the NHS. We must create conditions that make the best use of our resources, both human and financial. The Collaboratives are about doing the right thing first time and every time.”

The Patient Safety Collaborative programme was launched in 2014, and now falls under the responsibility of NHS Improvement. Each of the 15 Collaboratives is led by its local AHSN and works to tackle leading causes of avoidable harm, bringing together teams from across the local health economy to draw on talents from the NHS, academia and healthcare industries. The Collaboratives work to identify local safety priorities and develop solutions before testing and implementing them within local healthcare organisations.

The Collaboratives also work together nationally to share successful initiatives so they can be implemented in other parts of the country – accelerating improvement across all care settings from maternity care and nursing homes, to GP practices and acute hospitals.

Watch Rosie’s introduction to the launch of the first national PSC report, Making care safer for all, below on YouTube: