Education and qualifications

• 2019: Value Measurement for Health Care, Harvard Business School Executive Education, Boston USA
• 2018: Member of the Royal College of General Practitioners
• 2017: Doctor of Philosophy, Generating learning from patient safety incident reports from general practice, Cardiff University, UK
• 2014: Improvement Advisor Professional Development Program, Institute for Healthcare Improvement, Cambridge, USA
• 2011: Leading Innovation in Health Care & Education, Harvard Macy Institute, Harvard University, Boston, USA
• 2010: Master of Philosophy (Medical Education), Cardiff University, Cardiff, UK
• 2010: MB BCh, University of Wales College of Medicine, Cardiff, UK
• 2007: BSc (1st Class Hons, Public Health), University of Wales, Cardiff, UK

Honours and awards

Awards

• Yvonne Carter Award for Oustanding New Researcher, Royal College of General Practitioners / Society for Academic Primary Care, 2018
• Honorary Membership of The Faculty of Public Health, 2017
• Royal College of General Practitioners 'Spotlight Award', 2016
• Peter Wall Scholar, Institute of Advanced Studies, University of British Columbia, 2016
• Health Service Journal Rising Star Award, 2015
• Churchill Fellow, Winston Churchill Memorial Trust, 2013–2015
• Innovation and Engagement Award, School of Medicine Cardiff University, 2013
• NHS Wales Award (co-recipient) for Promoting Clinical Research and Application to Practice, 2012
• Permanente Journal Health Services Award, 2012
• Gold Award Winner, Worshipful Livery Company of Wales, 2010

Peer esteem

• Keynote speaker, Queen's University Health Quality Research Forum, Kingston, ON, Canada, May 2019
• Invited speaker, WHO Ministerial Summit on Patient Safety, Tokyo, Japan, April 2018
• ISQua expert, The International Society for Quality in Healthcare, March 2018
• Invited participant, International Symposium on Safety Investigation in Healthcare, organised by the Healthcare Safety Investigation Branch (England), March 2018
• Invited speaker, WHO Patient Safety Expert Meeting on Global Knowledge Sharing, Florence, Italy, November 2017
• Guest lecturer, Harvard Chan School of Public Health, Harvard University, Boston, USA, January 2017
• Member, World Health Organization Patient Safety Incident Reporting System Guideline Review Group, Geneva, Switzerland, November 2016
• Invited member, WHO Global Consultation `Setting Priorities for Global Patient Safety', Florence, Italy, September 2016
• Keynote speaker, National Association of Educators in Practice, UK, March 2015

Professional memberships

• Member, Royal College of General Practitioners (2018–)
• Fellow, Royal Society of Arts (2018–)
• Member, Q initiative, Health Foundation (2017–)
• Member, European Public Health Association (2017–)
• Honorary Member, UK Faculty of Public Health (2017–)
• Associate Member, Royal College of General Practitioners (2012–8)
• Registered medical practitioner, General Medical Council (2010–)

Academic positions

• 2019 – present: Adjunct Professor, Queen's University, Kingston, ON, Canada
• 2016 – present: Honorary Professor, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
• 2015 – present: Visiting Chair, Department of Family Practice, University of British Columbia
• 2015 – present: Patient Safety Research Lead, Primary and Emergency Care Research Centre, Wales
• 2012 – 2018: Wales Clinical Academic Training Lectureship (Clinical Lecturer), Cardiff University
• 2010 – 2012: Clinical Fellow, Cochrane Institute of Public Health, Cardiff University

Speaking engagements

INVITED PRESENTATIONS 

a). International (since 2015) 

• 08/2019 Piecing together healthcare’s data jigsaw puzzle for data-driven healthcare improvement. Healthcare Quality Exchange [online]. Queen's University. Kingston, Ontario. 
• 06/2019 Value-Based Health Care across the NHS in Wales. 2nd Meeting of the Working Party for the OECD Patient Reported Indicator Surveys. Paris, France.
• 06/2019 Patient safety research in Wales – making the most of data we already have. School of Public Health, University of Zambia. Lusaka, Zambia. 
• 05/2019 Maximising learning from unsafe care. Queen's University Health Quality Research Forum, Kingston, ON, Canada.
• 05/2019 Investigating unsafe primary care. Department of Family Practice Grand Rounds, Queen's University, Kingston, ON, Canada. 
• 05/2019 Navigating the Black Hole of Patient Safety Incident Reporting. Anaesthetic Grand Rounds, Kingston General Hospital, Kingston, ON, Canada. 
• 04/2018 Sources of unsafe care for older adults: lessons from a National Reporting and Learning System. WHO Global Ministerial Summit on Patient Safety. Tokyo, Japan.
• 11/2017 Methodological advances to analyse patient safety incident reports. WHO Patient Safety Expert Group. Florence, Italy.
• 11/2017 Recommendations for learning from incident reports. 12th Forum Risk Management in Sanità. Florence, Italy.
• 10/2017 Safety standards for digital health services – learning from a shared international perspective. ISQua Scientific Meeting on Quality and Safety in Healthcare. London, UK.
• 06/2017 Masterclass – the basics of quality improvement in healthcare. Delivered as faculty for the Institute for Healthcare Improvement. University of British Columbia. Vancouver, Canada.
• 01/2017 Generating hypotheses to improve healthcare from patient safety data. Epidemiologic methods to improve patient safety course, Harvard Chan School of Public Health. Boston, USA.
• 07/2016 Ask One Question to Learn and Act on What Matters to Patients. Institute for Patient- and Family-Centred Care 7th International Conference. New York City, USA.
• 04/2016 Mobilising rising leaders to improve care. International Forum on Quality and Safety in healthcare. Gothenburg, Sweden.
• 10/2015 System diagnostics for enhanced quality improvement. Menzies School of Public Health. Workshop. Brisbane, Australia.
• 10/2015 Improving primary care safety. Better Patient Safety Program. Victoria Risk Management and Insurance. Victoria, Australia.
• 10/2015 Improving medication safety by utilising the insights of frontline practitioners. University of Sydney. Sydney, Australia.
• 09/2015 Generating learning about patient safety in general practice – implications for policy and practice. Macquarie University. Sydney, Australia.
• 09/2015 Patient safety in primary care. Australian Commission on Safety and Quality in Health Care. Sydney, Australia.
• 08/2015 IHI Open School Student Organizing Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA.
• 03/2015 Using incident report data to improve paediatric safety. Institute for Professionalism & Ethical Practice, Boston Children’s Hospital. Boston, USA.
• 03/2015 Improving safety by maximising participation in quality improvement – summarising analysis of incidents using driver diagrams. Institute for Healthcare Improvement. Cambridge, USA.
• 02/2015 Improving the quality of ‘x’. British Columbia Family Practice Scientific Meeting. University of British Columbia. Vancouver, Canada.

b). National (since 2017 – full list available on request)

• 06/2019 Collaboration between academic leaders in primary and emergency care and research and development departments across Wales. R&D Directors Meeting. Welsh Government, Cardiff, UK.
• 01/2019 Measuring significant avoidable harm in general practice. National Quality Safety Forum Meeting. Welsh Government, Cardiff, UK. 
• 01/2019 Navigating the black hole of patient safety incident reporting. Department of Pharmacy, University of Nottingham. Nottingham, UK. 
• 05/2018 Primary Care Safety Data – What is out there and how do we use it? 1000 Lives learning event. Cardiff, UK.
• 03/2018 Service improvement in palliative care and supportive services. APM Supportive and Palliative Care conference. Bournemouth, UK.
• 02/2018 Methods for improving patient safety in general practice. Royal College of General Practitioners (Regional Faculty event). Birmingham, UK.
• 01/2018 Quality improvement in patient safety. Royal College of General Practitioners (Regional Faculty event). Glasgow, UK.
• 10/2017 Learning from patient safety incidents in practice. Royal College of General Practitioners Annual Conference. Liverpool, UK.
• 10/2017 Epidemiology of patient safety in primary care. 1000 Lives Primary Care Expert Reference Group. Wales, UK.
• 10/2017 Wales leading patient safety research for the world. Primary and Emergency Care Research Annual Conference. Swansea, UK.
• 06/2017 Realising a data-driven healthcare improvement agenda for NHS Wales. All Wales Therapeutic and Toxicology Centre Annual Conference. Cardiff, UK.
• 05/2017 Entering the Premier League – Research in Acute Medicine. Society for Acute Medicine Spring Meeting. Cardiff, UK.
• 04/2017 Realising quality improvement in primary care. One day workshop for the Improving Patient Safety in Primary Care programme organised by 1000 Lives. Cardiff, UK.
• 03/2017 Improving patient safety in primary care. Designed and delivered a one day workshop for the Improving Patient Safety in Primary Care programme organised by the Royal College of General Practice. Liverpool and London, UK.

SCIENTIFIC MODERATION AT MEETINGS 

a). International 

• 12/2016 Patient Safety Incident Report Expert Meeting. World Health Organization. Geneva, Switzerland.
• 09/2016 World Health Organization Global Consultation for “Setting Priorities for Global Patient Safety”. Florence, Italy.

Committees and reviewing

National

• Grant / final report reviewer for: National Institute for Health Research – HS&DR (2015-), Health Foundation (2017–), NIHR Programme grants for Applied Research (2018-); NHS Innovation Accelerator Awards (2018–); Medical Research Council (2019-)
• Member, Funding Committee of the National Institute for Health Research Policy Research Programme (2019-)
• Member, Salford Integrated Care Organisation Evaluation Panel, Advancing Quality Alliance (AQuA) (2019-)
• Scientific advisor, Patient Safety and Quality Improvement Research and Educational Development, NHS Education for Scotland (2018-)
• Member, College of Assessors for Innovating for Improvement and Scaling Up Improvement grants, Health Foundation (2017-)
• Member, Primary Care Safety Expert Group, 1000 Lives Improvement Service, Public Health Wales (2017-)
• Member, Reducing Medicines Related Harm in NHS Wales Working Group, Welsh Government (2017-)
• Executive Management Committee, PRIME Centre Wales (2015-)

International

• Grant reviewer, Ireland Health Research Board (2019) 
• Member, Working Party for the OECD Patient Reported Indicator Surveys (PaRIS) programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-)
• Member, Working Group for the OECD Patient Reported Safety Outcomes programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-)
• Expert advisory group, WHO Global Knowledge Sharing Platform for Patient Safety (1st meeting 2017, 2nd meeting 2019) 
• International scientific adivsory board, "Care Track Aged: appropriate care delivered to Australians living in residential aged care." Project No. 1143223 awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2018-)
• International scientific advisory board, “Harnessing systems science to build an effective and efficient health system” programme grant ($10.75 million) awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2017-)
• Editorial advisory board, BMJ Quality (2017-)
• Institute for Healthcare Improvement Scientific Symposium Advisory Board Member (2013)
• Coordinating member, World Health Organization Safer Primary Care Expert Group, (2012-)

• Date
• Type
• Selected

Overview of educational scholarship

I have taught quality improvement in Europe, Canada, USA and Australia, and frequently serve as Faculty for the Institute for Healthcare Improvement.

I share the methods developed by my research group (the 'PISA' group) to investigate and understand the epidemiology of patient safety incidents with other researchers. For example, I have trained over 45 health services researchers to independently use PISA methods. I was guest lecturer at the Harvard Chan School of Public Health in 2017 and co-taught a one-week course on  epidemiological methods for understanding patient safety. I also endeavour to support frontline healthcare staff, managers and leaders to learn from unsafe healthcare; for example, I was the Clinical Lead for Quality Improvement in Patient Safety at the Royal College of General Practitioners (2016-17) and co-authored the 'RCGP Guide for Reporting and Learning from Patient Safety Incidents in General Practice' and developed two free online modules hosted by RCGP Learning. I have contributed to Boston Children's Hospital / Harvard Medical School's OPEN Pediatrics programme on disclosure and apology to patients and families following unsafe healthcare. 

From 2012-16, I was the Institute for Healthcare Improvement UK and Ireland Faculty Lead for the online and community-based educational programme, the IHI Open School (2012-16) – now the largest provider of quality improvement and patient safety education worldwide.

As a medical student in 2008, I was an intern to Professor Donald Berwick at the Institue for Healthcare Improvement in Cambridge, USA. I was a co-founding leader of the IHI Open School. Utilising social organising methods and the IHI Open School's growing network of quality improvement enthusiasts, I was co-founder of a global patient safety campaign for junior healthcare professionals called "Check a Box. Save a Life." supporting the spread and dissemination of Professor Atul Gawande's Surgical Safety Checklist. In later years, as a faculty member, I developed methods for students to learn about the experience of patients and families in healthcare to inform quality improvement through Ask One Question – encouraging students to adopt simple strategies like asking every patient they meet, "What can I do to improve your care today?".

Educational leadership at Cardiff University

• Module leader, Changing Practice, Year 5 of C21 MB BCh programme, School of Medicine
• Module leader, Improving the Quality of Clinical Care (ME3079), Clinical Epidemiology BSc programme, School of Medicine
• C21 Lead, Division of Population Medicine, School of Medicine (2018–)

External teaching contributions

• Faculty, 'Building Essential QI Skills', co-taught (with Dr Kedar Mate) one-day course for Institute for Healthcare Improvement at the University of British Columbia, Vancouver, Canada, June 2017
• Invited faculty, 'Epidemiologic methods for patient safety', co-taught (with Prof Malcolm Maclure) one-week course at the Harvard Chan School of Public Health, Boston, USA, January 2017
• Faculty, IHI Open School Student Organizing Leadership Academy, Institute for Healthcare Improvement, Cambridge, USA; and, delivered workshop on 'Utilising social media for social mobilizing to improve patient and population health', August 2015
• Online lecture, 'What is quality Improvement?' for the Masters of Public Health Programme at King's College London, 2015
• Co-organiser, Quality Improvement Masterclass for Healthcare and Policy Leaders, Faculty of Medical Leadership and Management, March 2013

Quality assurance / examiner roles

• External Evaluator for the European Commission to the 'Improvement Science Training for European Healthcare Workers' Study, a multi-country educational research and development project
• PhD Examiner, University of Glasgow
• PhD examination chair, Cardiff University
• External examiner, Quality Improvement in MB BS curriculum, King's College London

Educational moderation at meetings (international)

• IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. Gothenburg, Sweden. April, 2016
• IHI Open School National (United States) Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2015
• IHI Open School Student Organising for Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA. August, 2015
• IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. London, UK. April, 2015
• IHI Open School Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2014
• IHI Open School Student Quality Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA. August, 2014
• IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. Paris, France. April, 2014
• IHI Open School Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2013

Textbook

• Co-editor, Patient Safety and Healthcare Improvement at a Glance, Wiley Blackwell

Overview of PISA Research Group

The PISA Group aims to determine the frequency, burden and preventability of healthcare associated harm in primary and emergency care settings, and to develop and implement interventions to improve patient safety in priority areas. 

We share the learning from our research and development with national (Welsh Government, UK Department of Health) and international policy makers (World Health Organization member state representatives).

The PISA Group aims to:

1. Generate learning from unsafe health and social care experienced by patients and families, through:

• investigating the frequency and avoidability of significant harm in healthcare;
• identifying patient safety priority areas from analysis of patient safety data and knowledge mobilisation with multiple stakeholders including NHS organisations and policymakers;

The PISA Group has developed a mixed methods research process to identify priorities for improvement from healthcare data describing patient safety incidents. The method has been used in two of the largest patient safety research studies in general practice including a national agenda setting study through analysis of patient safety free-text reports submitted to the England and Wales National Reporting and Learning System (funded by NIHR) and a case note review of >92,000 patient records in general practices in England (funded by Department of Health's Policy Research Programme). Our approach will now be applied in prison healthcare services across England from 2019 onwards.   

Our NIHR HS&DR funded study (2013-15) to characterise patient safety incidents occurring in in general practice identified a range of vulnerable patient groups and systemic weakness which warranted more in-depth investigation. Subsequent studies  focussed on identified priority areas including unsafe discharge from secondary to primary care settings and errors experienced by children in primary care, older adults, patients receiving palliative care, advanced care planning, patients with dementia, adults receiving mental health services in primary care, and adults receiving opiate replacement.  

Major studies completed by the PISA Group, include:

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice – published in the NIHR HS&DR journal https://doi.org/10.3310/hsdr04270

Automated classification of primary care patient safety incident report content and severity using supervised machine learning (ML) approaches – published in Health Informatics https://doi.org/10.1177/1460458219833102

Paediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database– published in Vaccine https://doi.org/10.1016/j.vaccine.2015.06.068

Safety incidents involving children in general practice – published in Pediatrics https://doi.org/10.1542/peds.2014-3259

Patient safety incidents involving sick children in primary care in England and Wales: A mixed methods analysis – published in PLOS Medicine https://doi.org/10.1371/journal.pmed.1002217

Harms from discharge to primary care: Mixed methods analysis of incident reports – published in British Journal of General Practice https://doi.org/10.3399/bjgp15X687877

Development of an international classification system for patient safety in primary care – published in the Bulletin of the World Health Organization http://dx.doi.org/10.2471/BLT.17.199802 

Nature of blame in patient safety incident reports: Mixed methods analysis of a national database – published in Annals of Family Medicine http://dx.doi.org/10.1370/afm.2123 

Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database – published in Palliative Medicine https://doi.org/10.1177%2F0269216318817692 

Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents – published in Palliative Medicine https://doi.org/10.1177/0269216318776846 

Sources of unsafe primary care for older adults: A mixed-methods analysis of patient safety incident reports – published in Age and Ageing https://dx.doi.org/10.1093%2Fageing%2Fafx044

Patient safety incidents in primary care dentistry in England and Wales: A mixed-methods study – published in the Journal of Patient Safety http://dx.doi.org/10.1097/PTS.0000000000000530

Patient safety incidents in advance care plans for serious illness: a mixed methods analysis – published in BMJ Supportive and Palliative Care http://dx.doi.org/10.1136/bmjspcare-2019-001824

Diagnostic error in the emergency department: learning from national patient safety incident report analysis – BMC Emergency Medicine In press.

2. Learning how to improve patient safety in different health and social care contexts (including care home), through:

• development and implementation of interventions to minimise harm to patients in health and social care settings;
• mixed methods evaluation of quality improvement initiatives;

Findings from our analyses are used to empirically inform the design of quality improvement initiatives and projects to improve patient safety in healthcare organisations. Lessons learnt from our primary care studies are being used by the 1000 Lives Improvement service in Wales to design their national-level improvement strategy for primary care patient safety. At a local level, one health board in Wales, used our analysis of reports about anticoagulation-related errors to highlight risks to patients being initiated on Warfarin in hospital. The subsequent quality improvement project led to a national Directed Enhanced Service for anticoagulation services to be delivered to patients in community settings instead (for more detail, watch a short video on  YouTube).

We conceptualise, investigate and support teams to improve patient safety for vulnerable patient groups across the care continuum. For example, with support from a Royal College of General Practitioners and Marie Curie funded fellowship, Dr Huw Williams MRCGP has assumed a 'researcher-in-residence' role at a large health board in Wales to evaluate a quality improvement project aiming to improve end-of-life care in the GP out of hours care setting. In collaboration with PRIME Centre Wales colleagues, the PISA group is also contributing to the design of an intervention to support primary health care teams, with the intention of reducing the time to diagnosis and improving cancer outcomes via the Cancer Research UK funded WICKED trial (CI: Neal, University of Leeds).

We evaluate the development, testing and implementation of patient safety interventions to understand how and in what contexts they can improve outcomes. The PISA Group use a theory-driven process evaluation approach developed with colleagues at Harvard Medical School and the Institute for Healthcare Improvement (see Parry, Carson-Stevens et al. 2013 for more detail). For example, supported by Health Foundation, we are evaluating an intervention, called the Polypharmacy Adverse Drug Reaction (PADRe tool), to detect adverse drug reactions experienced by residents in care homes.

3. Building capacity and capability to enable a transition from 'learning to action' , through:

• developing machine learning (artificial intelligence) approaches for automating patient safety data analysis;
• methodological innovation for sharing learning from medical error within (national) and between countries (international) including the development of taxonomy;

Lessons learnt from our research has been disseminated with support from the Royal College of General Practitioners to train the workforce to recognise, report and learn from patient safety incidents through e-learning courses, national seminars, and practical ‘how to’ guides (see my section on Teaching for more detail). 

We endeavour to build the capacity and capability of health service researchers to investigate patient safety (postgraduate students, clinical academics, post-doctoral fellows) through visiting appointments with the PISA group. 

Grant awards

Since 2012, I have secured or supported capture of research and programme awards in excess of £15 million from major health services research funders and charities.

Major funders include: 
Cancer Research UK
Health and Care Research Wales
Health Foundation (Advancing Analytics Award, Innovating for Improvement)
NIHR Health Services and Delivery Research
Royal College of General Practitioners
Royal College of Physicians (Wolfson Award)
NIHR Health Policy Research Programme
THIS Institute (post-doctoral award)

Academic collaborators

International 
Harvard Medical School, Boston, USA
Institute for Healthcare Improvement, Boston, USA
Macquarie University, Sydney, Australia
University of British Columbia, Vancouver, Canada
Queen's University, Kingston, Canada

United Kingdom 
Marie Curie Research Centre, Cardiff University and University College London
NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre
The University of Edinburgh
The University of Manchester
The University of Nottingham
The London School of Hygiene and Tropical Medicine