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Measuring and Monitoring of Safety
Chris Power, CPSI
Dr. Charles Vincent, University of Oxford
Dr. G. Ross Baker, University of Toronto
Speakers
Chris Power
Chief Executive Officer,
Canadian Patient Safety
Institute
Prof. Charles Vincent
Department of Experimental
Psychology, University of
Oxford
Dr. G. Ross Baker
Institute of Health
Policy, Management
and Evaluation,
University of Toronto
Welcome
What have you read about
the Framework?
Have not had
a chance yet
Read the
Practical
Guide only
Read the full
2013 Health
Foundation
Report
Using the Framework
No action
yet
Planning for
applying the
Framework
in a clinical
setting
Started to
apply the
Framework
in a clinical
setting
Chris Power
CPSI’s interest in the
Measuring and Monitoring
of Safety Framework
Professor Charles Vincent
Overview of the framework
and lessons learned from
its implementation
The Measurement & Monitoring of Safety
CPSI Webinar January 2017
Charles Vincent
Professor of Psychology,
University of Oxford
Susan
Burnett
Jane
Carthey
10% patients
harmed, half
judged
preventable
UK National Reporting & Learning System
Hospital Episode Statistics: 11.8M
hospital admissions in England
2004/5
But incident
reporting only
detects 5% of
harmful events
We do not know whether we
are making progress or not
Just tell me - are we safe?
Methods
 Reviews of research literature and reports from
organisations:
– Safety relevant industries
– Conceptual approaches and models of systems safety
– Measurement and monitoring in healthcare
– The role of patients and families
 Interviews with senior staff in national
organisations
 Case studies in healthcare organisations in the UK
and USA across sectors
Safety in high risk industries
 Lagging indicators
– Measures of events of incidents
– Reactive measures safety performance
– Lost time injuries, incident reporting, thoroughness of
incident investigation
 Leading indicators
– Precursors, events or measures that purportedly predict
safety performance
– Monitoring of key control systems or actions
– Safety management system audits, safety cases, culture
surveys and walk rounds
Safety
in NHS
High Risk
Industries
Models
of Safety
PatientSafety
?
The fundamental questions
 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
in NHS
High Risk
Industries
Models
of Safety
PatientSafety
Case Studies
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?
What do we mean by harm?
 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
Adverse events in older people
• Errors, omissions
• Operative/procedural complications
• Hospital acquired infections
• Adverse drug events
Adverse
events
affecting all
age groups
Adverse events in older people
• Errors, omissions
• Operative/procedural complications
• Hospital acquired infections
• Adverse drug events
Adverse
events
affecting all
age groups
• Falls
• Pressure sores
• Incontinence
• Functional ± mobility
decline
• Delirium
• Depression
• Nutritional decline
• Dehydration
The
geriatric
syndromes
Should be thought of as adverse events
• Preventable?
• Prolonged hospital stay
• Increased morbidity and mortality
+
 Clinical information available in hospital
outpatient clinics
 Prescribing for hospital inpatient
 Equipment availability in the operating theatre
 Equipment available for inserting peripheral
intravenous lines
Missing & faulty equipment
Site
Total
operations
studied
Number of
operations
with
equipment
problems
Percentage
operations
with one or
more
equipment
problems
A 258 50 19%
D 67 25 37%
F 165 19 12%
Total 490 94 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
Sensitivity to operations
 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.
Soft intelligence
 Safety walk-rounds
 Using designated patient safety officers
 Operational meetings, handovers and ward rounds
 Briefings and debriefings
 Day to day conversations
 And above all …. the patient voice
Experts are constantly
thinking ahead
 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.
Amalberti & Deblon, 1992
Anticipation and Preparedness:
Will care be safe in the future?
 WHO Surgery Checklist
 Risk assessments
– (falls, pressure ulcers, self harm)
 Risk registers
 Safety culture assessments
 Safety cases
 Bringing available information in the organisation
to anticipate safety in the future
Integration & learning. Are we
responding and improving?
Berwick Report
“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)
Great Ormond St: team level
 Number of days since the last serious incident (SI)
– narrative, 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.
Intermountain Healthcare
 Online reports portal with 80 quality and patient safety
metrics patient safety metrics
 Use of electronic records and data provided by care
provider as part of clinical workflow
 Web-enabled reporting and SPC charts on demand
including:
– Centres for Medicare and Medicaid Services (CMS)
– The Joint Commission core measures,
– Quality Forum (NQF) etc. Intermountain captures
patient harm from existing
Response & Evolution
Global impact of the report
Since report
published:
Downloads
24,600
Hard copies
12,200
36,800
interactions
globally
Changes in thinking & culture
 Rigid thinking
 Low awareness
 Blame culture
 Reactive thinking
 Disparate thinking
 Holistic view
 Increased awareness
 Increased ownership
 Proactive thinking
 Changed conversations
 Common language
 See safety through
patients’ eyes
‘Deceptive simplicity’
‘I thought it was a simple framework, I thought it
looked easy. I didn’t think we’d have 18 months of
work to do with it. Turns out I was pretty naïve. I
found it really difficult…. We gave it so much
thought and discussion, went round and round’
Safety manager, Site F
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?
Possible approaches for achieving
Are we responding and
improving?
.
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
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
Assurance Inquiry
Are we
safe?
What can we learn
about safety today?
Dr. Ross Baker
How the framework can be
used within the Canadian
Healthcare Context
Questions and Answers
Chris Power – Closing Remarks
Poll
Learn more, access Call
Recording and CPSI Contacts
To learn more about the framework
http://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient-
Safety/Pages/default.aspx
To access the recording of the call (available in about 5-7 days)
http://www.patientsafetyinstitute.ca/en/Events/Pages/Measuring-and-Monitoring-of-Safety-
Vincent-Framework.aspx
To learn more about SHIFT to Safety
http://www.patientsafetyinstitute.ca/en/About/Programs/shift-to-safety/Pages/provider.aspx
CPSI contacts
Virginia Flintoft
Vflintoft@cpsi-icsp.ca
416-946-8350
Anne MacLaurin
AMaclaurin@cpsi-icsp.ca
902-315-3877

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Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada

  • 1. Measuring and Monitoring of Safety Chris Power, CPSI Dr. Charles Vincent, University of Oxford Dr. G. Ross Baker, University of Toronto
  • 2. Speakers Chris Power Chief Executive Officer, Canadian Patient Safety Institute Prof. Charles Vincent Department of Experimental Psychology, University of Oxford Dr. G. Ross Baker Institute of Health Policy, Management and Evaluation, University of Toronto
  • 4. What have you read about the Framework? Have not had a chance yet Read the Practical Guide only Read the full 2013 Health Foundation Report
  • 5. Using the Framework No action yet Planning for applying the Framework in a clinical setting Started to apply the Framework in a clinical setting
  • 6. Chris Power CPSI’s interest in the Measuring and Monitoring of Safety Framework
  • 7. Professor Charles Vincent Overview of the framework and lessons learned from its implementation
  • 8. The Measurement & Monitoring of Safety CPSI Webinar January 2017 Charles Vincent Professor of Psychology, University of Oxford
  • 11. UK National Reporting & Learning System Hospital Episode Statistics: 11.8M hospital admissions in England 2004/5
  • 12. But incident reporting only detects 5% of harmful events
  • 13. We do not know whether we are making progress or not
  • 14. Just tell me - are we safe?
  • 15. Methods  Reviews of research literature and reports from organisations: – Safety relevant industries – Conceptual approaches and models of systems safety – Measurement and monitoring in healthcare – The role of patients and families  Interviews with senior staff in national organisations  Case studies in healthcare organisations in the UK and USA across sectors
  • 16. Safety in high risk industries  Lagging indicators – Measures of events of incidents – Reactive measures safety performance – Lost time injuries, incident reporting, thoroughness of incident investigation  Leading indicators – Precursors, events or measures that purportedly predict safety performance – Monitoring of key control systems or actions – Safety management system audits, safety cases, culture surveys and walk rounds
  • 18. The fundamental questions  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?
  • 19. Safety in NHS High Risk Industries Models of Safety PatientSafety Case Studies
  • 20. 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?
  • 21.
  • 22. What do we mean by harm?  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
  • 23. Adverse events in older people • Errors, omissions • Operative/procedural complications • Hospital acquired infections • Adverse drug events Adverse events affecting all age groups
  • 24. Adverse events in older people • Errors, omissions • Operative/procedural complications • Hospital acquired infections • Adverse drug events Adverse events affecting all age groups • Falls • Pressure sores • Incontinence • Functional ± mobility decline • Delirium • Depression • Nutritional decline • Dehydration The geriatric syndromes Should be thought of as adverse events • Preventable? • Prolonged hospital stay • Increased morbidity and mortality +
  • 25.
  • 26.  Clinical information available in hospital outpatient clinics  Prescribing for hospital inpatient  Equipment availability in the operating theatre  Equipment available for inserting peripheral intravenous lines
  • 27. Missing & faulty equipment Site Total operations studied Number of operations with equipment problems Percentage operations with one or more equipment problems A 258 50 19% D 67 25 37% F 165 19 12% Total 490 94 19%
  • 28. ‘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
  • 29.
  • 30. Sensitivity to operations  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.
  • 31. Soft intelligence  Safety walk-rounds  Using designated patient safety officers  Operational meetings, handovers and ward rounds  Briefings and debriefings  Day to day conversations  And above all …. the patient voice
  • 32.
  • 33. Experts are constantly thinking ahead  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. Amalberti & Deblon, 1992
  • 34. Anticipation and Preparedness: Will care be safe in the future?  WHO Surgery Checklist  Risk assessments – (falls, pressure ulcers, self harm)  Risk registers  Safety culture assessments  Safety cases  Bringing available information in the organisation to anticipate safety in the future
  • 35. Integration & learning. Are we responding and improving?
  • 36. Berwick Report “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)
  • 37. Great Ormond St: team level  Number of days since the last serious incident (SI) – narrative, 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.
  • 38. Intermountain Healthcare  Online reports portal with 80 quality and patient safety metrics patient safety metrics  Use of electronic records and data provided by care provider as part of clinical workflow  Web-enabled reporting and SPC charts on demand including: – Centres for Medicare and Medicaid Services (CMS) – The Joint Commission core measures, – Quality Forum (NQF) etc. Intermountain captures patient harm from existing
  • 40. Global impact of the report Since report published: Downloads 24,600 Hard copies 12,200 36,800 interactions globally
  • 41. Changes in thinking & culture  Rigid thinking  Low awareness  Blame culture  Reactive thinking  Disparate thinking  Holistic view  Increased awareness  Increased ownership  Proactive thinking  Changed conversations  Common language  See safety through patients’ eyes
  • 42. ‘Deceptive simplicity’ ‘I thought it was a simple framework, I thought it looked easy. I didn’t think we’d have 18 months of work to do with it. Turns out I was pretty naïve. I found it really difficult…. We gave it so much thought and discussion, went round and round’ Safety manager, Site F
  • 43.
  • 44. 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? Possible approaches for achieving Are we responding and improving? . 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
  • 45. 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
  • 47. Are we safe? What can we learn about safety today?
  • 48. Dr. Ross Baker How the framework can be used within the Canadian Healthcare Context
  • 50. Chris Power – Closing Remarks
  • 51. Poll
  • 52. Learn more, access Call Recording and CPSI Contacts To learn more about the framework http://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient- Safety/Pages/default.aspx To access the recording of the call (available in about 5-7 days) http://www.patientsafetyinstitute.ca/en/Events/Pages/Measuring-and-Monitoring-of-Safety- Vincent-Framework.aspx To learn more about SHIFT to Safety http://www.patientsafetyinstitute.ca/en/About/Programs/shift-to-safety/Pages/provider.aspx CPSI contacts Virginia Flintoft Vflintoft@cpsi-icsp.ca 416-946-8350 Anne MacLaurin AMaclaurin@cpsi-icsp.ca 902-315-3877