Patient Safety Congress 2013
Inspiring Improvement: Connecting safety, experience and effectiveness
Day One – 21st May 2013
08:00
09:05
Registration
Congress welcome from the Chair
Phil Hammond, GP and Broadcaster
International speaker
A ‘call to action’ – how is patient safety done differently elsewhere in the world and what can we learn from other
systems and methods?
Beth Lilja, Executive Director, Danish Society for Patient Safety
Acceptance is our biggest enemy
Professor Sir Bruce Keogh, National Medical Director, NHS Commissioning Board
Question time
Looking forward – what’s shaping patient safety strategy?
Setting out the new parameters in which safety will become a part of all health practitioners’ roles
What effect will the new regulators have on ensuring and standardising safer practice?
How will information and patients enhance safety?
Catherine Dixon, Chief Executive, NHS Litigation Authority
Peter Walsh, Chief Executive, Action against Medical Accidents
Morning refreshments
Life after the Mid Staffordshire Inquiry
Robert Francis QC, Chairman, Mid Staffordshire NHS Foundation Trust Public Inquiry
09:10
09.40
10.00
11.00
11.30
11.45
Robert Francis QC, Chairman, Mid Staffordshire NHS Foundation Trust Public Inquiry
In conversation with
Professor Sir Ian Kennedy, former Chairman, The Bristol Royal Infirmary Inquiry and former Chairman, the Healthcare
Commission
Co-operating for safety: Creating and delivering safer healthcare systems
PechaKucha 20x20
12.15
1. Structurally integrated system:
Dr Alan Willson, Director of 1000 Lives Plus Programme, NHS Wales
2. Virtually integrated system
3. Geographically based solution
4. Network based solution:
Robbie Pearson, Director of Scrutiny and Assurance, Healthcare Improvement Scotland
5. Radically different or new system
Lunch in the exhibition hall
Lunchtime learning sessions
13:00
14:15
Practical
approaches to
harm free care
Assuring safety
across service
boundaries
Leading and
governing with
purpose
Safety
thermometer:
Capturing
comparable data
to inform
improvements
What does this
tell us about the
treatment of the
4 harms
nationally?
How will the
commissioning
board deliver on
the outcomes
framework and
work to improve
patient safety?
Professor Danny
Keenan, Chair, NICE
Commissioning
Outcomes
Framework
committee and
Clinical Lead for
Surgery, Central
Manchester
University
Hospitals NHS
Mid Staffs
Inquiry: The role
of NEDs in the
securing safety of
your Trust’s
patients
Dr Ruth May,
Nurse Director,
NHS Midlands
and East
1
Moving to
prospective safety
management Health Foundation
Putting medicines
at the centre of
safety work
Professor Nick
Barber, Director of
Research and
Evaluation, The
Health Foundation
Building
engagement and
transforming
culture
Creating a culture
which is open and
accountable –
raising concerns,
speaking up and
out
Niall Dickson,
Chief Executive
and Registrar,
General Medical
Council
Dr Kim Holt,
Founding Member,
Patients First
Safe care seven
days a week –
NHS QUEST
Abolishing
weekend and
nights: Why
patients
deserve access
to senior clinical
decision makers
whenever they
are admitted to
hospital – A
medical
director’s
perspective
Patient Safety Congress 2013
Inspiring Improvement: Connecting safety, experience and effectiveness
Foundation Trust
14:50
Insulin bundles
for safe
administration
and use in the
community
How do you engage
commissioners to
incorporate safety?
What is the role of
Commissioning
Support Unit?
Dr Jean MacLeod,
Chair, Regional
Insulin and Safety
and Knowledge
Project
Using dashboards
meaningfully
-how has it been
defined?
-how will it be
embedded?
-what indicators
are included and
how will it
develop?
-how can it be
made
comparable?
How are we
measuring
improvement and
what can it tell us?
Professor Charles
Vincent, Director
of the Imperial
Centre for Patient
Safety and Service
Quality and
Professor of
Clinical Safety
Research, Imperial
College London
The nature of
human error
Looking beyond
error to focus on
social spread and
scaling up
Consistency in
care: What
could we do
differently to
enable the
same levels of
care morning,
noon and
night? Chief
executives’ and
finance
directors’ panel
discussion
Chair: David
Dalton, Chief
Executive,
Salford Royal
NHS
Foundation
Trust
Clinician
involvement in
developing
reporting systems
Moving from
hospital at
night to the city
at night:
Integration of
health and
social care
services
Jonathan Bamber,
Research and
Evaluation
Manager, The
Health Foundation
15:25
15:55
Afternoon refreshments
Medication
Developing
safety from a
standardised
systems
outcomes
perspective:
measures for use in
successful
community care
communication
to influence
individual
clinicians
Jamie Hayes,
Director, Welsh
Medicines
Resource Centre
16:30
Setting risk
parameters in
primary care
Dr Ruth
Chambers, GP
and Clinical
Director of
Practice
Development and
Performance,
NHS Stoke on
Trent CCG
Integrated Diabetes
Care: Implementing
the ‘Super Si’
Model and
Community
Diabetes Service
Dr Paru King,
Consultant
Endocrinologist,
Derby University
Hospital
Mid Staffs:
lessons for
leaders from
leaders – how did
it all go wrong?
Manjit Obhrai,
Medical Director,
Mid Staffordshire
NHS Foundation
Trust
Colin Ovington,
Director of
Nursing, Mid
Staffordshire NHS
Foundation Trust
The role of data
in improving
safety and quality
Safety Cases
Dr MarkAlexander Sujan,
Associate
Professor of
Patient Safety,
Warwick Medical
School
Dr Jacques de
Toeuf, General
Medical Director,
Chirec Asbl,
Belgium
Dr Elaine Maxwell,
Associate Director,
Patient Safety, The
Health Foundation
Proactive search
for risk – the
diagnosis in
patient safety
The role of
organisational
strategies in
improving safety
and quality
Andrew Weale,
Consultant
Vascular and Renal
Transplant
Surgeon, North
Bristol NHS Trust
Phil O’Connell,
Project Manager,
NHS Stoke on
Trent CCG
James Reason Annual Lecture
Thinking systemic when addressing quality and safety in healthcare: a revolution of the mind
Professor René Amalberti, Patient Safety Advisor, Haute Autorité de Santé, France and Vice CEO, IMASSA
Congress Drinks Reception
17:05
18:05
2
Andrew Gibson,
Deputy Medical
Director,
Sheffield
Teaching
Hospitals NHS
Trust
What are the
challenges and
solutions our
future doctors
and nurses face
to ensure harm
free care across
the week?
Lessons from
Aintree
Patient Safety Congress 2013
Inspiring Improvement: Connecting safety, experience and effectiveness
Day two – 22nd May
08:00
09:00
Registration
Congress welcome from the Chair
Dr Mike Durkin, Director of Patient Safety, NHS Commissioning Board
Lessons from Europe – drawing on the work of the QUASER and DUQuE projects
Two major EU research programmes have explored the effectiveness of quality improvement systems in European hospitals and
the relationships between the organisational and cultural characteristics of hospitals and the impact on clinical effectiveness,
safety and patient experience. There are crucial lessons for providers and commissioners alike
Professor Naomi Fulop, Coordinator, QUASER and Professor of Health Care Organisation and Management, Department of
Applied Health Research, UCL
Dr Oliver Groene, Co-Lead Investigator, DUQuE and Lecturer in Health Services Research, London School of Hygiene & Tropical
Medicine
Q+A Panel with QUASER’s European partners
09:05
09:45
10:05
Fresh eyes: Healthcare professionals in training as a force for patient safety improvements
Emma Fitzsimons, Staff Nurse, Nottingham University Hospitals NHS Trust and Florence Nightingale Foundation scholar
Dr Nikki Kanani, GP Registrar and Co-Chair, The Network
Rob Bethune, Surgical Registrar
Kirsten Gamet, Cardio-respiratory Physiotherapist, Allied Health Professional, Florence Nightingale Foundation scholar
Patient safety poster award: The top 3 poster organisations voted for by our advisory panel will present their patient safety
work to delegates. Delegates will have the opportunity to take part in live interactive voting for the winner
Morning refreshments
Practical
Assuring safety
Educating for
Harnessing the
Integrating
Measuring harm:
approaches to
across service
improvement
power of patient
human factors
past, present and
harm free care
boundaries
and staff
future – NHS
experience
QUEST
Learning and
Improving patient
Using simulation
Using patient and Learning from
Understanding
improving from
risk assessment in
exercises to
staff stories to
serious incidents
the strengths and
surgical never
ambulatory
engage staff in
generate change
challenges of
events – keeping it
services:
clinical safety
different data
practical: making it
Jocelyn Cornwell,
sources
 Determining the
real
Director, the
most appropriate Professor Bryn
Baxendale,
Point of Care,
Maxine Power,
care setting
Professor Jane
Director, Trent
King’s Fund,
Director of
 Creating referral
Reid, Independent
Simulation and
Visiting Professor,
Innovation and
pathways
Advisor and
Clinical Skills
Department of
Improvement
 Communicating
Research, Queen
Centre
Medicine,
Science, Salford
to multiple
Mary, University of
Imperial College
Royal NHS
providers
London
London and
Foundation Trust
Trustee, Picker
Mark Gregory, A&E
Dr Alastair
Institute Europe
Service Delivery
Williamson,
Manager, East
Consultant
James Titcombe,
Midlands
Anaesthetist and
patient relative
Ambulance Service
Associate Medical
NHS Trust
Director, Heart of
England NHS
Foundation Trust
The art of closing
Managing urgent
The role of
Openness and
Learning from the Triangulation of
the knowing-doing
mental health
education in
the role of the
field: Military
harm data –
gap
needs in the
improving safety
inquest
practice
making the most
Emergency
of all your data
Pelle Gustafson,
Department Sir Keith Pearson,
Chief Medical
simulation-based
Chair, Health
Maxine Power,
Officer,
training
Education
Director of
Patientförsäkringen
England
Innovation and
LÖF
Dr Steven Reid,
Improvement
Clinical Director,
Science, Salford
Axel Ros, Chief
Psychological
Royal NHS
Medical Officer,
Medicine, Central
Foundation Trust
10:45
11:05
11:30
12:10
3
Patient Safety Congress 2013
Inspiring Improvement: Connecting safety, experience and effectiveness
Ryhov County
Hospital,
Jönköping, Sweden
and North West
London NHS
Foundation Trust
Maria Palm,
Consultant,
Obstetrics and
Gynaecology, Gävle
County Hospital,
Sweden
Tobias Wirén,
consultant
orthopaedic
surgeon and Head
of the Orthopaedic
department, Capio
S:t Goran Hospital,
Sweden
Lunch
Developing never
events in primary,
community and
mental health
12:50
14:10
Improving
communication
with community
services to reduce
readmissions
Tomorrow’s
doctors –
engaging junior
doctors in safety
improvement
Dr Tricia
Woodhead,
Consultant
Radiologist,
Weston Area
Health Trust
14:50
Surviving Sepsis
Ron Daniels, Chief
Executive, Global
Sepsis Alliance
Integrated
medication
management: the
interface between
primary and acute
Academic Health
Science Networks
– a new way of
promoting safer
and higher
quality care
Dr James
Mountford,
Director of
Quality, UCL
Partners
15:30
Working with care
home staff and
residents to
improve medicines
safety in care
homes
4
Developing
commissioner
assurance in
community and
primary care
Dr Martin Kuper,
Medical Director
and ITU
Consultant,
Whittington
Health NHS Trust
Primary care
safety culture
survey – paving
the way for an
integrated
approach to
Alfred’s Story: An
avoidable death
Professor Aidan
Halligan, Director
of Education,
University
College of London
Hospitals NHS
Foundation Trust,
and Chief of
Safety, Brighton
and Sussex
University
Hospitals NHS
Trust
Caroline Spencer
Surgical
performance and
safety
Ralph Tomlinson,
Royal College of
Surgeons of
England
Human error
models and
emergency
medicine
Professor
Matthew Cooke,
Professor of
Emergency
Medicine,
Warwick Medical
School
The QUEST for
harm free care
across maternity
services
Captain Phil
Higton, Director
of Training,
Terema
Clinical Human’s
Factors Group
-what have CHFG
learnt since their
launch?
-Board Resource
Learning from the
Safety
Thermometer
Martin Bromiley,
Founder, Clinical
Human Factors
Group
Stephen
Ramsden
Engaging patients
and their families
to improve
services
Professor Alan
Never Events:
Dealing with
intractable
problems – a
human factors
based approach
The NHS QUEST
Interactive
Dashboard
Kate Cheema,
Special
Information
Patient Safety Congress 2013
Inspiring Improvement: Connecting safety, experience and effectiveness
safety
Dr David Alldred,
Lecturer in
Pharmacy, Leeds
Institute of
Diagnostics and
Therapeutics School
of Healthcare,
University of Leeds
Congress close
16:10
5
Paul Bowie, NHS
Education
Scotland
Wilson,
University of
Strathclyde
Business School
Dr Nick Toff,
Patient Safety
Adviser,
Cambridge
University
Hospitals NHS
Foundation Trust
Analyst, NHS
South East Coast
and Information
Analyst, NHS
QUEST
Ian Chappell,
Improvement
Lead, NHS QUEST