The Measurement and Monitoring of Safety

1. The Measurement and Monitoring of Safety Charles Vincent Health Foundation Professor of Psychology University of Oxford

2. Charles Vincent Jane Carthey Susan Burnett

3. 10% patients harmed, half judged preventable

4. UK National Reporting & Learning System Hospital Episode Statistics: 11.8M hospital admissions in England 2004/5

5. But incident reporting only detects 5% of harmful events

6. We do not know whether we are making progress or not

7. Just tell me - are we safe?

8. Commissioning. How do we know care is safe? • Tools and approaches to measuring safety • Provide a future direction • Jane Jones, Jonathan Bamber

9. Methods (1) • 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

10. Methods (2) • Case studies in healthcare organisations in the UK and USA • Acute & specialist trusts • Mental Health • Primary care • Combined organisations • Clinical services: maternity care, care of the elderly, anaesthesia

11. 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?

12. Safety in NHS Patient Safety High Risk Industries Models of Safety Case Studies

13. Conceptual Structure of Report Past Harm Principles of Safety Measurement and Monitoring Safety in NHS Reliability Patient Safety Concepts High Risk Industries Sensitivity to operations Models of Safety Anticipation & Preparedness Case Studies Integration & Learning

15. 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

16. 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? • Lead to prolonged hospital stay • Increased morbidity and mortality

17. NHS Safety Thermometer: Falls with Harm Data sourced from the NHS Safety Thermometer national data set April 2012. This data highlights the national mean proportion of patients with harm from a fall (based on a monthly point of care survey) is 1.2%. Caution must be taken regarding the sample – the control limits of this p-chart highlight the changes in sample size which includes pilot periods when submitting organisations were providing data on only 50% of pilot wards (4) through to 100% of patients in hospital care on one day. In March 2011 the sample was 5700. In March 2012 this was 49,917.

19. Are our clinical systems and processes reliable? • Measuring and testing reliability: the WISER study – • Clinical information availability at the point of decision making • Prescribing for hospital inpatients • Equipment in theatres • Equipment for inserting IV lines • Handover between wards

20. I’m looking for... Past medical history Referral letter/other specialty letter Discharge summary Current medication Radiology/imaging results Diagnostic test results Procedure notes/anaesthetic record Electrocardiogram (ECG) report Blood results

21. Missing information overall

22. Differences between organisations

23. Reliability of equipment availability in operating theatres

24. Missing & faulty equipment

25. ‘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

27. Sensitivity to operations • At the coal face, minute by minute, safety may either be eroded by the actions and omissions of individuals or, conversely created by skilful, safety conscious professionals • Clinicians monitor their patients, watching for subtle signs of deterioration or improvement, but also have to 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 a host of other potential problems.

28. 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

30. 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

32. Predicting mortality by day of the week There were 27 582 deaths within 30 days after 4,133,346 inpatient admissions for elective operating room procedures Crude mortality rate 6.7 per 1000) The adjusted risk of death was higher if the procedures were carried out on Friday (+ 44%) or a weekend (+ 82%) compared with Monday.

33. Nurse Staffing and Quality of Care • Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, • http://www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html. AHRQ Research in Action, Issue 14 (2004)

34. Integration & learning. Are we responding and improving?

35. 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)

36. Safety Information System • A safety information system should really be seen as an ‘information, analysis, learning, feedback and action’ system. • Many organisations currently expend most of their efforts on data collection, to the detriment of other aspects. • Too narrow a focus on reporting means less invested in the more critical areas of feedback and learning.

37. Integration of information • Data sources could include: • incidents reported, • Indicators administrative data, • complaints, health and safety • incidents, inquests, claims, • Clinical audits, routine data, • Observations, both quantitative and qualitative • informal conversations with patients, families and staff.

38. 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.

39. 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

41. 10 Guiding Principles (1) • A single measure of safety is a fantasy • Safety monitoring is critical and does not receive sufficient attention • ‘Leading indicators’ are needed to anticipate and be proactive • Safety information is fragmented in healthcare organisations – integration and learning needs investment in technology and data analysis • Safety information needs to be customised to the different levels in the organisation

42. 10 Guiding Principles (2) • There is a need for a blend of externally and internally agreed metrics • Clarity of purpose is when developing safety metrics • Empowering and devolving responsibility for the development of safety metrics is essential • Collaboration between the regulator and regulated is essential • Beware of perverse incentives!

43. What information do you have in your organisation which will tell you: • Has patient care been safe in the past? • Are your clinical systems and processes reliable? • Is care safe today? • Will care be safe in the future? • Is your organisation integrating, learning responding and improving? • Where do you need to focus attention in future to measure and monitor safety?

44. http://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety/http://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety/