“The UK’s first national conference about evidencebased Improvement in Healthcare” Day 1—Monday 21st November 2016 Harrogate International Conference Centre, Yorkshire, UK 09.00 10.15 10.45 Registration & poster set up The science and art of improvement: shifting the balance from evangelism to evidence John Wright, Director Bradford Institute of Health Research & Clinical Director Improvement Academy 11.00 Breakout sessions (choose one session below) 12.15 A4 PRASE: Patient Reporting and Action for Safer Environment A1 ‘Changing behaviour one conversation at a time’ A2 QI Basics workshop A6 Patient Safety and Human Factors A3 Return on Investment and the cost effectiveness of improvement 12.15 12.30 - 14.15 – 14.45 14.45 – 15.15 15.15 15.45 - 17.00 A7 Developing, evaluating and improving healthcare quality improvement Comfort break Are we really improving the safety of our patients? The national picture Mike Durkin, Director of Patient Safety, NHS England 13.00 13.00 A5 Patient Engagement in Improvement and Patient Safety Lunch & poster viewing To the service no harm: assessing the quality of health care Nick Black, Chair, National Advisory Group for Clinical Audit and Enquiries & Professor of Health Service Research Why is it so difficult to stop making mistakes and harming patients? Henry Marsh, Neurosurgeon, Patient Safety Expert and author of ‘Do No Harm’ Refreshments & poster viewing Breakout sessions (choose one session below) B1 Lego workshop: how to involve people in authentic and meaningful co-production B4 How can I make patient safety huddle work for my area? B2 Innovative approaches to improvement B5 Measurement and Monitoring of safety: using the Vincent framework B3 Using data to drive improvement and improve care: the Falls and Fragility Fracture Audit Programme B6 Learning from hospital deaths: from case note review to improvement B7 Improvement Labs 17.00 – 17.30 The National Mortality Case Record Review Programme: From Mortality Review to Quality Improvement Dr Kevin Stewart, Clinical Director CEEU and Dr Andrew Gibson, Clinical Lead for the NMCRR Programme RCP The National Mortality Case Record Review Programme: The Official National Launch Hosted by the Royal College of Physicians Breakout Session A Day 1, Monday 21st November, 11.00 – 12.15 A1 Changing behaviour one conversation at a time A2 QI basics A3 Return on Investment, cost effectiveness of improvement A workshop to explore different methods to create This workshop is an opportunity to share examples of Improving the care of osteoarthritis in primary care: An ‘safe’ safety conversations methods, tools and techniques that engage multidiscipli- evaluation of a new practitioner role nary teams in Quality Improvement initiatives Andrew Walker (Innovation Fellow) Health Innovation Net- Dr John Bibby, Quality Training Advisor work (South London’s AHSN), St George’s, University of Lon- Suzette Woodwood, Director—Sign up to Safety campaign don & Kingston University et al A7.Developing, evaluating and improving healthcare quality improvement Building Quality Improvement capacity & capability This workshop will how Social science can contribute through an improvement movement in an Acute Hospital to developing, evaluating and improving healthcare quality improvement setting Andrew Seaton, Director of Safety, Gloucestershire Hospitals Explore the current state of the evidence base for healthcare improvement, Discuss the consequences for efforts to improve quality, And look at what we should about it NHS Foundation Trust UK Victoria Collins, Safety Improvement Practice Educator, Gloucestershire Hospitals NHS Foundation Trust UK Economics of implementation based quality improvement in healthcare for non-economists Professor Carl Thompson, Chair in Applied Health Research, School of Healthcare, University of Leeds Social Return On Investment (SROI): An approach to cost-benefit analysis for improvement in health and social care? Fay Sibley (Darzi Fellow), Health Innovation Network (South London’s AHSN) et al Graham Martin, Professor of Health Organization and Policy, SAPPHIRE Group, Department of Health Sciences, University of Leicester, Format: Workshops Format: Workshop and Case Study Format: Presentation sessions Breakout Session A Day 1, Monday 21st November, 11.00 – 12.15 A4 PRASE: Patient Reporting and Action for a Safer Environment A5 Patient Engagement in Improvement and Patient Safety A6 Patient Safety and Human Factors This workshop will present the development, testing and Making use of patient experience feedback data: per- Preventing dehydration by the early identification of pa- evaluation of the PRASE intervention (Patient Reporting spectives of ward based staff tients with low fluid intake: The Jug Round and Action for a Safe Environment) Rosemary Peacock, Senior Research Fellow, Bradford Institute for Emma Cullingworth (HCA), William Lea (Clinical Leadership Fellow), Janet We will describe the co-design of theory-based measure- Health Research, et al Meggitt (ACP), Elaine Wagg (HCA), Amanda Ward (Sister), York Teaching ment tools to capture the patient perspective of the safety Can Patients be the ‘smoke detectors’ for the NHS? of care Following this, we will present the results of a large What Patients tell us about safety within Yorkshire Hospital NHS Foundation Trust Using Behavioural Theory to improve Sepsis Improvement randomised controlled trial across 33 wards in three NHS and Humber NHS Trusts Caitriona Stapleton- Patient Safety Programme , RFL Foundation Trust et al trusts within the north of England Sally Moore, Patient Safety Research Nurse, Bradford Institute for How can I implement human factors into practice Finally, we will discuss the findings from the qualitative pro- Health Research, Temple Bank House, Bradford Royal Infirmary et al cess evaluation, including staff engagement with the intervention and challenges of making patient-centred service Enhancing safety in maternity care: using social media Trust) to tackle maternal obesity improvement Michaela Senek, PhD Researcher, Hora Soltani, Professor in Mater- Wayne Robson (Patient Safety Lead – Barnsley Hospital NHS Foundation nal and Infant Health, Madelynne Arden, Professor of Health Psychology, Tom Farrell Professor, Consultant Gynaecologist, David Jane O’Hara, Lecturer in Patient Safety and Improvement Science, Bradford Institute for Health Research/University of Leeds, UK Rogerson, Phd Sport Nutritionist Patient involvement in diagnosing cancer earlier in primary care: potential strategies and key components Dr Jane Heyhoe, Senior Research Fellow,, Bradford Institute for Health Research, et al Format: Workshop Format: Presentation sessions Format: Presentation Sessions Breakout Session B Day 1, Monday 21st November, 15.45-17.00 B1 Lego workshop: how to involve people in au- B2 Innovative approaches to improvement thentic and meaningful co-production B3 Using data to drive improvement and improve care: the Falls and Fragility Fracture Audit Co-production is a Zeitgiest theme within Healthcare innovation work from a policy level, to research and right onto frontline service improvement work Many different terms are associated with it; PPI, participation, co-design, cocreation Yet much of the activity that comes under this broad umbrella could probably be defined as tokenistic in the worst case scenarios and in the best and most well intentioned cases, not achieving its full potential The Airedale Vanguard project to enhance healthcare This workshop from the Royal Collage of Physicians will demon- in Care Homes using telemedicine: Early insights from strate a range of ways that data from a national clinical audit can a novel developmental evaluation framework be used to support quality improvement activity in healthcare, Ms Rose Dunlop, Vanguard Evaluation Lead, Airedale NHS Trust, Dr including We will use Lego and the Lego Serious Play Methodology to demonstrate creative, participatory ways of involving people in research and improvement work Through the ‘doing’ of a Lego Serious Play workshop you will experience the benefits of co-production conducted in this way You will also get to keep a small Lego kit! Who says work, learning and conferences aren’t fun? Using IHI Breakthrough Series Collaborative approach Eileen McDonach, Senior Researcher, on behalf of Yorkshire and Humber Academic Health Science Network et al to reduce in patient harm from falls Mrs Geetika Singh, Patient Safety Programme Manager, Royal Free London NHS Foundation Trust, An innovative approach to fracture prevention using a Mobile Bone Density Service Dr Joe Langley Engineering Design Research Fellow at Sheffield Hollick, RJ Health Services Research Unit et al Hallam University NIHR Knowledge Mobilisation Research Fellow, hosted by NIHR CLAHRC YH Daniel Wolstenholme Visiting Research Fellow at Sheffield Hallam University and Associate of Lab4Living NIHR CLAHRC YH Theme Manager for Translating Knowledge to Action Format: Workshop Improving the meal time experience for in- patients using dietetic students as meal volunteers Vee LeBrunn, Clinical Nurse Educator and Helen Christodoulides Head of Nursing, Acute Medicine CSU, Leeds Teaching Hospitals Trust Format: Presentation sessions Informing commissioning: instigating change in the commis- sioning of fracture liaison services utilising clinical champions and data driven decision tools for commissioners Making quality improvement easy: data from the national audit of inpatient falls driving QI in a secondary care setting Monitoring continuous improvement: using the National Hip Fracture Database Empowering the patient: what patients want from clinical audit? Chair: Dr Roz Stanley, CEEU operations director, Speakers: Chris Boulton Project Manager, Vivienne Burgon Project Coordinator RCP, Dr Shelagh O’Riordan Clinical Lead NAIF, Dr Kassim Javaid Clinical Lead FLS-DB, Naomi Vasilakis Project Manager NAIF and FLS DB, Royal College of Physicians, UK Format: Workshop Breakout Session B Day 1, Monday 21st November, 15.45-17.00 B4 How can I make patient safety huddle work for B5 Measurement and Monitoring of safety: using B6 Learning from hospital deaths: from case note remy area? the Vincent framework view to improvement This workshop will; introduce participants to the key components of Measurement and monitoring of Patient Safety in With the launch of a national mortality review programme, an patient safety huddles practice: Evaluation of a multi-site project opportunity for acute trusts to deliver improvements to front- Present examples of how to tailor the core compo- Ms Eleanor Chatburn, Research Psychologist, Risk and Safety Renents to bespoke harms in different areas of search Group, University of Oxford; healthcare Application of the safety measuring and monitoring Raise awareness of the innovative approaches taken thus far across Yorkshire Lynn Pearl – Project Manager for the Measurement and Monitoring of Safety (Y&H Improvement Fellow), Katie Eacret – Clinical Safety Share enablers and barriers to measurement of bespoke harms framework To empower teams to take this approach in their Lead for the Measurement and Monitoring of Safety Measuring & Monitoring Quality & Safety across the line care, this workshop will explore how to analyse case note reviews and turn data into usable information Kevin Stewart, Clinical Director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU) Andrew Gibson, Clinical Lead for National Mortality Case Record Review, Consultant Neurologist, Deputy Medical Director, Sheffield Teaching Hospitals Prof Allen Hutchinson Section of Public Health, School of Health and Related RFL Patient Safety Programme Research (ScHARR), University of Sheffield, Sheffield, UK Margaret Mary Devaney, Head of Patient Safety, Royal Free London Dr Michael McCooe Consultant Anaesthetist, Bradford teaching Hospitals, Chairs: Dr Anna Winfield (PSQM LTHT), Dr Victoria Corkhill (Clinical NHS FT, Hester Wain, Deputy Director Safety & Risk, RFL Foundation Associate Clinical Director, Improvement Academy Leadership Fellow LTHT) Trust own area Usha Appalsawmy, Renal Registrar & Leadership Fellow, AHSN Improve- Speaker: Dr Alison Cracknell, Consultant in Elderly care, Head of Pa- ment Academy tient Safety Format: Workshop Format: Presentation sessions Format: Workshop “The “TheUK’s UK’sfirst firstnational nationalconference conferenceabout about evidenceevidence-based basedImprovement ImprovementininHealthcare” Healthcare” Day2—Tuesday 2—Tuesday22nd 22ndNovember November2016 2016 Day HarrogateInternational InternationalConference ConferenceCentre, Centre, Harrogate Yorkshire,UK UK Yorkshire, 08.30 Registration & poster set up Chair : Richard Taunt, Director of the UK Improvement Alliance 09.00 Swatting Mosquitoes: The end of an era for safety in healthcare - Rebecca Lawton, Director of Yorkshire Quality and Safety Research Group & Professor of Health Psychology 09.30 09.30 Take Care Son…the story of my Dads dementia - Tony Husband, Award-Winning cartoonist for The Times, The Spectator & Private Eye 10.00 10.00 Poster viewing 11.00 Breakout sessions (choose one session below) 12.15 12.15 C1 Being positively deviant: how organisations and teams deliver patient safety? C4 Achieving Behaviour Change for Patient Safety C5 Improving Patient Flow: learning from across the UK C2 Innovative approaches to improvement C6 Patient Engagement in Improvement and Patient Safety C3 Human Factors workshop C7 Learning from Hospital Mortality: The Yorkshire & Humber Experience Lunch 13.00 Breakout sessions (choose one session below) D1 ‘The patient will see you now’ D4 Safer Surgery workshop - D2 Innovative approaches to improvement 14.00 D3 How can we support the workforce to improve patient safety? D5 Improving Patient Flow: combining improvement science and coaching skills to transform care pathways 14.00 Comfort break 14.15 – 14.45 Are hospitals less safe at weekends? Mohammed Mohammed, Professor of Healthcare Quality and Effectiveness, University of Bradford 14.45 Improving Improvement – Nick Barber, Consultant at The Health Foundation 15.15 15.15 - D6 Improvement in the time of austerity: necessity or nice to have? Questions and close Breakout Session C Day 2, Tuesday 22nd November, 11.00 – 12.15 C1 Being positively deviant: how organisa- C2 Innovative approaches to improvement C3 Applying Human Factors to practice What is positive deviance and how can you identify Improving implementation progress using Normalization it? Process Theory: Development and validation of the NoMAD survey tool Join us in this interactive workshop where we will explore how human factors affect the care we deliver to patients T.L Finch, Institute of Health and Society, Newcastle University, Newcas- Using a case study we will analyse the impact of tions and teams deliver patient safety? Hip and knee services in Yorkshire and Humber: What does positive deviance look like tle upon Tyne, United Kingdom et al Identifying and understanding positive deviance in elderly medical wards Spreading the learning: a discussion (all) Practice nurse led frailty assessment in primary care Dr Halina Clare1,1Doctors Lane Surgery, Hambleton Richmondshire & non technical skills on a well known scenario and collectively develop solutions to reduce the impact of these issues in future practice Whitby CCG, Sarah De Biase, Y&H AHSN Improvement Academy To determine if it would be safe and practical to transfer Rebecca Lawton, Director of Yorkshire Quality and Safety Research Group Lesley Dewhurst, Senior Research Fellow Yorkshire Quality and Safety Research Group routine prescribing tasks from ward doctors to pharmacists and technicians Debbie Clark, Senior Lecturer in Nursing Sheffield Hallam University William Chellam, Stan Dobrzanski, Bradford Royal Infirmary, UK Seamless Surgery – Spreading and Sustaining Best Practice Ruth Baxter, PhD Student Yorkshire Quality and Safety Research Group Luke Wheldon, Mr, Sheffield Teaching Hospital NHS Foundation Trust, UK Tim Sands, Mr, Sheffield Teaching Hospital NHS Foundation Trust, UK et al Format: Workshop Format: Presentation sessions Format: Workshop Breakout Session C Day 2, Tuesday 22nd November, 11.00 – 12.15 C4 Achieving Behaviour Change for Patient Safety C5 Improving Patient Flow: learning from across the UK C6 Patient Engagement in Improvement and Patient Safety Improving Patient Flow – Learning from Experience This workshop is a taster version of the Yorkshire and Dr Jacqueline Smithson, Medical Director for Medicine, Hull and East Healthcare professional’s attitudes towards involving Yorkshire Hospitals NHS Trust, Liz Watson, Project Manager, AHSN Humber Improvement Academy popular “ABC for patients and their relatives in detecting clinical deterioPatient Safety” Improvement Academy et al Improving the Delivery model for a Chemotherapy Service Providing an opportunity to learn from leading researchers in behaviour change Interactive learning Dr Delia Pudney Consultant Clinical Oncologist, ABM University Health Board, Wales and enhanced practice in improving patient safety C7 Learning from Hospital Mortality: The Yorkshire & Humber Experience Using Structured Judgment Case Note Review in CQC Dr Judith Dyson, Senior Lecturer Mental Health, Acting Head of Mortality alert analysis Department Psychological Health and Wellbeing, University of Hull Abigail Albutt*; University of Leeds et al What patients see that staff don’t? Exploring the experience of patients as observers within an experience based co-design project and discussion will lead to improved understanding through behaviour change ration in hospital Ms Liz Thorp (MSc, RGN), University of Leeds, Bradford Institute for Health Research, Funded by the Health Foundation , England Transformational Learning – enhancing practice in Patient-led patient safety teaching Naomi Quinton, Dr, Leeds Institute of Medical Education, University of Mr Paul Curley, Deputy Medical Director, Mrs Kirstie McEnhill SRN, Lead Nurse for Quality, Medical Director’s Office, Mid Yorkshire Hos- Leeds, Leeds, UK, et al pitals NHS Trust Learning from mortality review in LTHT; a large teaching hospital's experience Dr Anna Winfield, PSQM Leeds Teaching Hospital Trust Format: Workshop Format: Presentation sessions Format: Presentation sessions Breakout Session D Day 2, Tuesday 22nd November, 13.00 – 14.00 D1 ‘The patient will see you now’ D2 Innovative approaches to improvement D3 How can we support the workforce to improve patient safety? Reframing research rigour in quality improvement using To provide an opportunity for researchers, improvement specialists, clinical staff, managers and members of the public to ask a panel of patient representatives questions about Patient and Public Involvement (PPI) Developmental Evaluation: Learning from four complex intervention projects in multiple, acute hospital settings in England Dr Eileen McDonach, Honorary Research Fellow et al within the context of patient safety research and quali- The Design, Development and Implementation of the Medity improvement in the NHS To consider and discuss workforce wellbeing in healthcare To understand how and why staff wellbeing is linked to patient outcomes cation Safety Thermometer To generate solutions: How can we support the work- Paryaneh Rostami, Ms., Manchester Pharmacy School, University of force to improve patient safety? Manchester, Manchester Academic Health Sciences Centre Members of the Yorkshire Quality & Safety Patient Panel Bradford Institute for Health Research Dr Claire Marsh (PhD) Senior Research Fellow (Quality & Safety) Directorate, Bradford Institute for Health Research, Ms Liz Thorp (MSc, RGN) PhD Research Student/Research nurse University of Leeds, Bradford Institute for Health Research, Funded by the Health Foundation, England, (MAHSC), Oxford Road, Manchester, UK Improving Intravenous Fluid Prescribing and Fluid Management in adult inpatients Miss Kathryn Melling & Dr Judith Johnson (co-chairing), Bradford Institute for Health Research, UK Dr Melanie Cockroft, ST3 Anaesthetics and Intensive Care Medicine, Gloucestershire Hospitals NHS Trust, UK Exploring multi-disciplinary staff experiences and the effect of implementing patient safety huddles on medical wards Miss Sofia Arkhipkina, University of Leeds Format: Workshop Format: Presentation sessions Format: Workshop Breakout Session D Day 2, Tuesday 22nd November, 13.00 – 14.00 D4 years of the WHO safer surgery checklist: are theatres safer? D5 Improving Patient Flow: combining improvement science and coaching skills to transform care pathways D6 How we keep Improvement relevant in times of austerity This workshop is informed by the results from a study Exploring the complexities surrounding collaborative The NHS is in the middle of a financial crisis 85% of using behaviour change theory to explore the biggest pathway improvement work acute trusts are in deficit, and even the Department of barriers to theatre teams embracing the checklist Participants will have the opportunity to; Introducing participants to the emergent Improving Flow programme Explore the original evidence base for the checklist, Understand why never events still happen, Review the biggest barriers to effective implementation Alison Lovatt, Clinical Improvement Network Director, Im- Health is struggling to stay within its budget Against this backdrop, what role can improvement play? This workshop, led by the UK Improvement Alliance, will focus on the importance of improvement in a time of Sarah Davies, Flow Project Support Officer, Sheffield Teaching Hos- austerity This is an exciting opportunity for participants pitals NHS Foundation Trust, UK to co-create a new programme of work for the Alliance Nick Miller, Flow Programme Manager, Sheffield Teaching Hospitals on improvement and efficiency, agreeing priority areas NHS Foundation Trust, UK for how improvement can best support productivity Tom Downes, Clinical Lead for Quality Improvement and Consultant across the NHS Geriatrician, Sheffield Teaching Hospitals NHS Foundation Trust, UK provement Academy Richard Taunt, Director of UK Improvement Alliance and colleagues Susan Douglas, Consultant, Rotherham NHS Foundation Trust Format: Workshop Format: Workshop Format: Workshop ... Format: Workshops Format: Workshop and Case Study Format: Presentation sessions Breakout Session A Day 1, Monday 21st November, 11.00 – 12.15 A4 PRASE: Patient Reporting and Action for a Safer Environment... NAIF and FLS DB, Royal College of Physicians, UK Format: Workshop Breakout Session B Day 1, Monday 21st November, 15.45-17.00 B4 How can I make patient safety huddle work for B5 Measurement and. .. Teaching Hospital Trust Format: Workshop Format: Presentation sessions Format: Presentation sessions Breakout Session D Day 2, Tuesday 22nd November, 13.00 – 14.00 D1 ‘The patient will see you