PSC Resources

The following resources relate to the Transforming Healthcare Event (12th June 2015)

Despite the application of many strategies and approaches to improve the delivery of care to patients, progress has been painfully slow. Over time however, three initiatives have taken shape, offering much promise in a health system that is often bewildered by the demands placed on it.

• Firstly, a case is made to show that old, negative ways of looking at patient safety are insufficient. We need to focus not just on things going wrong (our standard way of trying to keep patients safe, labelled Safety-I) to a newer approach which argues we must also direct our attention to things going right (labelled Safety-II).
• Secondly, we believe that the heart of good care involves an active, collaborating patient who participates much more completely in decisions affecting their treatment and care. A key component of person-centred care is shared decision-making (SDM).
• Finally, these paradigms are pulled together to show how we can enable safer, better care. We want nothing less than a transformed health system. This is one that is responsive, compassionate, inclusive, flexible, and safe.

 CHAIN Resources

The Contact, Help, Advice and Information Network (CHAIN) – is an online mutual support network for people working in health and social care. It gives people a simple and informal way of contacting each other to exchange ideas and share knowledge. The following resources have been added from the Canadian Patient Safety Institute, which may be of interest to PSC members.

Developing a network of champions interested in improving the safety of paediatric medicines

The Royal College of Paediatrics and Child Health have established a new project with the aim of developing a network of champions interested in improving the safety of paediatric medicines. It is also developing a quality assurance pathway for innovations in medicines safety to help spread effective solutions. More information about the project and the Champions’ launch event can be found on the Meds IQ website and in the overview document and Terms of Reference for the Champions’ Network. Information about the initiative has also been shared with our own regional Medicines Optimisation project.


Improvement FUNDamentals

NHS Improving Quality, together with The Jönköping Academy for Improvement of Health and Welfare have developed a new and innovative online course for people interested in developing quality improvement skills in healthcare. The next intake for ‘Improvement FUNdamentals’ :

  • starts in September 2015
  • Is open to anyone  with an interest in health and care improvement
  • Is delivered entirely online via videos, articles and exercises
  • Features live knowledge exchange events, allowing participants to learn from experts and debate and connect with each other
  • Is entirely free to join
  • Focuses on learning through fun!

For further details, please visit”

National Safety Standards for Invasive Procedures

The new National Safety Standards for Invasive Procedures (NatSSIPs) were published on the NHS England website on 7 September.

The standards have been developed under the auspices of the NHS England Surgical Services Patient Safety Expert Group (SSPSEG), which built on the Standardise, Educate, Harmonise report from the Surgical Never Events Taskforce. They have been developed to support NHS organisations to provide safer care and to reduce the number of patient safety incidents related to invasive procedures.

The principle behind the NatSSIPs is that organisations will review their current local processes for invasive procedures and ensure that they are compliant with the new national standards. This will be done by organisations working in collaboration with staff to develop their own set of standards known as ‘Local Safety Standards for Invasive Procedures’ (LocSSIPs).

A ‘Stage 2: Resource’ – NHS England Patient Safety Alert has also been published. The Alert will not only require for each relevant organisation to take local action to put the standards in place, it will also call for organisations to share their own local plans so that we can learn from one another and put proven best practice in place.

More information about the NatSSIPs is available on the NHS England website. If you require further details or have any questions you can also email the NHS England Patient Safety Domain directly on


Discharge Cluster Group

The Discharge Cluster Group is one of a number of national groups established to enable AHSNs to collaborate on issues of common interest. The terms of reference for the group are attached below. A number of resources have been made available by the group and these can also be found below, along with update reports on the group’s progress.

Terms of reference

Update reports

December 2015 Highlight report


  • Guide on improving transfers of care and handover (already there)
  • Step-by-step measurement guide on handovers and transfers of care (already there)
  • Case study: Moving to electronic transfer of District Nurse referrals within a 6 week timeframe (attached to this email)

NHS England and partners have published six Quick Guides to bring clarity on how best to work with the care sector. They can be accessed at or via the links below:

  • Better use of care at home (attached to this email)
  • Clinical input to care homes (attached to this email)
  • Identifying local care home placements (attached to this email)
  • Improving hospital discharge in to the care sector (attached to this email)
  • Technology in care homes (attached to this email)
  • Sharing patient information (attached to this email)

Gillian Findley, Director of Nursing at Durham Dales, Easington and Sedgefield CCG and North Durham CCG, says that “These resources will be useful for both commissioners and providers. They showcase great examples of how people across the country are working with the care sector to reduce unnecessary hospital admissions and delayed transfers of care.”

Guide on improving transfers of care and handover

Step-by-step measurement guide on handovers and transfers of care


Review of National Reporting and Learning System (NRLS) incident data relating to discharge from acute and mental health trusts – August 2014

NHS England’s Patient Safety Domain has undertaken a review of incidents reported to the National Reporting and Learning System (NRLS) between 1 October 2012 and 30 September 2013 as part of a programme of work aimed at improving handover at the time of discharge. The aim of the search was to identify the nature and scale of the problems associated with the process of handover from secondary care. It also provides supporting information for the Stage 1 Patient Safety Alert on risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care.


‘Safer Healthcare: Strategies for the Real World’ by Charles Vincent & Rene Amalberti

This book is published by Springer and, through the generous  support of the Health Foundation, is freely available in electronic form.

The authors are keen for the book to be widely available which is why the Open Access arrangement is so important. They would also appreciate comments, feedback and suggestions for developing these ideas if they prove to be valuable, and acknowledge that these ideas need to be tested in practice and that ultimately the test is whether this approach will lead in a useful direction for patients. The authors also believe the proposals they are making can only become effective if a community of people join together to develop the ideas and implications.