Creating a strong learning culture for safety and quality
Do you want to know more about human factors and how we can use this understanding to improve patient safety? Do you want to improve the effectiveness of your governance and M&M meetings? Then come and join us for a day of learning about how to create a strong learning culture for safety and quality. The Patient Safety Incident Response Framework sets a new direction in how the NHS responds to patient safety incidents, focusing on effective learning and improvement, compassionate engagement of those involved, and embedding a strong patient safety culture. Morbidity and mortality and governance meetings are a key place for teams to share and learn about patient safety risks and incidents. To be really effective these meetings need to create a safe space for learning, be multiprofessional, have a learning focus with clear meeting framework, link into wider hospital governance, and most importantly keep the patient at the centre of this learning. Come and join us for a day of human factors and systems thinking education and an exploration of how to create strong learning environments for safety and quality. These sessions will include real examples of learning from adverse events in ophthalmology. The aim is to introduce delegates to human factors and the importance of applying these to patient safety learning, and to think about how to create strong learning environments for their governance and M&M meetings From this day they will: 1. Understand how systems thinking takes the focus away from the individual involved to understanding what happened and why it made sense at the time 2. Understand how we take learning from investigations to develop strong safety themes and how this can inform quality improvement work 3. Feel inspired to work within their organisations to improve the quality of learning within the M&M/governance meetings, including how to create psychological safety, use an appreciative approach and learning from safety II. This event has been sponsored by Roche by the purchase of stand space only, they have had no influence on this agenda
09:30 – 10.00 Introductions
10.00 – 13.00 Introduction to systems thinking and human factors
- systems thinking
- leadership and performance
- tools for improving safety (how these are used in investigations and for safety II)
- case to run through the day (either never event or vision loss from gas in eye)
Ben Tipney, Christina Rennie
13.00 – 13.45 Lunch
13.45 – 14.45 PSIRF – what is it, what happens in investigations, and how does this apply to ophthalmology
- Background on PSIRF
- Just and learning culture
- Applying tools in investigations
C Rennie/ Clare Cox
14.45 – 15.30 Creating strong learning environments, How to address uncivil behaviour
Ben Tipney, Christina Rennie
15.30 – 15.50 Tea break
15.50 – 16.10 What is the role of M&M and governance meetings?
What should we consider within these meetings?
Eoin O’Sullivan
16.10 – 16.30 Use of appreciative inquiry in the M&M
Radhika Krishnan
16.30 – 16.45 How to keep the patient central to learning in M&M meetings
Patient partner
16.45 – 17.00 Discussion and next steps
Christina Rennie