Programme 2022

Building a safe culture

Chaired by Professor 
Murray Anderson-Wallace, Visiting Professor, Health Systems Innovation Lab London South Bank University

Human factors

Chaired by Professor 
Martin Bromiley OBE, Founder, Clinical Human Factors Group and Professor Chris Frerk, Chair, Clinical Human Factors Group

In association with BD

Patient safety in non-acute settings

Patient and family engagement

Chaired by Rachel  Power, Chief Executive, The Patients Association

Supporting our workforce

Chaired by Annabelle Collins, Senior Correspondent, HSJ

Humanising harm: Using a restorative approach to heal and learn from adverse events

• Explore how current investigative responses can increase harm for all those affected, by neglecting to respond to the human impacts
• Understand how the risk of harm can be reduced if investigations respond to the need for healing alongside system learning (with the former having been consistently neglected)
• Debate why incident responses should be conceived within a relational as well as regulatory framework and how this can radically shift the focus, conduct and outcomes of patient safety investigations
• Identify the preconditions and mechanisms that enable the success of restorative approaches in global health systems

Human factors challenges for the safe use of artificial intelligence in patient care

• Learn about the incorporation of AI-supported services in clinical practice and the benefits it has on patient care
• Find out what human factors challenges are likely to emerge with the collaboration of humans and AI in clinical processes
• Finding the right balance between humans and technology to avoid overreliance on automation which can lead to errors

In association with BD

Restart a Heart: Optimising survival rates through rapid response to out-of-hospital cardiac arrests

• Hear directly from an athlete who suffered a cardiac arrest and how the immediate response from medical staff saved his life
• Gain insight into the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
• Learn about a clinician-led quality improvement initiative around prompt CPR to improve patient outcomes
• Join a practical workshop on CPR training across the 2 day Congress to learn how to respond in life- threating situations

Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England, Academic Health Science Network

Marisa Mason, Chief Executive, NCEPOD

Prof Andy Lockey, President of Resuscitation Council UK

Assessing quality of care in the home: Ensuring patients and families have the tools to safely self-manage

• How covid-19 has challenged perceptions around what patients can or should do – causing a major shift towards self- management at home
• Assess the situational variables that could present risks to patients
• Understand the type of training and resources required for patients, families and clinicians to effectively identify and prevent potential risks in the home
• Hear examples of tools and training available that enhance safety in the home

Jono Broad, Senior Manager for Co- Production and Patient Experience, Lead for the Integrated Personalised Care Team, South West Regional Team, NHS England and NHS Improvement

Behind the brave face: Normalising human emotions at work and coping with the ups and downs

• Hear about research carried out on staff wellbeing and what the results show about staff experiencing conflicting emotions due to not being able to achieve consistently high standards of care
• It’s ok not to be ok: Creating an environment that reassures staff when feeling low or distressed
• Practical advice and steps you can take related to psychological first aid to understand what’s really going on under the ‘brave face’
• Current trends around wellbeing – what does the data show and where do we go from here?

Maria Paviour, Occupational Neuropsychologist, Author and Founder of Wellbeing with Cari and the NeuChem Coaching Model

Rooting out racism from organisational cultures to enable progress on healthcare staff inequities

Discuss the findings of the study which conclude that tackling staff inequalities is marred by a culture of racism embedded in the NHS, which sustains such inequalities

• Address reasons why we have ended up with a culture of high diversity but low inclusion for racial and ethnic minority healthcare staff
• Identify ways to start breaking down racist structures in your organisation that are preventing change and progress
• Take back recommendations and practical actions you can begin to implement to eliminate inequalities in the workplace

Examining errors that contribute to death or serious harm: A human factors perspective

• Hear about Beth’s Story from Clare Bowen, mother of Bethany who died during routine surgery
• How and why: Understand the multiple human factors and medical errors that lead to Bethany’s death
• Hear perspectives from a trust CEO on what the death of a patient taught him about human factors
• How to change defensive organisational behaviours, with emphasis on learning rather than denial
• Hear perspectives from a trust CEO on what the death of a patient taught him about human factors
• How to change defensive organisational behaviours, with emphasis on learning rather than denial
• Share strategies and examples to ensure complete transparency and candour when things go wrong to achieve true restorative justice for families involved
• Take away strategies you can implement to reduce the incidence of similar errors

Clare Bowen, Patient Representative and Trustee, Clinical Human Factors Group

Professor Joe Harrison, Chief Executive, Milton Keynes University Hospital NHS Foundation Trust

Achieving true integration: Valuable lessons from mature integrated care systems outside England

• Take a closer look at the Scottish and Welsh integrated care models and explore specific lessons you can take away from their approaches to partnership working
• How advanced levels of integration significantly enhanced patient safety, especially against the backdrop of covid-19
• Find out what initial challenges these systems faced when starting their integration journey, as well as key elements required for ICSs to succeed

What does true co-production look like? The impact of patient input and involvement on quality improvement

• Hear how the involvement of patients helped challenge trusts to think differently about safety initiatives based on their own experience using the health service
• Discuss and share approaches you can take to attract patient partners, and understand what training, support and conditions are required to enable meaningful co-production
• Hear successful examples from trusts that involved patient partners in QI projects and assess the positive impact on patient safety and staff experience
• Key takeaways: Take back strategies to help you involve patients as partners in your work to help shape and influence improvements in your organisatio

Deborah Tighe, Partner Manager, Leeds Teaching Hospitals NHS Trust

Dr Anna Winfield, , Patient Safety & Quality Manager and Specialty Doctor in Elderly Medicine, Leeds Teaching Hospitals NHS Trust

Beds, backlog and bureaucracy: Aligning national strategies with local realities for a safe system reset

• Hear perspectives from frontline clinicians on how dealing with continued service disruption and uncertainty is impacting staff and patient safety
• Discuss and share practical recommendations for making patient safety a priority as the systems recovers
• Share strategies and case studies on how patients and families can be involved in system redesign led by clinicians

Tackling discrimination and inequality in medicine

We know that inclusive workplaces are crucial for both staff wellbeing and for patient safety. So why are so many still experiencing discrimination and what can we do to change it?

In this interactive session we will:

• Reflect on the impact of discrimination in medicine
• Consider how cultures aid discrimination at work
• Explore the work the GMC is doing to tackle inequality issues
• Identify what you can do locally to create a more inclusive culture, including resources and support available to you

In association with the GMC

Challenges and possibilities of integrating human factors and ergonomics into healthcare

• Hear from experts on the current barriers and opportunities of bringing human factors into the health system
• Discuss ways you can get past system and cultural issues to operationalise human factors thinking
• Hear different perspectives on the system from each speaker, whilst also learning from their shared thinking to help you incorporate human factors in your organisation

Dr Tracey Herlihey, , Head of Patient Safety Incident Response Policy, NHS England and NHS Improvement

Professor Chris Frerk, , Chair, Clinical Human Factors Group

Professor Paul Bowie, , Programme Director (Safety & Improvement), NHS Education for Scotland

Debate
Rolling out virtual wards at scale: A risk to patient safety?

• Outcomes from the national covid-19 oximetry implementation across the UK so far and impact on staffing pressures and patient safety
• Address lessons learnt so far and discuss patient safety concerns around plans to roll out virtual wards at scale and pace
• Issues around workforce capacity and how this will impact the implementation of virtual wards as well as patient safety

Positive family engagement and involving families well: Impact on the system and patient safety

• Families are often ‘managed’ rather than treated as central to the investigation process, despite holding key information
• Helping you gain a better understanding of the outcomes which families feel are important after an incident involving serious harm or death
• Improving your learning and your confidence around the delivery of the Duty of Candour with a greater understanding of how this affects families
• The crucial involving of families in a compassionate manner in all care from first contact and as an essential part of the investigation process.
• Giving you a more in-depth understanding of involving families positively achieves better care and better investigations for everyone

Rosi Reed, Training Coordinator, Making Families Count

Frank Mullane MBE, Member, Making Families Count

Stephen Habgood, Director, Making Families Count

Prioritising care in the face of service disruption: The impact on staff and patient safety

• Assess the psychological impact on staff who have to make ethically challenging decisions when prioritising care between patients, sometimes resulting in delayed treatment or avoidable harm
• Address how departing from established care procedures during covid-19 has challenged professional values, knowing that usual standards of care cannot always be achieved
• Practical steps leaders can take to ensure staff are able to make difficult decisions with consistency and clarity, keeping patient safety as the primary focus
• Find out what is being done at national level to help staff get back to usual standards of care once pressures ease

Panel discussion
Balancing no-blame with accountability: Playing your part by speaking up to create a health system that owns up to error

• Address issues around blame and defensiveness as key contributors to the lack of safety progression over the past decades
• Debate why defensiveness remains a core issue within the system and understand what factors are preventing a shift in culture, at both national and local level
• Practical, initial strategies for leaders to build a psychologically safe environment, that encourages transparency and honesty amongst staff
• Responding to error: Learn how you can ensure staff are held responsible for mistakes without blame or fear of reprisal
• Understand the impact this will have on patient safety through the prevention of repeat errors

Jasvinder Sohal, Chief People Officer, Solent NHS Trust

John Walsh, OD Lead / Freedom To Speak Up Guardian, Leeds Community Healthcare NHS Trust

Tom Bell, Author, Consultant and Founding Director, Humanity and Integrity in Public Sector Services

Being proactive to uncover unknown risks and reduce never events

• Learn about a common never event involving a nasogastric tube and why it is also a national issue
• Hear about the post-incident investigation process which resulted in no findings of care gaps or staff errors
• The importance of being proactive and inquisitive and how this resulted in identifying previously unknown gaps
• Learn how one trust is evaluating all PH strips on the market in order to adopt the best device and minimise error
• How this work has resulted in new guidelines that openly acknowledge the gaps in the system with the aim of preventing incidents

Karl Emms, Lead Nurse for Patient Safety, Birmingham Women’s and Children’s NHS FT

Improving outcomes and experiences of patients discharged from mental health hospitals

• Hear from a mental health service user who experienced difficulties when discharged due to no plan being put 
  in place
• Gain insight into the factors and challenges that prevent mental health hospitals from providing a seamless 
  discharge experience for patients
• Find out about a research study led by a patient, working together with trusts to 
  improve outcomes for patients being discharged from 
  mental health hospitals
• Hear how they have co-produced a new support package and 
  toolkit for discharge which can be applied and adapted to the 
  discharge process and understand how this will positively impact 
  patient safety and the patient experience

Sarah Rae, Patient Representative

Dr Jon Wilson, Consultant Psychiatrist, Norfolk and Suffolk NHS Foundation Trust

Professor John Clarkson, Professor of  Engineering Design, 
University of Cambridge and Professor of Healthcare Systems, Delft University of Technology

Liaising with families through adversity: The value of communication to achieve high quality care

• Learn how ICU units adapted in order to maintain high quality, family-centred care during the crisis
• Hear from family liaison teams that were developed to improve communication between ICU patients and their families
• Address the impacts virtual communication had on alleviating family concerns and improving quality of care
• Find out how this can be further leveraged across wider teams to enhance the patient and family experience

Preparing for a digital future: Striking the balance between staff skills and technology

• Get an update on national plans to drive digital transformation across the NHS
• Debate the importance of clinician involvement when integrating digital products to ensure the right balance between staff skills and technology to sustain patient safety
• Hear from digitally advanced organisations on how to avoid over- reliance on automation and ensure staff are confident with rapidly changing ways of working

Governance and regulation

Chaired by Rosi Reed,
Training Coordinator,
Making Families Count

Clinician-led innovation

Safety for vulnerable people

Chaired by Annabelle Colling, Senior Correspondent, HSJ

The deteriorating 
patient

Chaired by Lesley 
Durham, President, International Society for Rapid Response Systems(iSRRS)

Women’s healthcare

Chaired by Susanna Stanford, Patient Advocat

What does a good patient safety investigation look like?

• Learn about the new Patient Safety Incident Response Framework (PSIRF)
• Understand the importance of overseeing system structures and processes to drive the right behaviours
• Hear from early adopters of PSIRF and gain insight specific learnings from the pilot
• Get advice from early adopters on how best to prepare for the implementation of PSIRF in your organisation

Dr Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

Donna Forsyth, Director, Patient Safety Science

Unleashing local innovation: Fine- tuning the efficiency of systems and services by giving clinicians freedom to innovate

• The value of listening to the experiences of frontline staff who and using this to inform the re- design of services and changes in policies to improve patient care
• Hear about innovative initiatives led by healthcare professionals and assess the impact this had on patient safety
• Address the need to encourage staff to take positive risks, with patient safety at front of mind, and debate how this could transform the delivery of care

Revolutionising the delivery of mental health services to meet patient needs

• Gain insight into research commissioned by NHS England on the forecasted demand for mental health services nationwide
• Hear from trusts who have successfully innovated services during covid-19 and find out what lessons they can share to help inform future plans
• Re-thinking our approach to digital pathways to ensure inclusion and a blended care approach where required to sustain safety during surges in demand

Listening to families’ Call 4 Concern to prevent patient deterioration and avoidable deaths

• Hear from patient representatives whose concerns were ignored, leading to rapid deterioration and suicide
• Taking family concerns more seriously as those who know the patient best
• Learn how the Call 4 Concern initiative provides patients and families with more choice about who to consult about their care and facilitates the early recognition of patient deterioration

Tackling Gaps in Patient Safety in Maternity: Embedding a Learning Culture

• Are we training the frontline in themes that relate to avoidable harm?
• Overcoming barriers to a learning culture: a frontline perspective
• Listening to families effectively

Is anybody ‘Learning from Deaths’? – Implementing safety improvements based on a review of the national LFD Programme

• Analysis of national statutory reporting within the NHS in England 2017- 2020
• Understanding what ‘Learning’ and ‘Actions’ have occurred
• A review of how trusts have assessed the impact of their actions
• Hear examples of how trusts are engaging with and involving families in their LfDs work
• Recommendation s for how the LfDs programme can be developed and implemented further and what this means for your organisation

Dr Zoe Brummell, Anaesthetic and Intensive Care Medicine Specialist, University College London Hospitals NHS Foundation Trust

Dorit Braun , Patient Representative

Dr Emma Rowland, A&E Consultant, Homerton University Hospital NHS Foundation Trust

The creation of the Patient Safety Managers Network: Set up by staff, for staff to help spread safety innovation

• Learn about the fast-growing Patient Safety Managers Network, set up by staff, and the motivation behind it
• Understand how members of the network are working to break down barriers to improvement by sharing best practice between trusts
• Discuss the impact of communicating with peers in similar roles regarding patient safety challenges and innovation
• Find out what the network has achieved so far and how it supports the implementation of best practice across 82 different trusts
• Assess the impact of the network on patient safety so far and future plans to continue sharing learning

Claire Cox, Patient Safety Lead, King’s College Hospital NHS Foundation Trust

Jordan Nicholls, 
Serious Incident, 
Governance and Quality Improvement 
Lead, Central and 
North West London 
NHS Foundation Trust

Jayne Addison, Patient 
Safety and Risk Lead. 
The Christie NHS 
Foundation Trust

Chaired by Helen Hughes,Chief Executive, Patient Safety Learning

Reducing health inequalities for people with learning disabilities: Looking beyond the disability to improve safety

• Recognise the dangers of diagnostic overshadowing with LD patients and hear examples of avoidable patient harm caused as a result
• Find out what you can do to prevent diagnostic overshadowing – hear about the RCP Acute Care toolkit for people with learning disabilities
• Take back practical, reasonable adjustments you can make in your organisation to enhance safety for patients
• Learn about how addressing inequalities can be embedded as a golden thread to help drive improvement”

Scott Riley, South West Inclusion Health Lead, NHS England and NHS Improvement (South West)

Hilary Gardener, Strategic Liaison Nurse for Adults with Learning Disabilities - Primary Health, Hertfordshire County Council

Gavin Howcraft, Expert by experience

Chaired by Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England Academic Health Science Network

Dying with dignity: Innovative end of life care models

• Understand the challenges practitioners face in ensuring a good death for dementia patients
• Learn about innovative heuristics approaches which aim to better equip and train clinical staff on palliation and end of life care for patients
• Discover how these approaches can be applied and evaluated in other areas of end-of- life care for people living with other critical conditions

The systematic dismissal of women’s safety concerns and it’s contribution to avoidable harm

• Hear from patients who were not informed of the risks of taking sodium valproate and the harm this caused to them and their families
• Ending the culture of doctor knows best: Is there a clash of values between medical paternalism and patient autonomy?
• Discuss why concerns raised by female patients are still being dismissed as ‘women’s problems’, leading to avoidable harm
• Learn from successful case studies on how to ensure full transparency when preparing women and girls of potential risks in an ethical and responsible way
• Find out what is being done at national level to ensure the system listens and responds to concerns raised by female patients, putting patient voice at the centre of patient safety

Emma Murphy, Founder, Independent Fetal Anti Convulsant Trust (IN-FACT)

Janet Williams, Founder, Independent Fetal Anti Convulsant Trust (IN-FACT)

Minimising the risks of extravasation

• Understand the volume of claims submitted relating to extravasation injury and the cost this has on patients and the system
• Hear from a trust that has implemented innovate ways to reduce the risk of extravasation injury
• Get an update on national guidance and new recommendations

Advancing from ‘requires improvement’ to ‘good’ – Taking the next step in your improvement journey

• Hear from trusts who have gone from ‘requires improvement’ to ‘good’ by the CQC and find out what which areas they focused on to raise quality standards
• Hear examples of inspirational projects from trusts that helped bridge the gap from ‘requires improvement’ to ‘good’
• Take back practical and relatable advice to help you in your own improvement journey

Hayley Flavell, Director of Nursing, The Shrewsbury and Telford Hospital NHS Trust

Dr Ruth O’Dowd, Consultant Anaesthetist and Associate Medical Director Patient Safety and Quality Improvement, North Cumbria Integrated Care NHS Foundation Trust

Chaired by Dr Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

Managing the effects of Long-covid on staff to prevent human error

• Hear from frontline staff affected by Long- covid and get an understanding of how it is impacting their ability to carry out daily roles safely
• Share practical steps managers can take to effectively support staff experiencing symptoms of Long-covid
• Recommendation s and examples of how the current approach to long-covid can be improved to avoid harm and deterioration

Dying with dignity: Innovative end of life care models to ensure patients die well and safely

• Understand the challenges practitioners face in ensuring high quality end of life care for patients and support for families
• Hear about best practice studies and innovative approaches to end-of-life care which have ensuring high quality of care for patients and support for families
• Take back practical advice and support to enable you to transform end of life care in different settings
• Gain insight into the national framework for end-of-life care and how this can be translated into local action

The first Women’s Health Strategy: Redesigning the system to prioritise care on clinical need, not gender

• Learn about the government-led Women’s Health Strategy in England as part of plans to level up health care
• Get an update on key issues raised in response to a call for evidence to inform the government’s approach to tackling gender health inequality
• Find out how these insights will inform the upcoming Women’s Health Strategy to create a healthcare system that prioritises care on the basis of clinical need, not gender