Collaborate to create and test a robust safety frameworkaws-cdn.internationalforum.bmj.com/pdfs/2016_A7.pdf · April 2016 Safety Measurement and Monitoring Programme •Reflective

Collaborate to create and test a robust safety framework

Professor Charles Vincent – University of Oxford

Dr Brian Robson - Healthcare Improvement Scotland

Dr Vicky Brown Yorkshire & Humber AHSN Improvement Academy

Andrea McGuinness Advancing Quality Alliance (AQuA)

Katharine Goldthorpe Haelo

April 2016

Safety Measurement and Monitoring ProgrammeApril 2016

• Introduce the Health Foundation and the Safety Measurement & Monitoring Framework

• Understand the value of working in partnership at a national level for safety improvement

• Understand the range of testing taking place

• Identify and network with colleagues from across the UK

Objectives of this session


Time Topic

11am Introduction

11:05am Background to the research

11:30am The testing programme

11:40am Focus on testing in one system NHSScotland

11:50am Our testingAQuA, Haelo, Yorkshire and Humber

12:05pm Q&A

12:25pm Close

Session outline

Our 90 minutes together


Programme #THFSMP This session #qfa7

Listen carefully!


#quality2016#qfa7

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Professor Charles Vincent , Professor of Psychology, University of Oxford



Charles VincentSusan BurnettJane Carthey



We do not know whether we are making progress or not


Just tell me - are we safe?


Methods

•Reviews of research literature and reports

oSafety relevant industries

oConceptual approaches and models of systems safety

oMeasurement and monitoring in healthcare

oThe role of patients and families

• Interviews with senior staff in national organisations

•Case studies in healthcare organisations in the UK and USA


•Has patient care been safe in the past?

•Are our clinical systems and processes reliable?

•Is care safe today?

•Will care be safe in the future?

•Are we responding and improving?

The fundamental questions


Assurance Inquiry


Has patient care been safe in the past?

Are our clinical systems and processes reliable?

Is care safe today? Will care be safe in the future?

Are we responding and improving?


•Treatment specific harm

•Harm due to over treatment

•General harm from healthcare

•Harm due to failure to provide appropriate treatment

•Harm due to failed or inadequate diagnosis

•Psychological harm and feeling unsafe

•Harm due to neglect and dehumanisation

What do we mean by harm?


Missing & faulty equipmentin the operating theatre

SiteTotal

operations studied

Number of operations

with equipment problems

Number of equipment problems

Percentage operations with

one or more equipment problems

A 258 50 56 19%

D 67 25 28 37%

F 165 19 19 12%

Total 490 94 103 19%


‘We always need a colposcope with

that list and time and time again it

isn’t there or it’s broken or it isn’t

back or nobody knows where it is’ Surgeon 3 Organisation A


•Clinicians monitor their patients, watching for subtle signs of deterioration or improvement,

•Leaders monitor their teams for signs of discord, fatigue or lapses in standards.

•Managers have to be alert to the impact of staff shortages, equipment breakdowns, sudden increases in patient flow and other problems.

Sensitivity to operations


•Safety walk-rounds

•Operational meetings, handovers and ward rounds

•Briefings and debriefings

•Day to day conversations

•And above all …. the patient voice

Soft intelligence: are we safe today?



•Pre-mission planning for fighter pilots often takes longer than the mission

•Each part of the route is analysed for possible threats, whether from hostile aircraft, personal factors, weather or technical breakdown.

•During the flight pilots devoted over 90% of available time to anticipation

•Typically they developed a ‘tree’ of events that might occur over the course of the flight.

Experts are constantly thinking ahead

Amalberti & Deblon, 1992



•WHO Surgery Checklist

•Risk assessments

•Risk registers

•Safety culture assessments

•Safety cases

Anticipation and Preparedness:Will care be safe in the future?


•Reflective work using framework

•Previously focused on incident data

•Now using measures relating to the number and type of vehicles out of service to help them to anticipate and prevent delayed response times.

•Safety huddles in the call centre where this information is communicated to the whole team

•Shared situational awareness of how out of service vehicles could impact on performance.

North West Ambulance Service



Integration & learning. Are we responding and improving?


“Most Health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed and that early warning signals can be valued and should be maintained and heeded” (Berwick, 2013, p26)

Berwick Report


•Number of days since the last serious incident (SI)

onarrative, lessons learnt and recommendations

•Central venous line, MRSA (MSSA) infection rates

•Hand hygiene compliance rate

•WHO Surgical Safety Checklist compliance rate per clinical unit

•Common themes identified in executive walk-rounds

•Medication errors

•Top three risks from the clinical unit’s risk register.

Great Ormond St: team level


Response & Evolution


•‘Deceptively simple’ or ‘elegantly simple’

oBut very different from current approaches

•‘We realised we were mainly focused on past harm’

•‘Structuring our thinking about safety’

•The proof of the framework will be in the expansion, validation & application

Reflections on the framework & the report



Has patient care been safe in the past?

Ways to monitor harm include:

•mortality statistics (including HSMR and SHMI)

•record review (including case note review and

the Global Trigger Tool)

•staff reporting (including incident report and

‘never events’)

•routine databases. Are our clinical systems

and processes reliable?

Ways to monitor reliability

include:

• percentage of all

inpatient admissions

screened for MRSA

• percentage compliance

with all elements of the

pressure ulcer care

bundle.

Is care safe today?

Ways to monitor sensitivity to

operations include:

• safety walk-rounds

• using designated patient

safety officers

• meetings, handovers and

ward rounds

• day-to-day conversations

• staffing levels

• patient interviews to identify

threats to safety.

Will care be safe in the future?

Possible approaches for achieving

anticipation and preparedness

include:

•risk registers

•safety culture analysis and safety

climate analysis

•safety training rates

•sickness absence rates

•frequency of sharps injuries per

month

•human reliability analysis (e.g.

FMEA)

•safety cases.

Are we responding and

improving?

Sources of information to

learn from include:

• automated information

management systems

highlighting key data at a

clinical unit level (e.g.

medication errors and

hand hygiene

compliance rates)

• at a board level, using

dashboards and reports

with indicators, set

alongside financial and

access targets.

Source: Vincent C, Burnett S,

Carthey J.

The measurement and monitoring

of safety. The Health Foundation,

2013


•What kind of safety problems could you reasonably anticipate?

•What kind of information would be useful?

•At what level of the organisation?

•How could you integrate, analyse and respond to such information?

Some questions


Dr Brian Robson,Executive Clinical Director, Healthcare Improvement Scotland



• Carry out research and in-depth policy analysis

• Run improvement programmes to put ideas into practice

• Support and develop leaders

• Share evidence to encourage wider change

@Healthfdn

www.health.org.uk

They:

The Health Foundation

- an independent charity working to improve the quality of health care in the UK.

http://www.health.org.uk/


• Road-tested the framework

• Held a public consultation and then summit in 2013

• Informed the Berwick Review on Mid Staffordshirewww.gov.uk/government/publications/berwick-review-into-patient-safety

• Produced a practical guide and materials

• Launched a new improvement testing programmewww.health.org.uk/publication/measurement-and-monitoring-safety

From the research we have:

From theory to practice

http://www.gov.uk/government/publications/berwick-review-into-patient-safety

http://www.health.org.uk/publication/measurement-and-monitoring-safety


• 18 months (June 2016)

• £1.8m funding

• Working closely with 3 regional improvement bodies & 6 test sites

• ‘Learning Partner’ capturing learning

AIM:

Translating the research and developing an approach that can be successfully adopted in diverse health care practice settings

Testing programme overview


Image https://commons.wikimedia.org/wiki/File:Uk_outline_map.pngTest sites

40

NHSScotland


Imageswww.theguardian.com, www.mountain-adventures.co.uk/cuillin-ridge-traverse.html

http://www.theguardian.com/

http://www.mountain-adventures.co.uk/cuillin-ridge-traverse.html


42

•5.3 million population

•£12 billion health budget

•14 territorial boards

•Special boards

-NHS Education for Scotland

-NHS Health Scotland

-NHS National Services Scotland

-Scottish Ambulance Service

-State Hospital

-NHS 24

•Public Body - Healthcare Improvement Scotland


Death Certification Review Service


Hospital Standardised Mortality Ratio


Image: www.autobarn.net


46

“Health statistics represent people with the tears wiped off” Sir Austin Bradford Hill

The (hospital standardised mortality ratio)HSMR should not be used as a sole basis to make judgements (positive or negative) about the quality or safety of patient care, as it is not a direct or absolute measure of quality or safety

HSMR Working Group Report, June 2014

“The patient experience will define the future of the NHS in Scotland” Paul Gray


Charles’ ‘bubbles’ broadened our thinking

47


All improvement is local

Mental health

• Inpatient mixed sex ward

• Natural evolution from Scottish Patient Safety Programme Mental Health

Frailty

• Focus at point of admission to acute services

• Natural evolution from work on Older People’s Care Improvement programme


49


NHS Borders

Daily Weekly Monthly

•Ward safety briefs•Ward safety information•Hospital safety brief

•Weekly operational forums

•Monthly board and decision making groups


MDT communication

Past Harm

Reliability

Sensitivity to

Operations

Anticipation and

Preparedness

Integration and

learning

Safety Planning

Past Harm

Reliability

Sensitivity to

Operations

Anticipation and

Preparedness

Integration and

learning

Safer Medicines

Past Harm

Reliability

Sensitivity to

Operations

Anticipation and

Preparedness

Integration and

learning

Past Harm

Reliability

Sensitivity to OperationsAnticipation and Preparedness

Integration and learning

Past Harm

Reliability



Past Harm

Reliability



Past Harm

Reliability



Past Harm

Reliability



Medication errors

Past Harm

Reliability



NHS Tayside



53

Safety is not a measure or a dataset

Safety is a process of inquiry


•Dr Victoria Brown, Yorkshire and Humber Improvement Academy

•Andrea McGuinness, Advancing Quality Alliance (AQuA)

•Katharine Goldthorpe, Haelo

Testing in different settings

Our testing across the UK



•Bradford Teaching Hospitals NHS Foundation Trust

•Integrated trust providing acute and community in-patient health care

•Bradford District Care NHS Foundation Trust

•Community, mental health and learning disability care provider

Regional Improvement Body committed to working with frontline services, patients and the public to deliver real and lasting change in healthcare.

Yorkshire and Humber Improvement Academy


1. Accessibility and interpretation of the Framework

2. Measuring and Monitoring safety at the Frontline

3. Important factors influencing change

Three key reflections from testing

Yorkshire and Humber Improvement Academy


•Mersey Care NHS Trust

•Provides specialist inpatient and community mental health services, medium secure & high secure services covering the North West of England, the West Midlands and Wales.

•North West Ambulance Service (NWAS)

•Covering an area of over 5,400 square miles & serving a population of seven million people. The service receives over 1.1 million 999 calls each year & works in partnership with multiple stakeholders and a significant number of volunteers.

An NHS health and care quality improvement organisation at the forefront of transforming the safety and quality of healthcare

Advancing Quality Alliance (AQuA)


1. Sharing safety intelligence – all formats, huddles, dashboards & even talking!

2. Quality improvement knowledge, skills & an opportunity to practice

3. Involving & engaging teams


Advancing Quality Alliance (AQuA)


Nature of testing

Haelo

Aim: to improve the measurement and monitoring of safety, working with senior leaders across health and social care economies by using the ‘Measurement and Monitoring of Safety’ framework (Vincent et all, 2013).

Key outcomes:o Improved understanding and capability for measuring and monitoring

safetyo A whole health and social care economy plan for measuring and

monitoring safety o Improved measuring and monitoring of safety across the health and

social care economy


1. The framework is a sophisticated way for organisations to frame their safety conversations

2. There is a great appetite for teams to think differently about how they measure and implement change across whole health and social care economy settings.

3. Although most of our safety knowledge resides in Past Harm, organisations, and their boards are developing more leading measures and are in a good place to begin predicting the future safety of their organisation.


Haelo


• Without the Framework we wouldn’t have

• “talked about safety they way we do now”

• “Challenged ourselves to ask if we are measuring the right things?”

• “recognised patterns & changed staffing to anticipate high risk times”

• Teams have recognised the value their contributions have made

• Sense of achievement

• Ownership with our work.

• Invested in team knowledge

Final thoughts



Time Topic

11am Introduction

11:05am Background to the research

11:30am The testing programme

11:40am Focus on testing in one system NHSScotland

11:50am Our testingAQuA, Haelo, Yorkshire and Humber

12:05pm Q&A

12:25pm Close

Session outline

Our 90 minutes together


Who’s been listening?

Remember the prize?

Image : blog.sfgate.com Programme #THFSMP This session #qfa7

http://blog.sfgate.com/sfmoms/2010/08/31/winning-and-losing-lessons-kids-need-to-learn/


a. Investigation

b. Inquiry

c. Imagination

d. Interrogation

e. Improvisation

Professor Vincent suggests that we need to shift from assurance to what?

Question 1


a. 3 .1 million

b. 4.2 million

c. 5.3 million

d. 6.4 million

e. 7.5 million

What is the population of Scotland?

Question 2


a.North West Ambulance Service

b. Bradford District Care NHS Foundation Trust

c.Royal London Hospital

d.NHS Borders

e.Great Ormond Street Hospital

Advancing Quality Alliance (AQuA) is supporting two test sites, one of which is:

Question 3


How well did you do?

Pass your answers to the person on your left to mark them


a. Investigation

b. Inquiry

c. Imagination

d. Interrogation

e. Improvisation

Professor Vincent suggests that we need to shift from assurance to what?

Question 1

Assurance Inquiry


a.3.1million

b. 4.2 million

c. 5.3 million

d. 6.4 million

e. 7.5 million

What is the population of Scotland?

Question 2

ftp://ftp.cs.vu.nl/pub/dick/tartan/Baird.gif

ftp://ftp.cs.vu.nl/pub/dick/tartan/Baird.gif


1.North West Ambulance Service

2.Bradford District Care NHS Foundation Trust

3.Royal London Hospital

4.NHS Borders

5.Great Ormond Street Hospital

Advancing Quality Alliance (AQuA) is supporting two test sites, one of which is:

Question 3


The winner(s) .....

Image : blog.sfgate.com Programme #THFSMP This session #qfa7

http://blog.sfgate.com/sfmoms/2010/08/31/winning-and-losing-lessons-kids-need-to-learn/


How many kilometres is it from Gothenburg to Glasgow?

Tie breaker

1010 kilometres




……our interactive and informal session this afternoon,

1:30-3pm in the networking and learning zone

– it will be fun!

Come along to…………

Want to find out more?


Thank you


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Documents

Collaborate to create and test a robust safety frameworkaws-cdn.internationalforum.bmj.com/pdfs/2016_A7.pdf · April 2016 Safety Measurement and Monitoring Programme •Reflective