systems that fail: service user and carer perspectives on patient safety
TRANSCRIPT
Systems that fail: service user and carer perspectives
on patient safety
Presented by:Tim Bryson – Project ManagerSarah Rae - Service User Advisor
Systems that fail ?
• Our project focused on recognised significant systemic risk issues in mental health care
• We worked on redesign of care pathways and care processes using ‘systemic tools’
• We sought to involve service users and carers through the course of the project
Project Sites
Trust Site – Project Safety Improvement Focus
NEPFT Personalisation, reduced violence and aggressionIncreased skills and confidence in dealing with self-harm
NSFT Personalisation, reduced violence and aggressionStrengthened approach to incident investigation and reporting
CPFT Prevention and management of falls
SEPT Improved safety communication and caseload management
HPFT Safer discharge and transfers of care, user focused approach
Project interventions
• Learnt about systems safety assessment• Learnt about human factors training and
coaching, especially in mental health• Learnt about the integration of these
approaches• And about service user and carer involvement
Through systemic assessment we sought to shift the balance towards minimising future risks
Prospective
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Approach to patient safety: Retrospective vs. Prospective
Retrospective
LimitationsWhat hasgone wrong?
What could possiblygo wrong?
“The single greatest impediment to error prevention is that we punish
people for making mistakes”
Dr Lucian Leape, Harvard School of Public Health
Through human factors training we sought to shift the culture, towards a culture of open patient safety communication
We learnt that co-design makes patient safety interventions even more effective
System safety assessment
Human factors training and
coaching
Patient experience-based
co-design and improvement
Service user and carer perspectives
• Adverse events can have a significant impact on service users and families, up to and including death of a loved one.• Service users and carers are in a unique position to provide insights into their own care, into care systems and into care systems.• Dr Sarah Ryan, mother of Connor Sparrowhawk is one such carer……..
About me
• Severe and enduring mental illness• Alerted to safety issues during inpatient stay• Trained as an Expert by Experience and Patient
Leader• Led to national and local involvement opportunities• Invited to be a PPI Advisor to the SCPMH project in
2014
Why PPI?
• Service users and carers are good problem solvers• They bring a unique perspective and can raise
concerns• Ethical - end users have a right to influence care
delivery• It is government policy that people be involved in
the commissioning, planning, designing and delivering services
Learning from the project
• PPI should have been hardwired into the project from the start
• All the Trusts struggled with PPI to an extent• PPI can slip down the agenda when there are
competing priorities • Capturing the views patients and carers takes time
and persistence
Learning from the project
• Reviewing time, space and structures to facilitate PPI can help
• Involving service users and carers with experience of that pathway is key
• A culture of trust and openness is needed to encourage feedback
• People may feel freer to contribute in a session that is less process driven than the SSA
Where PPI worked well. . . . . . .
• Service users and carers helped to assess the benefit and impact of potential solutions
• Active role in developing and refining the care pathway interventions
• Pathway interventions were co-designed• People were keen to be involved • There was a marked culture shift
Where PPI worked well. . . . . . .
“…being in the group…I feel listened to”
“The group has helped me make sense of it all”
“I’m always made to feel welcome”
“My comments were valued and taken on-
board”
Human Factors Training
• Dr Harriet Nicholls, Associate Medical Director Luton and Dunstable NHSFT• Tim Bryson, Consultant. Bryson Consultancy• Dr Cinzia Pezzolesi, Senior Lecturer in Human Factors, University of Hertfordshire• Dr Jane Carthey, Human Factors and Patient Safety Consultant
Human Factors definitionHuman factors encompasses all
of those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work.Clinical Human Factors Group. 2009
Carayon et al., 2006
What we did
• Adapted one day human factors training programme from acute to mental health
- error and cognition- safety culture - non-technical skills- human factors based design
• Delivered coaching programme for Trust Champions
Two complementary interventions
• Systems safety assessment (SSA) and• Human factors training and coaching to improve the
non-technical skills of mental healthcare professionals.
Human factors training without SSA
Improved non-technical skills of frontline teams
No improvement in systems design
Healthcare team fire-fighting
SSA without human factors training Like looking through a
kaleidoscope without having the foundation of ‘systems thinking.’
Difficult to identify how leadership, teamwork, cultures, communication and situational awareness impact on safety
Two complementary interventions: Dimensions of safety
Dr James WardDr Terry Dickerson
Prof. P John Clarkson
System Safety Assessment
The interventions
24Evaluation
Solutions + Learning
2) Human FactorsTraining
1) System SafetyAssessment (SSA)
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• System Safety Assessment involves thinking about problems before they happen
• It asks the following questions:
System Safety Assessment
What is going on?What could go wrong?What problems might it cause?What are we doing to prevent it?How bad is it if it does go wrong?How likely is it to go wrong?Should we do anything about it? What should we do about it?
System Safety Assessment
SSA is:1.Proactive2.Systematic / structured3.Holistic / systemic
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Why?
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0-1-2
-3
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3
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Reactive
What hasgone wrong?
Proactive
What couldgo wrong?
Limitation or incentive?
John Illingworth, 2015. Continuous improvement of patient safety: The case for change in the NHS. The Health Foundation.
“Shifting away from delivering improvement through reducing incidences of harm to the proactive identification and management of hazards offers huge opportunities…”
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What did we do?Immersion event
Process mapping
+
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What did we do?
SSA Workshop 1:
What could possibly go wrong?
SSA Workshop 2:
What should we do about it?
+ Engagement with Service Users and Carers
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What did we do?
Development and implementation of solutions
What did we learn? Users’ feedback on SSA:•Well received •SSA “Best use of time today” (+ small increase afterwards)•SSA “Will be important”•Slightly lower scores after SSA2, but still positive. •Confident to use in future – but need expert facilitation.
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What did we learn? SSA Team’s evaluation:•Good attendance and engagement
– Across the organisations / across the professions– But needed more medical representation and
service user / carer input
•More time needed to be more comprehensive, accurate and creative•Significant variation across groups
– Size of groups– Complexity of subject– Atmosphere and buzz?
•SSA’s rigour is valued, but is hard!
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Some of the challenges
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Like a triathlon, when you don’t know the distances
What would we do in the future?• More time?• More frequent meetings? CQC /
staffing changes• Pre meeting to decide subject• Smaller groups?• Mindset?• HF first, THEN SSA.• More service user / carer
engagement• Training course / facilitators (NIHR
CLAHRC funding)• New SSA Toolkit!
– Simplified language / template– www.ssatoolkit.com
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