‘One Year on’ – Project Learning Event

Project team presentations

Safer Care Pathways in Mental Health ProjectThursday 2 July, 2015

Oliver ShanleyProject Board Chair

Aims of the event

• To provide an overview of project progress ‘One Year on’, • To hear about the baseline evaluation findings• To share the learning and progress from all of the project

sites on their safety improvement work to date• To provide an opportunity for all project stakeholders to

work on planning the next phase of the project up until June 2016, including service user and carer involvement

Programme

• 9.30 Welcome and aims for the event – Oliver Shanley and Tim Bryson• 9.45 One Year On – Project Progress Overview

• System safety assessments – James Ward• Evaluation findings – Kai Ruggeri• Patient safety measurement – Jane Carthey• Questions and discussion

• 10.30 ‘Sharing the Learning’ session – Trust project site leads• A: Older peoples care workshop – CPFT, NEPFT, NSFT.• B: Acute adult care workshop – HPFT, SEPT.• 11.15 Refreshments • 11.30 Service user and carer involvement in patient safety – Sarah Rae, and Sue Vincent• 11.45 Project site safety improvement planning - Table Workshops• 12.45 Plenary and closing summary – Tim Bryson and Project Team• 13.00 Close: lunch and networking

PROJECT OVERVIEWTIM BRYSON, PROJECT MANAGER

Project progress overview

Click to edit Master text styles• Third level• Third level• Third level• Third level

Process Output

Launch event and immersion event Engagement and project establishment

Care pathway mapping Focus and map for SSA process

System safety assessment 1 Identified and prioritised risks

System safety assessment 2 Evaluated safety solutions for key risk

Human factors training (in progress): champions and front line staff

Skills and tools for embedding safety communications changes

Baseline evaluation Analysis of pre-intervention status

How did it go so far ?

High lights• Enthusiastic and energetic project

team and project sites• Collaborative approach• Stages of work largely completed

on time and with good participation

• Clear focus from project sites on patient safety outcomes

• Wllingness to flex and be creative• Learning and feedback on tools

and approach

Low lights

• External factors (e.g. CQC and organisational change) have

caused delays and discontinuity• Service user and carer

involvement has been variable• Medical involvement low

Next project phase

• Continuing supported work on patient safety improvement projects in each project site

• Completion of human factors training programme by end November 2015

• Mid-point and end-point evaluation• Project write up from January 2016 onwards• Preparation of bid for continuation funding

• https://www.youtube.com/watch?v=JwCZwIz0v0o

System Safety Assessment (SSA) Review

Dr James WardPrincipal Research Associate, Healthcare

Dr Terry DickersonAssistant Director, Healthcare

“Immersion Event” – 23 October 2014

12

Nov-Dec Jan-Mar Mar-Jun

SSA – parts 1 and 2

13

SSA1 SSA2 HF Implementation

Process Mapping and Baseline Data

SSA 1 – What can go wrong?

•What could go wrong?•Why?•How likely?•How bad?•Should I do anything?

SSA 2 – What shall we do?

•Expand options•Analyse options•Decide on solution(s) to implement

14

1 Recap of SSA1 – for each Group in each Trust

15

Recap of SSA1

Risk score 1Risk 1

Solutions to Risk 1

SSA2 outline

16

1.0 Background Section 1.1 Problem Framing

1.2 Criteria for Success

Some possiblities listed below:Patient feedback (compliments and complaints)GP feedbackFeedback from other stakeholdersReadmissions due to discharge plan failing (readmissions rate could be used)Put together a survey on "discharge: how are we doing?" to the stakeholders. Could do a before and after survey. Could include confidence of staff. Ask stakeholders how well they felt they were involved.Clearer and broader understanding across staff on what is a good discharge process?Check eg 3months after discharge that the care plan has gone through. Eg audit some discharges.Measurement of Transfer Delay - through manual audit.

In this section, you will describe the risk to be controlled, translate the potential causes & contributing factors into solution-neutral problem statements, and define the criteria for successful control of this risk.

1.1.2 Restate the risk and causes / contributing factors as solution-neutral problem statements

Define successful control of this risk. The definition should be SMART (Specific, Measurable, Achievable, Realistic, and Time-bounded)

Decision to discharge (/transition of care) a patient has been made (hopefully with the patient), but there are problems (eg delays or gaps in care, or patients might feel abandoned, or staff may be worried about the patient) with carrying out actions (discussion with the service user, outlining the plan, making the referral, contacting the team, discharge letter to GP, involving carers) and involving all of the relevant people in the process. [others include service users, carers, community workers, GPs, Spectrum].

1) Lack of staff continuity (especially care coordinators) means the receiver is not in place yet, or the allocated person changes, leading to delay or uncertainty.2) Complex arrangement of teams - travel, time and resources, and communication issues, etc. Community care has been reorganised.3) May not always be clear how to do the referral, especially at night when the receivers are not at work (particularly when they are not on PARIS - eg Spectrum).4) People not aware of the correct way of working (eg agency staff).5) People not following the system.6) May not be clear whether the referral has been accepted.7) Decisions are made on a single assessment, which may not be perfect.

Establish the context

Examples include: Examples include:Examples include: –New or revised policies / procedures

Examples include: –Walls or locked doors

–Substituting less dangerous drugs or other treatments

–Identifying / training backups for important people and for important equipment

2.0 Generating Options for Active Risk Control (GO-ARC)

Risk Control OptionsIf you can't contact the people you are referring to, who else do you contact?

–If a surgery is likely to lead to significant blood loss, making sure that matching blood is available and staged in an appropriate location for use

–Developing emergency operations plans detailing the response to events like severe flu pandemics, evacuation, active shooter scenarios, etc.

–Testing equipment shortly before use

This structured brainstorming technique will help you generate a broader and stronger pool of risk control options to choose from.

2.5 PreparednessPreparedness is the state of being ready for predictable risks. Risk controls in this category involve having a reasponse ready to go if the risk is realized. It means more than having a plan: It also means having the resources available and ready to be used to implement that plan. Drills and exercises are important for sustaining preparedness.

Examples include:

Follow up patients at 48hrs (?) to see how they are getting on. These would be only people who have not been transferred into HPFT services.Introduce a system where staff can flag up problems or suggestions.

–Use of “daily goals” and/or multidisciplinary rounds so the care team (and patients) know the treatment objectives

–Post-discharge follow-up

–Auditing, surveys, near-miss reports

Risk Control Options

–Remote monitoring (e.g. telemetry, CCTV, RFID)

–Clinical alarms (ideally with usability testing first)

–Asking the patient to alert staff if specific signs / symptoms occur

2.0 Generating Options for Active Risk Control (GO-ARC)

This structured brainstorming technique will help you generate a broader and stronger pool of risk control options to choose from.

2.4 Detection / Situational AwarenessThese risk controls focus on knowing that something is going wrong, or is likely to do so, in time to reduce its impact or prevent it altogether.

–Observation, continuous or intermittent (e.g., hourly nursing rounds)

Do disharge process around "big meetings" or conference call.

Provide written information to patients at discharge, which includes their crisis / care plan.

–Training and education

Note: Some studies have found that using training / education as a risk control may be associated with worse outcomes. While training is sometimes necessary, it is probably best to make sure there is a genuine and clearly-defined training requirement before selecting this approach.

–Checklists, signs, quick reference guides, other memory aids –Double checking

–Patient safety alerts

Risk Control OptionsInduction checklist for staff, to help them know what to do around the discharge process.

Add discharge planning into the clinical risk training programme

This structured brainstorming technique will help you generate a broader and stronger pool of risk control options to choose from. Consider both prevention and resilience.

–Human factors / usability improvements like changing the layout of crash carts with standardized compartments so materials are easy to find

–Failsafe / mistakeproof design (e.g., O2 connectors that won’t connect to the anesthetic gas lines)

–Isolation: Of patients, processes, equipment

–Permanent location changesProduce a directory on who to contact, around the discharge process. Could put this into the induction process.

2.0 Generating Options for Active Risk Control (GO-ARC)

–Awareness and persuasion campaigns

Develop a discharge planning tool, e.g. sheet of A4, which shows the things to discuss in a meeting. Could be implemented in PARIS.

2.3 Administrative Controls

–Automation without forcing functions (computerized physician order entry without any forcing functions to prevent a 10x overdose)

Policies, procedures, training, signs, alarms and other controls that depend on people taking the correct actions

2.0 Generating Options for Active Risk Control (GO-ARC)

Risk Control OptionsChange process so you can't discharge the patients until things are ready.This structured brainstorming technique will help you

generate a broader and stronger pool of risk control options to choose from. Consider both prevention and resilience.

Change PARIS so that it can help handle the discharge process

2.2 Design ControlsWith a focus on physical barriers, isolation, forcing functions, human factors, and failsafe design, design controls improve safety without relying on people to do the right thing.

Merge care across the units, e.g. staff follow the patient the whole way through treatment.

–Complete automation, or partial automation with forcing functions (e.g., software that prevents ordering a 10x overdose)

2.1 Eliminate the Hazard or the TargetElimination can mean transferring the risk to another entity, substituting a less hazardous process, material medication, etc., or simply not using the hazardous process / materials, not delivering the hazardous service, etc.

–Transferring the risk of drug preparation from the ward to the pharmacy through unit dosing, or to the pharmaceutical company by procuring pre-filled syringes

–Closing a low-volume ED where doctors are not getting enough practice to maintain their surgical skills

–No longer serving psychiatric patients in a given facility, if elopement cannot be controlled

Don't make referrals at night. Ask SPA to do it instead.

Introduce a document which helps the service user to have more buy-in to the execution of the discharge plan. Write a document to help SUs to know what to expect, e.g. roles of different people, around the discharge process, and who to contact if a problem, and suggested questions they could ask.

2.0 Generating Options for Active Risk Control (GO-ARC)

This structured brainstorming technique will help you generate a broader and stronger pool of risk control options to choose from. Consider both prevention and resilience.

Risk Control Options

Recruitment of more permanent staff, rather than agency staff.

Terry's idea

Generate possible solutions

3.3 Force Field Analysis 3.9 Risk Control ScoreBriefly describe the forces acting for and against the implementation and lasting success of this risk control A. Risk Reduction(i.e., strengths / weaknesses, barriers / facilitators). Do not forget to consider the expected reactions of key stakeholders. Risk reduction as a result of the risk control (not counting side-effects)

Score 1-6 (1 = negligible; 6 = very significant) B. Negative Side-Effects New risks introduced as a result of the risk control Score 1-6 (1 = negligible; 6 = very significant) C. Positive Side-Effects Score 1-6 (1 = negligible; 6 = very significant) D. Robustness Score 1-3 1 = Administrative control 2 = Design control 3 = Elimination of the hazard or the target E. Ease of use

Score 1-6 (1 = very difficult to use; 6 = very easy to use)F. CostHow much will this risk control cost, taking into account implementation, sustainment, and evaluation?Score 1-6 (1 = very inexpensive; 6 = very expensive)G. Risk Control Score (RCS)The RCS provides initial guidance on prioritizing risk control options

Might help staff to raise a concern about a discharge.

5How easy will it be to use this risk control, taking into account implementation, sustainment, and evaluation?

1

12.5

3.2 Mechanism of Action (How / why is this expected to work?)

The tool will help them to follow all the important parts of the process, and avoid missing out important parts. Will help less experienced staff.

Briefly describe the hazard (cause or contributing factor) the risk control addresses, and how the risk control is expected to reduce risk.

Mechanism to document evidence and helps audit Could take longer to get to a decision point

Forces in favor of success

3.4.1 Briefly describe the resources required 3.5.1 Briefly describe the resources required 3.6.1 Briefly describe the resources requiredList any positive side-effects (secondary benefits) that may be associated with this risk control

Briefly describe how outcomes will be measured and the standard against which they will be evaluated.

List any negative side-effects (secondary risks) that may be associated with this risk control 4

Staff might see it as more work to do

Additional risk improvements as a result of the risk control; other benefits (e.g., savings, improved patient satisfaction)

13.8.1 Positive Side-Effects

Change process so you can't discharge the patients until things are ready.

Develop a discharge tool for the MDT to help them in their decision making over discharge. E.g. an algorithm.1

2

Forces against successHelps planning to be more effective.

3.0 Options Analysis Worksheets 3.0 Options Analysis Worksheets 3.0 Options Analysis Worksheets 3.0 Options Analysis Worksheets 3.0 Options Analysis Worksheets

3.1 Description of the Risk Control 3.4 Implementation Planning 3.5 Sustainment Planning 3.6 Summative Evaluation Planning 3.7 Negative Side-Effects

Addressess issue of involving carersHelps provide more clarity on what to do.should help avoid missing out key stepsRegulator might like it

Worksheet 5 (Option 2)Worksheet 4 (Option 2)Worksheet 3 (Option 2)Worksheet 2 (Option 2)Worksheet 1 (Option 2)

Component scoresBriefly describe what will be done, where and by whom, how long it will take, and how success will be measured Briefly describe how the risk control will be implemented and how

successful implementation will be measured.Briefly describe how the risk control will be sustained and how successful sustainment will be measured (developmental

3.3 Force Field Analysis 3.9 Risk Control ScoreBriefly describe the forces acting for and against the implementation and lasting success of this risk control A. Risk Reduction(i.e., strengths / weaknesses, barriers / facilitators). Do not forget to consider the expected reactions of key stakeholders. Risk reduction as a result of the risk control (not counting side-effects)

Score 1-6 (1 = negligible; 6 = very significant) B. Negative Side-Effects New risks introduced as a result of the risk control Score 1-6 (1 = negligible; 6 = very significant) C. Positive Side-Effects Score 1-6 (1 = negligible; 6 = very significant) D. Robustness Score 1-3 1 = Administrative control 2 = Design control 3 = Elimination of the hazard or the target E. Ease of use

Score 1-6 (1 = very difficult to use; 6 = very easy to use)F. CostHow much will this risk control cost, taking into account implementation, sustainment, and evaluation?Score 1-6 (1 = very inexpensive; 6 = very expensive)G. Risk Control Score (RCS)The RCS provides initial guidance on prioritizing risk control options

3.0 Options Analysis WorksheetsWorksheet 4 (Option 1)

5How easy will it be to use this risk control, taking into account implementation, sustainment, and evaluation?

1

15

Staff feel more reassured.External stakeholders might feel their toes are being stepped on.Lower readmissions.

3.0 Options Analysis WorksheetsWorksheet 5 (Option 1)

Component scores

3

1

4Additional risk improvements as a result of the risk control; other benefits (e.g., savings, improved patient satisfaction)

3.6 Summative Evaluation Planning 3.7 Negative Side-EffectsBriefly describe how outcomes will be measured and the standard against which they will be evaluated.

1

Monitoring system. Service user feedback. New teams may feel anxious about implementing the idea.External stakeholders may be impressed with going the extra mile.Could take staff away from current patients.

3.8 Positive Side-EffectsList any positive side-effects (secondary benefits) that may be associated with this risk control3.6.1 Briefly describe the resources required

3.0 Options Analysis WorksheetsWorksheet 3 (Option 1)

Team leaders collect feedback from staff, and feed back this to the project lead.

3.4.1 Briefly describe the resources required 3.5.1 Briefly describe the resources requiredReview with a team lead's meeting

3.5 Sustainment Planning3.4 Implementation Planning

Consider whether 72 hours (or other) is best and evidence based.

What will we do if we can't get through.Look at why it didn't happen automatically last time.How to record that you have made the call. Eg on PARIS or on electronic whiteboard.Whether to text the patient instead / in addition (especially if you haven't got through).Do this with all four quadrants.Consider whether to implement with other teams outside Crisis as well - eg RAID and Wellbeing.

Focus on caring for patientsAcceptable to staff (based on previous trial)

Forces in favor of success Forces against successCheap to implementDone before - not new. Seems to work.

Anxiety if you can't contact the patient.It is an additional thing for staff to do.

Need for documentation of the call + monitoring of thisPatients may expect to have a phone call, and if they don't…

3.0 Options Analysis WorksheetsWorksheet 2 (Option 1)

Some evidence base (USA)

3.0 Options Analysis WorksheetsWorksheet 1 (Option 1)

3.1 Description of the Risk ControlBriefly describe what will be done, where and by whom, how long it will take, and how success will be measured

There could be additional things to do afterwards.

Check consent with patients to see whether they are happy to be contacted.

Follow up patients with a "care" call by telephone at up to 72 hours to see how they are getting on. These would be only people who have not been transferred into HPFT services.

Audit to see whether a) the follow up has occurred in the time frame and b) whether appropriate action has been taken as a result.

3.2 Mechanism of Action (How / why is this expected to work?)

List any negative side-effects (secondary risks) that may be associated with this risk control

Briefly describe how the risk control will be sustained and how successful sustainment will be measured (developmental

Briefly describe how the risk control will be implemented and how successful implementation will be measured.

Briefly describe the hazard (cause or contributing factor) the risk control addresses, and how the risk control is expected to reduce risk.This is for patients (e.g. who have been discharged from A&E, following assessment but not taken on by HPFT) this should help patients not to feel abandoned and staff to feel confident that their ex-patients are alright.

Analyse possible solutions

SSA2 outline

17

4.0 Options Evaluation Matrix

Hazards

/

Not clear if referral is accepted Single assessment

/ /

lack of staff continuity Complex team arrangement Unclear process Lack of awareness

/ / /

Present risk control recommendations in ranked order, from highest to lowest priority, and illustrate the relationship between the risk control recommendations and the hazards (causes and contributing factors) identified in Section 1.2 (Background)

Risk Control Options1 - Follow up phone call (14)

Not following system

/

2 - Discharge tool (12.5)

/

Select desired solutions

Output deadline Today Meetings

Milestone Go live

17/04/2015 15:20

Task Activity LeadStatus Against

Work PlanIssues/Comments

A Development of the Interventions

1 Green

2 Green

3

B Development of the Evaluation Method

1 Green

2 Amber

3 Amber

C Recruitment of Participating Wards/Services

1

2

3

4

D Implementation of the Intervention

1

2

3

E Evaluation

1

2

3

F Reporting to the HF Team

1

2

3

G Reporting to other Trusts

WEEK COMMENCING

Develop implementation plan

SSA1:

•5 Trusts

•9 Groups

•55 Staff

•57 risks

(figures in italics are approximate)

SSA results – headline figures

18

SSA2:

•5 Trusts

•7 Groups

•49 Staff

•109 initial ideas, 42 shortlisted, 13 analysed

SSA summary

19

SSA2 SummaryWho No. of Staff

(No. of Team members)

Number of groups running

concurrently

Focus of assessment # possible ideas

# proposed ideas

# analysed ideas

Examples of proposed actions

HPFT 5 (5) 1 Problems around point of discharge of patients

16 9 2 Follow up patients with a "care" call by telephone at up to 72 hours to see how they are getting on. Develop a discharge tool for the MDT to help them in their decision making over discharge.

CPFT 6 (6) 1 Falls in specific locations 28 7 3 Improve access to spill kitsPut a day and night clock in the patients' bedroomsPut up a notice about each patient's mobility needs, e.g. in their wardrobe.

NEPFT 13 (4) 2 GP1: Self harm and staff not feeling equipped to deal with change in pt. profile

15 4 2 KUF trainingHaving one consultant as medical lead for the ward

GP2: Harm from V&A 3 3 1 Instigate regular patient safety (V&A) data feedback

NSFT 15 (5) 2 GP1: V&A on arrival at ward

22 9 3 Have early conversation to learn more about the patient Give carer and information leaflet, preferably prior to admissionSeparate the new patients (eg first 72 hours) from the other patients

GP2: Falls 8 8 1 Design a ward walking rota

SEPT 10 (5) 1 Decision not to admit a patient

17 2 1 Patient makes the decision, which can override the clinical decision, after a discussion with them.

General observations on the SSA process

20

• Participants. Good turnout and engagement. Ideally more service users and medics.

• Just one issue for SSA1.

• Time gap = some changed priorities (Issues). Need to maintain engagement.

• CQC!

• Readdressing some SSA1 work.

• Just one risk for SSA2.

• Challenging sections:

• Prioritisation of issue(s) to focus on.

• Clear problem statement.

• Criteria for success.

• Completing the form, e.g. “Options Evaluation”

• Hard work. Steep learning curve.

General observations on SSA2 process

21

hard

work

“The second time was much faster

and we were getting into the flow.”

Language and concepts

“hard to get head round”

“We got quite focussed.”“Hard going but really

helpful.”

“It’s full-on”

“You can apply this to the

mental health setting.”

“I think there’s huge

potential in SSA”

“I’m really pleased with

what we got done”

“We didn’t get caught [up

in] your paperwork.”

SSA2 – next steps• Other meetings arranged with Terry / James• But mainly it’s over to you!• Implementation

– Planning– Development of ideas– Development of evaluation plan– Implementation planning– Sustainment planning

• And now it really is over to you… at 10:30!

22

What you’ve told usPresented byEvaluation Team Lead – Dr Kai Ruggeri

Evaluation overview

What you’ve provided Baseline templates Workshop feedback Patient Safety Culture

Questionnaires Interviews Reflective diaries

What are we aiming for?

• What is the context?

• What are the key positive and negative factors?

• What specific issues could be addressed?

• What has worked? What has not worked?

• For today: What have we learned so far?

What we’ve learned: Baseline Templates

Feedback and conclusions on summary In general, all trusts make use of extensive risk

matrices and frameworks, risk descriptions, information from patients and carers, quality improvement projects (e.g. human factors training)

There is no abnormal spread of risks across the different types of risk categories

Most reported incidents were minor or non-incidents

Proactive vs reactive

What we’ve learned: SSAs

Feedback and conclusions on summary Generally positive about topics discussed Some felt a positive improvement by the end Perhaps would’ve liked more guidance in practice

PSCQ Descriptives

SEPT NEPT HPFT CPFT NSFT Total

M SD SE M SD SE M SD SE M SD SE M SD SE M SD SETeamwork Within Units 3.91 .51 .14 3.82 .49 .08 4.06 .48 .14 3.87 .51 .10 3.40 .77 .14 3.77 .60 .06Supervisor/Manager Expectations& Actions Promoting Patient Safety

3.68 .46 .12 3.82 .70 .12 3.96 .66 .19 4.10 .53 .10 3.48 .71 .13 3.80 .67 .06

Organizational Learning - Continuous Improvement 3.64 .44 .12 3.78 .35 .06 3.65 .39 .11 3.85 .50 .10 3.35 .72 .14 3.66 .54 .05

Management Support for Patient Safety 3.64 .59 .16 3.30 .77 .13 3.22 .80 .23 3.60 .80 .15 2.98 .78 .15 3.32 .79 .07

Overall Perceptions of Patient Safety 3.34 .50 .13 3.34 .78 .13 3.21 .77 .22 3.56 .66 .13 2.74 .67 .13 3.23 .75 .07

Feedback & Communication About Error 3.88 .64 .17 3.46 .58 .10 4.00 .45 .13 4.14 .71 .14 3.44 .72 .14 3.72 .70 .07

Communication Openness 3.74 .72 .19 3.63 .58 .10 4.03 .54 .16 3.80 .80 .15 3.35 .58 .11 3.65 .68 .06Frequency of Events Reported 3.95 .58 .16 3.83 1.03 .17 3.03 1.06 .31 4.04 .85 .16 3.60 .85 .16 3.76 .94 .09Teamwork Across Units 3.16 .65 .17 3.35 .62 .10 3.29 .44 .13 3.69 .57 .11 3.08 .71 .13 3.34 .65 .06Staffing 2.58 .71 .19 2.89 .78 .13 2.66 .72 .21 2.85 .55 .11 2.25 .48 .09 2.67 .69 .06Handoffs & Transitions 3.20 .62 .17 2.88 .73 .12 3.00 .75 .22 3.37 .64 .12 2.90 .45 .09 3.05 .66 .06Non-punitive Response to Errors 3.24 .55 .15 3.05 .79 .13 3.00 .85 .25 3.22 .77 .15 2.79 .81 .15 3.04 .78 .07

Patient Safety Grade* 2.14 .53 .14 2.15 .64 .11 2.17 .72 .21 2.04 .59 .11 2.96 .58 .11 2.32 .70 .06Number of Events Reported* 2.26 1.16 .31 2.02 1.09 .18 2.07 .92 .27 2.56 1.08 .21 3.27 1.29 .24 2.48 1.22 .11

*All scales are low/negative to high/positive except those with *

PSCQ Totals

Teamwork W

ithin U

nits

Superviso

r/Manager E

xpecta

tions

& Actions P

romoting Patient Safety

Organizational L

earning - Continuous I

mprovement

Management Support

for Patient S

afety

Overall P

erceptions o

f Patient S

afety

Feedback & Communica

tion About Erro

r

Communication O

penness

Frequency of E

vents

Reported

Teamwork Acro

ss Units

Staffing

Handoffs & Transiti

ons

Nonpunitive Resp

onse to

Errors

Patient Safety

Grade

Number of E

vents

Reported

1

2

3

4

5

Asking your help!

What we’d like Reflective diaries

Interviews were a great source More would be ideal!

Assessment plans Check emails tomorrow!

Presented by Dr Jane CartheyHuman Factors and Patient Safety Consultantwww.janecarthey.comEMAIL: jane@janecarthey.com

Measuring and Monitoring Safety

Professor Charles Vincent

Dr Jane Carthey

Ms Susan Burnett

Has patient care been safe in the

past?

Are we responding and improving?

Will care be safe in the future?

Is care safe today?

Are our clinical systems and

processes reliable?

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.

A framework for the measurement and monitoring of safety

Source: Vincent C, Burnett S, Carthey J.

The measurement and monitoring of safety. The Health Foundation, 2013

Mental health safety thermometer

• Enables teams to measure harm and the proportion of patients that are 'harm free' from:

– self-harm, – psychological safety, – violence and

aggression, – omissions of medication

and restraint (inpatients only). http://www.safetythermometer.nhs.uk/

index.php?option=com_content&view=article&id=4&Itemid=109

GP retires: New GP

Red buses & restaurants: Advertisements

Outbursts per week

Voices telling her to only use her right hand

Friends/community pharmacist/dentist./hairdresser

Keeping track of a complex repeat prescription with 11 medications on it

Your safety improvement work

• How are you measuring whether the change leads to improvement?

• Do you use a combination of measures from the 5 dimensions?

• How are you capturing the service user and carer’s perspective in your measurement plan?

Service User and Carer Involvement in Patient Safety

Presented by: Sue Vincent - Carer Advisor and Sarah Rae - Service User Advisor

Learning from the project

• All the trusts have found service user and carer involvement challenging

• Capturing service user and carer views takes time• There are specific structures and factors to consider• Service users and carers often feel more able to

contribute in a dedicated session• Their input has influenced the development of the

HPFT interventions.

“We met yesterday for our project meeting and clearly thought about shaping our actions form the service user point of view. For example, we had planned a discharge algorithm for the MDT (Multi-Disciplinary Team) to use to make discharge safer, we are now planning to make it a shared document that is worked on and discussed together with the SU so that they feel informed and involved in the discharge plan, they would then have information to take with them to their next professional and GP that would hopefully help the transition from acute care to community feel less uncertain”.

“No, not surprised but really excited about how useful the information we stumbled across was. It was a really important element that needed to be dragged in”.

Sarah Biggs (HPFT)

Learning from the project

Learning from the project

Involving the carer

• Advantages• Disadvantages

Over to you

Finding ways to amplify the voice of service users and carers has been difficult

•What can we do to work further in their area?

•What might some of the issues be?

Patient safety improvement plan – review questions

• Project goals – Are we agreed ? Are they clearly stated ? How realistic ? How ambitious ?

• Key milestones – Are these set out ? (SMART ?)• Safety outcome measures –Have we established safety outcome

measures or proxy measures ? How will we make sure data is collected ?• Involvement and communication – How well are we involving service

users and carers ? How well are we involving staff ? What could we do to strengthen involvement and communication ?

• Next steps – Who is doing what by when ? Are we clear about planned project actions ?

• Support – do we need any additional support from within the Trust ? Do we need any additional support from the project team ?

• Three key points to feed back.