Loughborough University postgraduate programme in healthcare governance – next intake November 2012

February 7, 2011

This well established and popular part-time postgraduate programme in healthcare governance, run by Loughborough University School of Business and economics, will take its next intake in November 2012.

The programme accepts anyone interested in healthcare governance and with suitable qualifications and/or experience to undertake postgraduate level study. It is not always a necessity to have a first degree.

Students can study for a postgraduate certificate, postgraduate diploma or Master of Science (MSc) degree in healthcare governance. The full MSc degree takes a minimum of 2 years by part-time study and includes modules on corporate governance in healthcare, clinical governance (including patient safety) and managing healthcare risk, together with a dissertation on any healthcare governance related topic.

For further information, click here.


NPSA publishes data on ‘Never Events’

October 17, 2010

The National Patient Safety Agency (NPSA) has published its first ever national report on Never Events.

Never Events are patient safety incidents that are preventable because: there is guidance that explains what the care or treatment should be; there is guidance to explain how risks and harm can be prevented; there has been adequate notice and support to put systems in place to prevent them from happening.

The NPSA definition of a Never Event is: A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.

Never Events are one of the indicators that can be used to demonstrate how safe an organisation is and its patient safety culture. Continued occurrence of Never Events can be considered an indicator of an organisation that has not put the right systems and processes in place to prevent them from happening.

A total of 111 Never Events were reported to the NRLS at the NPSA. In summary:

– The Never Events were spread throughout England, occurred throughout the year and across different trusts.

– Just over half were related to wrong site surgery (57).

– The second highest reported Never Event was related to misplaced naso or orogastric tubes (41).

– There were no reports of Never Events related to wrong route administration of chemotherapy, in-hospital maternal death from post-partum haemorrhage after elective caesarean section and inpatient suicide using non-collapsible rails.

– The remaining three Never Events had fewer than 10 events reported over the year.

Download the NPSA’s Never Events Annual report 2009/10 here.


Guidelines for informing the media after an adverse event

August 31, 2010

The Canadian Patient Safety Institute has published guidelines for informing the media after an adverse event. Cursory inspection of the guidelines by Healthcare Governance Review suggests that the guidelines are good and entirely applicable to the UK.

Download the Guidelines for informing the media after an adverse event here.

ACKNOWLEDGMENT – Thanks to Datix Ltd. for bringing this to our attention through their Twitter site www.twitter.com/datixltd


NHS Appointments Commission and National Patient Safety Agency abolished in Arms Length Body cull

July 27, 2010

Bureaucracy will be cut and the functions of several organisations will be streamlined, following a review of arm’s length bodies (ALBs), published by Health Secretary Andrew Lansley yesterday. In total, the changes outlined in yesterday’s report will reduce the number of health ALBs from eighteen to between eight and ten; they are expected to deliver savings of over £180m by 2014/15.

In line with the wider reforms set out in the White Paper, Equity and Excellence: Liberating the NHS, the Department of Health’s ALB sector will be transformed to cut cost and remove duplication and burdens on the NHS.

The review has assessed whether the work of each of the Department of Health’s 18 Arm’s Length Bodies’ remains essential nationally. It also looked at whether work is being duplicated or could be better carried out by a different body.
Subject to Parliamentary approval, organisations which are no longer needed will be removed from the sector, with essential work moved to other bodies. This process will increase the ability of the organisations to do their important work in the most efficient way. It is also part of the cross-Government strategy to increase accountability and transparency, and to reduce the number and cost of quangos.

Of particular note to those interested in ‘healthcare governance’ is the abolishing of the NHS Appointments Commission and the National Patient Safety Agency.

The NHS Appointments Commission is responsible for handling the appointment of chairs and non-executive directors (NEDs) to the boards of Strategic Health Authorities (SHAs), Primary Care Trusts (PCTs) and NHS trusts. Given that SHAs and PCTs are going, and all NHS trusts will become NHS foundation trusts, and therefore able to appoint their own chairs and NEDs, there will be little role for the NHS Appointments Commission. Hence its demise, with any outstanding work being transferred to the Department of Health.

The National Patient Safety Agency (NPSA) has, sadly, never met expectations originally set out for it in the Department of Health document Building a Safer NHS for Patients. From it’s establishment in 2001 it has suffered from poor CEO and board/chair leadership together with ineffective oversight from the Department of Health. The NPSA was castigated by the Public Accounts Committee (PAC) in 2006 for providing poor value for money.

For further information on which ALBs are being kept and which are being abolished, click here.


FT seeks ‘Head of Patient and Healthcare Governance’ – Band 8d

April 11, 2010

Sheffield Teaching Hospitals NHS foundation trust is looking for a ‘Head of Patient and Healthcare Governance’ (band 8d, accountable to the medical director). The right person will have an “Excellent working knowledge of clinical governance, process redesign, risk management, safety systems, statistical information analysis complaints and claims” and a “Proven ability to think laterally at a strategic level.”

The job purpose is “To provide operational leadership for the Department of Patient and Healthcare Governance within the Medical Director’s office and be responsible for Healthcare Standards, Corporate Governance and Risk Management through the Directorate leads. The post holder has an expert role in delivering the Trust’s Healthcare Standards programme.”

“The Department has been created to provide a Trust-wide focus for patient and healthcare governance and ensure that governance issues are managed through the “eyes of the patients” irrespective of the original source of the governance issue.”

The closing date for applications is 18 April 2010.

For further information, click here.


Stronger and more accountable Foundation Trusts needed to avoid “Staffordshire 2”

March 3, 2010

The MAC Partnership, specialists in public involvement, have produced an excellent blog article on the recently published Francis inquiry report on Mid Staffs foundation trust.

According to MAC “The Francis enquiry report  is not strong enough on improving Foundation Trust governance. It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors.   A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise -  but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to.”

“Most worrying of all” says MAC “is the question “where was the voice of professional nursing as the patients’ champion?”  The Trust’s diverse nursing team are the most numerous group of employees and always will be. They are  everywhere and they see everything.  Had nurses taken a united stand and made their collective voice heard, the care failings of the Trust would have come to light much earlier. Where were the letters to MPs that the hundreds of nurses working in this hospital should have written?  Where were the local nursing clinical leaders? Where were the nursing trade unions and professional bodies?”

Commenting on the MAC blog article the well known commentator on NHS management issues, Roy Lilley, says “Nothing matters but an answer to the question – where were the nurses? They are front-line hands-on and ubiquitous. They MUST have known what was going on. They could not have been blind to events. Why they did not speak out is the only question – the answer to which will guide us in trying to make sure this ‘plane-crash’ of deaths does not happen again.”

Read the full MAC blog article here.


Report on NHS failure to implement patient safety alerts

February 23, 2010

The Charity Action Against Medical Accidents (AvMA)has published a report on the NHS in England’s failure to implement patient safety alerts.

Titled Adding insult to injury – NHS failure to implement patient safety alerts, the report is based on a Freedom of Information request AvMA made to the Department of Health.

When the National Patient Safety Agency (NPSA) issues an alert, NHS bodies have to report to the Central Alerting Service (CAS) when the recommended actions have been completed. Compliance with implementing the alerts within a given deadline is one of the "core standards" in the Standards for Better Health, which all NHS trusts in England are supposed to meet.

The research carried out by AvMA revealed that there is no system in place for monitoring compliance.

Download the report Adding insult to injury – NHS failure to implement patient safety alerts here.