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What is the challenge your project is going to address and how does it connect to your chosen theme?

Since the National Guidance on Learning from Deaths was published in March 2017 provider trusts have been working to implement the Learning from Deaths programme, reporting learning and actions taken from review and/or investigations in their quality accounts. While common insights and learning themes, such as ‘problems in recognising or escalating deteriorating patients’ can be found in quality accounts, the actions and improvements undertaken by trusts are wide-ranging. Evidence that individual provider trusts are accessibly sharing this learning outside of their own organisations other than in the quality account is lacking.

By sharing learning and successful actions undertaken by individual provider trusts, it will be possible for other healthcare providers (primary care, secondary care and ambulance trusts) to gain insights into the processes undertaken, enabling spread of improvements across organisations to improve future patient safety.

What does your project aim to achieve?

  • This project will collate and distil the insights from the 200+ provider trusts quality accounts and combine this information with input from members of the Q community about successful, evaluated ‘Learning from Deaths’ actions and improvements within their trusts.
  • This project will use a multimedia (an annual ‘Learning from Deaths: sharing insights across boundaries’ report, podcasts, video) approach to sharing this information to the Q community, the wider healthcare community and to the public.

How will the project be delivered?

I am currently undertaking an MD at University College London which involves an evaluation of the impact for the Learning from Deaths programme. As part of this evaluation I have reviewed, collated and analysed all 200+ provider trust quality accounts. I have gained a great deal of insights in improving patient safety from reviewing the quality accounts and feel that the useful information should be available in one place to other clinicians and to the public.

Where I have found significant positive actions from learning in the trust quality accounts I will approach the trust’s patient safety team or equivalent for further details. This information will form the written/audio and video reports.

As part of my research I have formed a public and relatives steering group who are involved in the planning, design and analysis of this study.

By including evaluated actions undertaken by provider trusts we will reduce the risk of promoting actions with low or no impact on patient safety.

What and how is your project going to share learning throughout?

Sharing learning is the overall aim of this project. Podcasts, video casts and the annual written report will be made available to Q community members and the wider system.

Podcasts and videos will be released to the public as they are made.

A regular blog will be written by the team on the Q community website on a bimonthly basis to share the development of the project as well as valuable learning gained from provider trusts Learning from Deaths programmes.

How you can contribute

  • Members of NHS staff to share actions and improvements from their provider trusts that have come out of the Learning from Deaths programme which have been evaluated for impact and have had a positive impact on future patient safety.
  • Members of the public who as a relative or carer of a person who has died while under the care of the NHS have had either positive or negative experiences and insights to add to this project.
  • Experience of either making and or producing podcasts and/or video casts

Plan timeline

13 Nov 2019 Winners announced
29 Nov 2019 Extended public and relatives steering group meeting
2 Dec 2019 Collect detailed learning/evaluation from trusts (4-6 mths)
6 Jan 2020 Write blog with update and learning
10 Feb 2020 Produce first podcast
27 Feb 2020 Extended public and relatives steering group meeting
9 Mar 2020 Write blog with update and learning
13 Apr 2020 Produce second podcast
11 May 2020 Write blog with update and learning
15 Jun 2020 Complete detailed learning/evaluation from trusts (4-6 mths)
18 Jun 2020 Extended public and relatives steering group meeting
13 Jul 2020 Write blog with update and learning
20 Jul 2020 Produce videocast
7 Sep 2020 Produce podcast/videocast
24 Sep 2020 Extended public and relatives steering group meeting
28 Sep 2020 Write blog with update and learning
5 Oct 2020 Written report completed and published
7 Oct 2020 Report launch event
3 Nov 2020 Final blog with update and learning

Comments

  1. If any members of the public who are Q members would like to join the team undertaking this project we would really appreciate your input. Please message me if you would like any further information.

  2. This is a great idea, it is universally acknowledged that adoption and spread is a challenge in the NHS. By focusing on success stories of evaluated actions   from the learning from deaths programme, this idea will enable spread in a targeted, evidenced way. I particularly like that the tool will be public facing, open to patients and clinicians alike. This will continue to build a no blame culture, encourage frank dialogue and   incentivise meaningful engagement with, and follow up from, the LfD programme.

    1. Hi Shruti, thanks for your comment. I really hope that this project usefully builds on the work of the Learning from Deaths programme and that it will support meaningful engagement with both the public and relatives of patients who have died.

  3. The current process does not support the sharing of learning and improvements made from the information collected when undertaking mortality reviews. We know improvement work is underway at a local level but have no way to clearly identify or collect these examples to benefit others.  This initiative will help solve some of this problem.

    Its fantastic to see you partner with public and family representatives to help co-design and plan this work.

    1. Hi Kevin, thank you for your input. The public and relatives steering group are a key part of this project and will hopefully ensure it is meaningful and useful to both the public and healthcare professionals.

  4. Great example of co-design here with extensive triangulation of data from various sources. I feel there is a lack of shared learning around deaths/ mortality in the NHS and this work will help rectify this.

    Best wishes

    Nick

    1. Hi Nick, thank you very much for your comment. I hope the outputs from this project will make it easier for trusts to both share their learning and for trusts to see what actions other trusts have successfully undertaken.

       

  5. Many thanks Jo, I'll email you

  6. Hi Zoe. Great to see you are co-designing and working with public and relatives. There is some work being undertaken via the AHSNs/Patient Safety Collaboratives that might be of interest - 2 fellows currently scoping and collating this. I can put you in touch if you'd like to link with them. I'll DM my email address.

    Thanks Jo

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