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What is a Significant Healthcare Event?

Health Foundation SHINE Award 2012/13 Enhanced Significant Event Analyses: A Human Factors Systems Approach for Primary Care Paul Bowie, Elaine McNaughton, Deirdre Holly, David Bruce www.nes.scot.nhs.uk/shine/. What is a Significant Healthcare Event?. (Bowie et al, 2009; McKay et al, 2007).

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What is a Significant Healthcare Event?

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  1. Health Foundation SHINE Award 2012/13Enhanced Significant Event Analyses: A Human Factors Systems Approach for Primary CarePaul Bowie, Elaine McNaughton, Deirdre Holly, David Brucewww.nes.scot.nhs.uk/shine/

  2. What is a Significant Healthcare Event? (Bowie et al, 2009; McKay et al, 2007)

  3. Investigations of Significant Events Poorly Conducted: Issues and Impacts • Incidents are highly selective (or non-engagement) • Negative feedback (interferes with ability to assimilate & process information beyond the ‘self’ level) • Second-victim syndrome (impact on health & wellbeing of clinician: guilt, embarrassment, shame…) • Perceived blame culture (fear, distrust, punitive action, litigation…) • Lack of a structured analytical framework (long standing issue) • Many SEAs demonstrate a lack of ‘systems thinking’ • Most clinicians attribute events to their own actions/inactions

  4. Lack of meaningful and constructive investigations Missed opportunities to learn & improve (personal, team & organisational) SEA becomes a tick-box exercise Increased workforce stress, frustration & sick levels Wasted time, energy and resource Low engagement in formal incident reporting Investigations of Significant Events Poorly Conducted: Issues and Impacts

  5. History of SEA(compared to hospital based techniques) Case-based discussion (Bradley, 1992; Pringle et al, 1994) Flanagan’s Critical Incident Technique (John C Flanagan, 1954) Embedded in practice (most professions) Quality of SEA (Bowie et al, 2009; McKay et al, 2007)

  6. What We Set Out to AchieveWe aimed to design and develop a theory-informed ‘guiding tool’ to support the SEA process in primary care settings. Overcome SEA deficiencies by introducing human factors systems principles Highlight and differentiate the interactions between the individual professional and the wider workplace and organisational issues at play. Individual level: guide clinicians to reflect upon their emotional reactions - achieve a state of psychological readiness to move on. Team level: a systems-centred analysis of the significant event. Underlying assumptions: individuals and care teams would gain a deeper understanding of the human-system interactions contributing to events may lessen emotional reactions and the propensity to apportion personal blame may lead to more meaningful and effective action plans for improvement.

  7. What did we do? • Multi-professional steering group/project manager • Tapped into existing human factors and safety science expertise • Literature review • Design of a conceptual framework (error theory and ergonomic model) • Development of ‘guiding tools’ (individual & team levels) • Recruitment of clinicians and managers (qualified and in-training) • Testing Phase • Evaluation • Final project report

  8. CONCEPTUAL FRAMEWORK

  9. THE GUIDING TOOLs - enhancedSEA Method • The new approach is divided into three parts:  • 1. A Small Personal Booklet to help individuals reflect on the potential emotional impacts of a significant event - and their own role in the event - by using human factors principles to gain a clearer understanding of all of the contributory factors involved.   • 2. An A3 size Desk Pad for the care team, the sheets from which can be distributed to all those who attend a team meeting to analyse significant events.  Each sheet contains instructions and prompts to guide the care team to take a systems-based approach to analysing the event in question and take notes on what was agreed – a small set of card prompts may also be used in conjunction. • 3. A new written report format for enhancedSEA has been designed – to prompt a systems based analysis.

  10. Evaluation – Completion Rates

  11. Evaluation(n=117)

  12. Evaluation(n=117) *P<0.05

  13. Selected Evaluation Quotes • “I think SEA is a difficult and demanding process but these tools simplified the process for me and made it easier to try to be more objective” • “I think the human factors model is a very useful approach to looking at an SEA and without doubt caused me to think differently about this SEA and feel the outcomes were more meaningful”. • “Very worthwhile. Definitely made the SEA feel more in depth / thorough. Whole team very approving. Developed some really useful action points” • “If eSEA was recognised, it would be more beneficial and more useful than existing SEA” • “We’ll look at things more closely, when an SEA comes in use, use of the eSEA will have greater impact, will influence initial discussions” • “eSEA breaks stuff down further that you wouldn’t have considered....which I wouldn’t have considered before” • “I found it made the process more laborious and confusing in some ways. I think the booklet was helpful but the report format needs to be simplified. Some of it felt like writing in order to fill in boxes. I think we would have come to the same conclusions if I had used our normal format”.

  14. What has gone well? • We made the project aims more realistic and manageable. • By and large core group has stayed together and functioned well (?) • Educational Leaders clearly interested, very supportive and helpful • The approach developed based on solid theory and has high face validity (particularly amongst those informed in safety) • Operational team – managed to call upon additional, valuable resource • Health Foundation – relatively low maintenance • Post-pilot implementation looks promising, but may take a while to embed • Infrastructure to improve and build upon – a lasting legacy • TROJAN HORSE STRATEGY

  15. What could have been better/different? • Website design and access issues – bit rushed • Tool content and design – took longer than expected, not sure if we had a shared mental model of final output (but a Pilot) • Impacted slightly on testing period – knocked some out of sync. (e.g. Pharmacy) • Quality of design could be much better • Different interpretations of ‘human factors’ science and role in project/and also of evaluation expectations • Test numbers plucked out of thin air – over-confidence and naivety? • Email bombardment irritated a fair few GPs wearing different hats!

  16. Project Learning and Outputs • Once evaluation feedback incorporated, enhancedSEA method ready for roll out – good interest from Educational Leaders/SPSP/Others • Conference Presentations (e.g. Poster at RCGP, Oral at IEHF) • Basic e-learning (BMJ Learning, NES website) • Book Chapters (NES book and Good Practice GP Training Guide) • Journal Submissions (conceptual framework, evaluation…) • Team learning (human factors, logic models, error theory…) • Organisational impacts (e.g. inter-professional working, good publicity)

  17. Positive External Interest • RCGP Scotland/Specialty Training/Dental • Vocational Training for GPNs/PMs • SPSP-PC and Scottish Government • Department of Health in England/PS Toolkit • NHS Boards • NES Human Factors Conference – March 2014 • Patient Safety Congress – Liverpool, May 2014 • IEHF Spring Conference – Southampton, April 2014 • Other regional and national conference invitations • Feedback to all via Newsletter

  18. Quick Questions?SMALL GROUP WORK

  19. Quick Analysis • A GP surgery decided to have their health visitor trained to administer childhood immunisations to ease their practice nurse’s workload. • The health visitor started working under the supervision of another qualified health visitor after completing her training. • A 3-month-old girl attended one of the ‘new’ immunisation clinics to receive her second booster. The clinic was very busy. The MMR and DTP/Hib vaccinations were placed on the same table. • The health visitor picked up the ‘wrong’ vial while attempting to answer some of the mother’s general questions and accidentally administered the MMR rather than the required DTP/Hib vaccine. • She realised her error when performing the ‘double-check’ of the vial after administering the vaccine. The health visitor immediately informed the GP and the parents and apologised for ‘my accident’. • The GP and the health visitor contacted the local hospital paediatric department to check for likely complications and reassessed the child on several further occasions. • The child did not suffer any harm and received the appropriate vaccinations a few days later. • The actual and potential impacts • People factors • Activity factors • Environment factors • Learning issues (individual and practice level • Action plan (system improvements)

  20. THANK YOU VERY MUCH www.nes.scot.nhs.uk/shine/

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