The measurement and monitoring of safety

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In this presentation, Jonathan Riddell Bamber looks at a new proposed framework to help answer the question 'how safe is care today?'

The framework is from a report by Charles Vincent, Susan Burnett and Jane Carthey of Imperial College London, commissioned by the Health Foundation.

The framework highlights five dimensions which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety.

The Health Foundation is exploring how to develop and adapt the framework discussed in this presentation.we are seeking the thoughts and insights of a wide range of stakeholders – including those with a specialist role in patient safety, those involved in direct care delivery, patients and carers and the public in general.

If you would like to share your thoughts, please complete our response form at https://www.surveymonkey.com/s/safetymeasurement or email measurement@health.org.uk by 1 July 2013.

The form includes the following questions:

Does the framework in this report reflect your experience of healthcare?
Are there other dimensions of safety and how would this framework relate to them?
Would using this framework make it easier for you to know whether care is safe?
Please tell us how you could use this framework.
What do you think needs to be done to help you use the framework in practice?
How could the intelligence from the framework be used to improve care?

We will share what we learn widely to help those involved in patient safety work. We will also use the responses to help develop our thinking about how to improve patient safety.

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The measurement and monitoring of safety

  1. 1. The measurement andmonitoring of safetyJonathan Riddell BamberResearch Manager
  2. 2. Why measuring andmonitoring of safety isimportantThe measurement and monitoring of safety2 We measure a lot, but...- are patients any safer than they were 10 years ago?- is your organisation safer than it was last year? Different facets, different perspectives- harm, error, reliability, resilience, other indices? Focus on how harmful our systems have been, not how safe our systems are- moving to prospective safety management.
  3. 3. CommissioningThe measurement and monitoring of safety3 Currently measuring safety Tools and approaches to measuring safety Positively illustrate a potential future
  4. 4. MethodsThe measurement and monitoring of safety4 Literature reviews Interviews with senior staff in nationalorganisations 11 case studies with healthcare organisationsin the UK and USA
  5. 5. How do we know care issafe?The measurement and monitoring of safety51. Has patient care been safe in the past?2. Are our clinical systems and processes reliable?3. Is care safe today?4. Will care be safe in the future?5. Are we responding and improving?
  6. 6. FrameworkThe measurement and monitoring of safety6Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learning
  7. 7. FrameworkThe measurement and monitoring of safety7Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learningHas patient care beensafe in the past?
  8. 8. FrameworkThe measurement and monitoring of safety8Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learningHas patient care beensafe in the past?Are our clinical systemsand processes reliable?
  9. 9. ReliabilityThe measurement and monitoring of safety9 Defined as ‘failure free operation over time’ How safe are clinical systems? Dean-Franklin et al. (2010), Health Foundation- 81% and 87% reliability- 15% missing information- 6% exposed to risk Much being done in isolation, but ‘whole system’ reliability still a challenge Identify safety critical processes and behaviours across a system and specify levelsexpected
  10. 10. FrameworkThe measurement and monitoring of safety10Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learningHas patient care beensafe in the past?Is care safe today?Are our clinical systemsand processes reliable?
  11. 11. FrameworkThe measurement and monitoring of safety11Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learningHas patient care beensafe in the past?Is care safe today?Will care be safe in the future?Are our clinical systemsand processes reliable?
  12. 12. FrameworkThe measurement and monitoring of safety12Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learningHas patient care beensafe in the past?Is care safe today?Will care be safe in the future?Are our clinical systemsand processes reliable?Are we responding andimproving?
  13. 13. Integration and learningThe measurement and monitoring of safety13 How do you integrate a wealth of information meaningfully? Different levels, different needs e.g. Clinical Unit c.f. Board Not just integration: analysis, learning, feedback and action
  14. 14. 10 Guiding PrinciplesThe measurement and monitoring of safety141. A single measure of safety is a fantasy2. Safety monitoring is critical and needs more recognition3. Anticipation and proactive approaches to safety are important4. Focus more on analysis and learning of integrated information5. Map safety measurement and monitoring across the organisation6. A blend of externally required metrics and local development7. Clarity of purpose is needed when developing safety measures8. Empowering and devolving responsibility for the development and monitoringof safety metrics is essential9. Collaboration between regulators and the regulated is critical10. Beware of perverse incentives
  15. 15. What is yourorganisation’s approach?The measurement and monitoring of safety15Past harmReliabilitySensitivity tooperationsAnticipationandpreparednessIntegrationand learning
  16. 16. Reflections from theHealth FoundationThe measurement and monitoring of safety16 Key components of a safe system We recognise the need for adaptation and customisation for differentaudiences and settings Life gets in the way - context matters Different approaches for an organisation compared with a patient pathway ora population
  17. 17. Thank youThe measurement and monitoring of safety17Centre for Patient Safety and Service Quality (CPSSQ)Professor Charles Vincent, Susan Burnett, Dr Jane CartheyDr Alex Almoudaris, Dr Jonathan Benn, Dr Rachel Davies, Dr Anna Pinto,Dr Stephanie RussThe Health FoundationProfessor Nick Barber, Dr Jane Jones, Dr Elaine MaxwellAdvisory BoardDr Mike Durkin, Dr Chris Jones, Dr Suzette Woodward, Dr ChristineGoeschel, Dr Eamonn Breslin, Dr Jo Bibby, Julie Hendry, HelenCrisp, Margaret Goose, Dr Tim Draycott

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