Building a culture of learning and accountability: learning from when things go wrong (virtual conference)

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The King’s Fund co-host this virtual conference in partnership with the Parliamentary and Health Service Ombudsman on 13–16 September, in the lead up to World Patient Safety Day on 17 September, to explore how culture is key to enable professionals, patients and organisations to use the learning from mistakes and serious incidents to drive improvement in the safety and quality of care.

Register now to catch up on demand until Sunday 3 October, when the virtual conference platform closes.

Speakers

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Richard Murray

Chief Executive, The King’s Fund

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Rob Behrens CBE

Parliamentary and Health Service Ombudsman

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Rt Hon Jeremy Hunt MP

Chairman, Health and Social Care Select Committee

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Dr Toby Lowe

Visiting Professor of Public Management, Centre for Public Impact

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Abi Howarth

Director of Operations, Parliamentary and Health Service Ombudsman

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Charlotte Augst

Chief Executive, National Voices

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Saffron Cordery

Deputy Chief Executive, NHS Providers

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Kate Eisenstein

Assistant Director of Insight and Public Affairs, Parliamentary and Health Service Ombudsman

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Ted Baker

Chief Inspector of Hospitals, Care Quality Commission

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Fatima Khan-Shah

Programme Lead, Unpaid Carers Programme, West Yorkshire and Harrogate Health and Care Partnership

Rebecca Hilsenrath

Director of Strategy and Communications, Parliamentary and Health Service Ombudsman

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Russell Parkinson

Head of Office, National Guardian for Freedom to Speak up Guardian for the NHS, National Guardian’s Office

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Dr Kevin Stewart

Executive Medical Director and Deputy Chief Investigator, Healthcare Safety Investigation Branch

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Helen Vernon

Chief Executive Officer, NHS Resolution

Deirdre Micklethwaite

Assistant Director of Complex Casework, Parliamentary and Health Service Ombudsman

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Karl Banister

Director of Legal and Quality, Parliamentary and Health Service Ombudsman

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Tony Dysart

Senior Lead Clinician, Parliamentary and Health Service Ombudsman

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Amanda Amroliwala CBE

Chief Executive Officer, Parliamentary and Health Service Ombudsman

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Sir Robert Francis QC

President, Healthwatch England

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Andrea Sutcliffe CBE

Chief Executive, Nursing and Midwifery Council

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James Titcombe OBE

Expert Advisory Panel Member, Parliamentary and Health Service Ombudsman

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Dr Bill Kirkup CBE

Private Investigator

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Aidan Fowler

National Director of Patient Safety, NHS England and Deputy Chief Medical Officer, Department of Health and Social Care

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Dr Sam Hare

National Clinicial Director for Imaging, NHS England and NHS Improvement

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Jodie Moffat

Head of Early Diagnosis or Early Diagnosis Programme Lead, Cancer Research UK

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Dr John Machin

Post-CCT Hip and Knee Surgery Fellow and Clinical Lead for Litigation - Getting It Right First Time Programme (GIRFT) NHS England & Improvement

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Annie Laverty

Chief Experience Officer, Northumbria Healthcare NHS Foundation Trust

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Dan Wellings

Senior Policy Fellow, The King’s Fund

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Beccy Baird

Senior Policy Fellow, The King’s Fund

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Ceinwen Giles

Founding Director, Partnerships & Evaluation, Shine Cancer Support

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Alex Baylis

Assistant Director of Policy, The King’s Fund

Week one

Monday 6 September

Access the conference

We will send you an email on Monday 6 September with a link to access the conference. Please log in and get familiar with the platform. Take this opportunity to introduce yourself to other attendees and visit the exhibition stands. You will need to use an up-to-date web browser. We recommend using Google Chrome on a laptop or desktop computer.

Week two

Monday 13 September

9.30am – 11.00am (BST) Session one - Shifting culture from blame and fear to learning and accountability

9.30amWelcome and introduction

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Richard Murray, Chief Executive, The King’s Fund

10.05amLearning and accountability

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Rob Behrens CBE, Parliamentary and Health Service Ombudsman
  • Understand why accountability and learning are intertwined. 
  • Learn about the current debates and difficulties around creating a culture of learning that promotes accountability for putting learning into practice.

10.15amThree perspectives on how to create a culture of learning

  • Our three speakers will share their unique perspectives on how the NHS can achieve a change in culture.

Dr Toby Lowe, Visiting Professor of Public Management, Centre for Public Impact 
Mr John Machin, Post-CCT Hip and Knee Surgery Fellow and Clinical Lead for Litigation - Getting It Right First Time Programme (GIRFT) NHS England & Improvement
Ceinwen Giles, Founding Director, Partnerships & Evaluation, Shine Cancer Support

10.45amLive Q&A

11.30am – 12.30pm (BST) Session two - Lessons from Covid-19

11.30amWelcome and introduction

Abi Howarth, Director of Operations, Parliamentary and Health Service Ombudsman

11.35amLessons from Covid-19

In this session you will hear about the lessons from the Covid-19 pandemic; what have key stakeholders learnt and how has their thinking transformed by the unprecedented impact of Covid-19? How can the NHS better use this experience, capitalising on the learning to promote a more just and open culture?

Charlotte Augst, Chief Executive, National Voices 
Saffron Cordery, Deputy Chief Executive, NHS Providers

12.10pmQuestions and discussion

Tuesday 14 September

9.30 – 10.30am (BST) Session three - Empowering patients and families to speak up

9.30amWelcome and introduction

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Kate Eisenstein, Assistant Director of Insight and Public Affairs, Parliamentary and Health Service Ombudsman

9.35amEmpowering patients and families to speak up

In this session you will hear about the steps health and social care services can take to promote patients being able to talk openly about their care experiences and how a culture of honest feedback can make all the difference in improving quality. 

Ted Baker, Chief Inspector of Hospitals, Care Quality Commission
Fatima Khan-Shah, Programme Lead, Unpaid Carers Programme, West Yorkshire and Harrogate Health and Care Partnership 

10.15amLive Q&A

11.00am – 12.00pm (BST) Session four - Empowering staff to share their insight

11.00amWelcome and introduction

Rebecca Hilsenrath, Director of Strategy and Communications, Parliamentary and Health Service Ombudsman

11.05amEmpowering staff to share their insight

In this session you will hear from national leaders on how the NHS can harness learning from its core asset – the staff serving the wider public – on how to best establish a culture open to honest and productive feedback giving. 

Russell Parkinson, Head of Office, National Guardian for Freedom to Speak up Guardian for the NHS, National Guardian’s Office 
Dr Kevin Stewart, Executive Medical Director and Deputy Chief Investigator, Healthcare Safety Investigation Branch 
Helen Vernon, Chief Executive Officer, NHS Resolution 

11.45amLive Q&A

Wednesday 15 September

9.30 – 10.30am (BST) Session five - Leadership to bring about necessary change

9.30amWelcome and introduction

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Dan Wellings, Senior Policy Fellow, The King’s Fund

9.35amLeadership to bring about necessary change

In this session you will learn about the leadership that is needed to create the necessary changes in culture  to promote accountability and compassion. In a health care system constantly under pressure, the path to least resistance and business-as-usual mentality can prevail, leading to missed opportunities to learn from mistakes, create openness and promote compassion.

Annie Laverty, Chief Experience Officer, Northumbria Healthcare NHS Foundation Trust
Aidan Fowler, National Director of Patient Safety, NHS England and Deputy Chief Medical Officer, Department of Health and Social Care 
Deirdre Micklethwaite, Assistant Director of Complex Casework, Parliamentary and Health Service Ombudsman

11.00am – 12.00pm (BST) Session six - Case study: Improving the imaging pathway after systemic failings

11.00amWelcome and introduction

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Karl Banister, Director of Legal and Quality, Parliamentary and Health Service Ombudsman

11.05amCase study: Learning from mistakes in imaging services

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Tony Dysart, Senior Lead Clinician, Parliamentary and Health Service Ombudsman

In this session you will see how a learning-from-mistakes culture works in practice. We’ll discuss a detailed case study on the impact of failing to learn and improve after something goes wrong. Building on the Parliamentary Health and Service Ombudsman’s recent work on the way imaging is requested, reported and acted on, you will hear a range of perspectives on the impact of failing to learn, as well as the momentum needed to drive improvements in this area.

11.20amResponse

Dr Sam Hare, National Clinician Director for Imaging, NHS England and NHS Improvement 
Jodie Moffat, Head of Early Diagnosis or Early Diagnosis Programme Lead, Cancer Research UK
 

11.40amLive Q&A

Thursday 16 September

9.30 – 10.30am (BST) Session seven - In conversation

9.30amWelcome and introduction

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Beccy Baird, Senior Policy Fellow, The King’s Fund

9.35amIn conversation

In this session, The Ombudsman Rob Behrens, will be joined by Dr Bill Kirkup, Private Investigator,  in a conversation about learning from mistakes in the long term.
Drawing on Dr Kirkup’s extensive experience leading independent inquiries and reviews into NHS patient safety failings and the learning from the thousands of NHS complaints The Ombudsman looks into each year, you will hear about the challenges and opportunities for embedding a sustainable culture of learning after things go wrong in health care.

10.10amQuestions and discussion

Beccy Baird, Senior Policy Fellow, The King’s Fund 
Dr Bill Kirkup, Private Investigator
Kate Eisenstein, Assistant Director of Insight and Public Affairs, Parliamentary and Health Service Ombudsman 

10.30amNetworking break and exhibition

11.00am – 12.30pm (BST) Session eight - Bringing it all together to facilitate change

11.00amWelcome and introduction

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Alex Baylis, Assistant Director of Policy, The King’s Fund

11.05amThe benefits of culture change

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Amanda Amroliwala CBE, Chief Executive Officer, Parliamentary and Health Service Ombudsman

Hear about some of the big opportunities that lie ahead for those looking to transform systems, processes and cultures to better support a culture of learning and accountability in health and care.

11.15amNext steps and immediate priorities towards promoting change

Bringing together the conclusions from the whole week, our speakers will share the key priorities and necessary actions to drive this agenda forward.

Sir Robert Francis QC, President, Healthwatch England 
Andrea Sutcliffe CBE, Chief Executive, Nursing and Midwifery Council
Rt Hon Jeremy Hunt MP, Chairman, Health and Social Care Select Committee 
James Titcombe OMB,  Expert Advisory Panel Member, Parliamentary and Health Service Ombudsman

 

12.00pmLive Q&A

Weeks three-four

Closes Sunday 3 October

Catch up and complete

You will have until Sunday 3 October to re-watch or catch up on any sessions you've missed.

Throughout the conference, we will share PDFs of the presentation slides in the lecture theatre, links to resources in the networking area and various materials in the exhibition. Once the platform closes on this date, you will no longer have access to the resources so please ensure you have downloaded all of the materials beforehand. 

FAQs

Format and time

High-quality, up-to-date content is delivered to you via an online platform that is open for four weeks. During the first week, you will have the opportunity to log in, test your connection and become familiar with the set-up. The live sessions will take place over four half-days in the second week, giving you the option to catch up on demand until the end of week four.

Virtual conferences mean you can digest content at your own pace and work around a busy schedule. You can pause and rewind presentations and put your questions to our expert speakers. There is an activity feed for public conversations and the option of one-to-one networking. Virtual exhibition stands enable you to interact with a range of organisations who will share expertise and information – all at a time that suits you.

Networking

If you choose to opt-in to networking, you will appear on the attendee list, where other delegates will be able to click on your profile and see whether you are online or offline. 

If you discover someone that you would like to talk to, you can send them a message or invite them to have a one-to-one video conversation during the week that sessions take place. If you are interacting with others like this, be assured that the messages and calls are encrypted and entirely private. If you are offline and another delegate sends you a private message, you will receive a notification so you will never miss out. 

You are in control, so you can choose whether to accept or decline invitations and you can change your settings at any point in the four weeks, either to opt-in or opt-out of networking. On your profile, you can share as much or as little information about yourself as you’d like, including your contact details, photo and biography, social media profiles or any websites you would like others to see. If you prefer not to share this information and only list your name, that is fine. Your profile is accessible throughout the event and you can update this at any time.

During sessions, there are separate tabs on the righthand side of the video, including a place to post questions for the speakers, make notes, take part in polls and a session chat where you can interact with other delegates.

If you prefer group/public conversations and would like to interact outside the session times, there is the activity feed. Here, delegates can post images and links and reply to one another in conversation threads (like a social media wall). 

Taking notes

If you use the note-taking functionality during the sessions, you can access these later by clicking on your profile image (top righthand side of the screen) and selecting My notes. Here, you can update your notes and add images. These notes will be saved in the platform until the conference closes (at the end of week four). To email yourself a copy of your notes, just click on the small envelope icon. 

Exhibition

Virtual exhibition stands enable you to interact with a range of organisations who will share expertise and information – all at a time that suits you. 

Games and competitions

Throughout the first two weeks, there will be an opportunity to take part in some fun interactive challenges. Delegates who take part will boost their scores on a leaderboard and be in with the chance of winning one of three prizes.

Resources 

As well as the video content, we will share pdfs of the slides and other materials in the resources section. The exhibition will also contain links, videos and documents from the various exhibitors.

  • Before the event, tell your colleagues that you are taking part and block out the time in your diary. 
  • Make sure you are using an up-to-date web browser on a laptop or desktop. We recommend Google Chrome for the best experience.
  • Make the most of the online community by taking part in the live Q&A sessions and opting in to networking
  • In week one, introduce yourself on the activity feed. This is an easy way of ‘getting your voice in the room’, starting conversations and establishing new relationships with colleagues in health and care. 
  • Avoid as many distractions as possible so you can immerse yourself in the sessions as you would at a physical conference. Treat each session as a meeting, put your phone on silent and close down your emails.
  • If you know you won’t be able to watch certain sessions live, you can submit your questions in advance and put aside time in the third or fourth week to catch up on demand.
  • Each session is approximately one hour long and there is always at least a half-an-hour break between sessions so you can take a screen break or catch up on emails.
  • Make sure you secure time in your diary at some point over the four weeks to visit the exhibition, where you will find free resources and can have conversations with experts from across the health and care system.

When the event is taking place, we will be on hand to offer technical support, but it is worth using the extra time before the first session to log in and test your connection, just in case.

Throughout the conference, we will share pdfs and links in the resources section and in the exhibition. The portal is open for four weeks, when you will have the opportunity to either watch, save or download these materials. 

Once the platform closes (on Sunday 3 October), you will no longer have access to these resources so please ensure you save everything you need beforehand. 

The King's Fund is an independent charitable organisation working to improve health and care in England. Our events are a key source of income, and this income enables us to continue with our charitable objectives. 

The cost of running a virtual conference is similar to that of a physical event. Although a virtual conference has fewer room hire and catering costs, in order to produce a high-quality event, we still need to pay the costs for the technical supplier, support and developing the platform. With some sessions taking place in our building, we do have to cover some venue costs. We also have a team of dedicated events professionals, content experts, digital, marketing and finance support that work on these events.  

Any profit that is made from these events goes directly towards achieving our strategic priorities. You can find out more about how we are funded here

We offer a number of free bursary places for patients and carers. These places are limited to maintain a balance of voices in the room between patients, service users, carers, and health and care professionals.  To apply for a bursary place please email us a short paragraph explaining why you wish to attend.

Captions are live across all video presentations as standard. If you have other accessibility requirements you would like to discuss, please email us at events@kingsfund.org.uk

Contact us

Booking enquiries

If you’d like to make a booking enquiry, please email Anna Viralainen at events@kingsfund.org.uk

Programme enquiries

If you have any queries relating to this event programme please email Caroline Viac at c.viac@kingsfund.org.uk

Sponsorship and exhibition enquiries

Please email Chloe Smithers at c.smithers@kingsfund.org.uk or give her a call on 020 7307 2482.

Ticket prices

Please note, there is a £20+VAT surcharge to cover the cost of processing invoices. This is an addition to the ticket price and will be added to your invoice. There is one invoice fee per order, not per ticket. There is no charge for paying by debit or credit card.

Public sector, charity or university £155 + VAT
Small-medium sized enterprise (SME) £220 + VAT  
Commercial/profit-making organisation £310 + VAT

Student tickets

If you are a student in full-time education, please email us for a promotional code, with a photograph of your valid student ID. Student tickets are £50+VAT.

Bursary tickets

We offer a number of free bursary places for patients and carers. These places are limited to maintain a balance of voices in the room between patients, service users, carers, and health and care professionals.  To apply for a bursary place please email us a short paragraph explaining why you wish to attend.