collaborate to create and test a robust safety...
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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
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
Programme #THFSMP This session #qfa7
Listen carefully!
Safety Measurement and Monitoring ProgrammeApril 2016
#quality2016#qfa7
Tweet, tweet, tweet Image http://ed100.org/success/measures/
Let’s be the best!
Safety Measurement and Monitoring ProgrammeApril 2016
Professor Charles Vincent , Professor of Psychology, University of Oxford
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
Charles VincentSusan BurnettJane Carthey
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
We do not know whether we are making progress or not
Safety Measurement and Monitoring ProgrammeApril 2016
Just tell me - are we safe?
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
Assurance Inquiry
Safety Measurement and Monitoring ProgrammeApril 2016
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?
Safety Measurement and Monitoring ProgrammeApril 2016
•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?
Safety Measurement and Monitoring ProgrammeApril 2016
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%
Safety Measurement and Monitoring ProgrammeApril 2016
‘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
Safety Measurement and Monitoring ProgrammeApril 2016
•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 Measurement and Monitoring ProgrammeApril 2016
•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?
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
•WHO Surgery Checklist
•Risk assessments
•Risk registers
•Safety culture assessments
•Safety cases
Anticipation and Preparedness:Will care be safe in the future?
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
Integration & learning. Are we responding and improving?
Safety Measurement and Monitoring ProgrammeApril 2016
“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
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
Response & Evolution
Safety Measurement and Monitoring ProgrammeApril 2016
•‘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
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
Dr Brian Robson,Executive Clinical Director, Healthcare Improvement Scotland
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
• 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.
Safety Measurement and Monitoring ProgrammeApril 2016
• 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
Safety Measurement and Monitoring ProgrammeApril 2016
• 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
Safety Measurement and Monitoring ProgrammeApril 2016
Image https://commons.wikimedia.org/wiki/File:Uk_outline_map.pngTest sites
40
NHSScotland
Safety Measurement and Monitoring ProgrammeApril 2016
Imageswww.theguardian.com, www.mountain-adventures.co.uk/cuillin-ridge-traverse.html
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
Death Certification Review Service
Safety Measurement and Monitoring ProgrammeApril 2016
Hospital Standardised Mortality Ratio
Safety Measurement and Monitoring ProgrammeApril 2016
Image: www.autobarn.net
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
Charles’ ‘bubbles’ broadened our thinking
47
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
49
Safety Measurement and Monitoring ProgrammeApril 2016
NHS Borders
Daily Weekly Monthly
•Ward safety briefs•Ward safety information•Hospital safety brief
•Weekly operational forums
•Monthly board and decision making groups
Safety Measurement and Monitoring ProgrammeApril 2016
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
Sensitivity to OperationsAnticipation and Preparedness
Integration and learning
Past Harm
Reliability
Sensitivity to OperationsAnticipation and Preparedness
Integration and learning
Past Harm
Reliability
Sensitivity to OperationsAnticipation and Preparedness
Integration and learning
Past Harm
Reliability
Sensitivity to OperationsAnticipation and Preparedness
Integration and learning
Medication errors
Past Harm
Reliability
Sensitivity to OperationsAnticipation and Preparedness
Integration and learning
NHS Tayside
Safety Measurement and Monitoring ProgrammeApril 2016
Safety Measurement and Monitoring ProgrammeApril 2016
53
Safety is not a measure or a dataset
Safety is a process of inquiry
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
•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
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
•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)
Safety Measurement and Monitoring ProgrammeApril 2016
1. Sharing safety intelligence – all formats, huddles, dashboards & even talking!
2. Quality improvement knowledge, skills & an opportunity to practice
3. Involving & engaging teams
Three key reflections from testing
Advancing Quality Alliance (AQuA)
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
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.
Three key reflections from testing
Haelo
Safety Measurement and Monitoring ProgrammeApril 2016
• 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
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
Who’s been listening?
Remember the prize?
Image : blog.sfgate.com Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
a. Investigation
b. Inquiry
c. Imagination
d. Interrogation
e. Improvisation
Professor Vincent suggests that we need to shift from assurance to what?
Question 1
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
How well did you do?
Pass your answers to the person on your left to mark them
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
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
Safety Measurement and Monitoring ProgrammeApril 2016
The winner(s) .....
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Safety Measurement and Monitoring ProgrammeApril 2016
How many kilometres is it from Gothenburg to Glasgow?
Tie breaker
1010 kilometres
Safety Measurement and Monitoring ProgrammeApril 2016
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
……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?
Safety Measurement and Monitoring ProgrammeApril 2016
Thank you
Safety Measurement and Monitoring ProgrammeApril 2016
Questions from you ?
Programme #THFSMP This session #qfa7
Safety Measurement and Monitoring ProgrammeApril 2016
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