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Lighting the Blue Touchpaper

Lighting the blue touch paper

The trainers are excellent, engaging, knowledgeable and enthusiastic. The Training was brilliant and it has really set fire to my personal blue touch paper. It has made me think about how to look at things differently, and as a result I revisited a policy I am working on; so that lessons learned can be applied in a more meaningful, informative way, rather than staff feel they are being blamed and penalised.

Project Lead, Safe Services, Cheshire and Wirral Partnership Foundation Trust

This was feedback from this week when we presented a train the trainer course for Cheshire and Wirral Partnership Mental Health Trust. This is the second in a series aiming to bring about sustainable improvements in a Zero Harm campaign. Other selected comments from the evaluation sheets:

 

·         Very eye-opening course which used common-sense ideas & delivered them in a structured constructive manner

·         Thoroughly enjoyable & thought-provoking. Ought to be part of mandatory training

·         Need more staff from clinical area to attend this training to enhance knowledge, practice, empower them.

·         Hope the Trust fully embeds this learning into the culture

·         Excellent course – pragmatic, common sense & gives words to describe how I feel about potential change culture

The initial response has been fantastic.

 

At the end of Day 1 one of the delegates from the first course spoke passionately of the changes she now felt able to make. She really enthused her colleagues.

Most startling and pleasing was to hear from her how what had begun as a disciplinary inquiry became a lesson in learning and understanding the good reasons why a staff member had deviated from procedures in efforts to do the best for the patient or service user.

We offer a flow chart based on that of Professor James Reason that clarifies when training is the correct treatment for rule violations and those rare occasions when disciplinary action is necessary.

In simple terms if you are not employing psychopaths or sociopaths in your teams, then most errors are unintentional or made with good outcomes in mind.

Understanding why and how errors are made at the Human level is so beneficial to creating a resilient high performing sustainable system.

It could even mean a redesign of some procedures. Many of our clients are doing that now.

If it results in a reduction in avoidable harm it must make sense!

Reporting Near Misses - Untoward Incident or Known...
Real positive change at the frontline
 

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Monday, 16 September 2019