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Development of the Patient Safety Incident Management System (DPSIMS) Introduction to and Outputs of reportingfocussed User Workshops, Winter 2016 Patient Safety Vision for 2020: “We want to support the NHS to become a system devoted to continuous learning and improvement of patient safety” Increasing our understanding of what goes wrong in healthcare Enhancing the capability and capacity of the NHS to improve safety By tackling the major underlying barriers to widespread safety improvement The NRLS at present https://www.youtube.com/watch?v=ALXROv7ryck&list=PLHpuGzxwlagy6uRNGdd WCtRRD-yROHPmF NRLS vs STEIS Wastes time NRLS Confusing • • • • • • • any Patient Safety incident any degree of harm voluntary* no deadline to report for learning access by agreement operated by Imperial Trust Laborious STEIS Poor data quality Poor standardisation Patient • Any category of Serious Incident Safety • Serious Incidents only Serious Incidents • mandatory (“Severe • must be reported within 48 hrs Harm” or “Death”) • for management/investigation • commissioners have access • operated by DH * NHS organisations satisfy their duty to submit statutory notifications to CQC by reporting through NRLS. While this isn’t all incidents, it approximately equates to moderate, severe, and death as well as incidents dealing with abuse. Neither the local nor national learning systems are perfect – they both meet some requirements, but neither make best use of the other as a supporting resource or channel Improving our systems The patient story is often lost from the incident, unless they make a complaint - which is then handled through separate systems – or if the incident goes to full investigation Other learning frequently is developed, but often sits outside of this system – NRLS processes don’t fully integrate with culture Investigation Results Patient Story Locally derived learning Subjective classifications, reports of varying quality/detail Acute Route PSI Most other settings Time and resource intensive; frequently sits outside local processes, requiring duplication of effort. Low reporting rates. Live file in STEIS for action/ management Report made to STEIS (within 48hrs) Report extracted for NRLS Clinical Report in LRMS Cleansing/ anonym’ion eForm Report Source of poor standardisation, as local arrangements vary KEY: Incident Data Document Process Stored data This separation of “live” management files and static NRLS records can lead to “two versions of the truth” Loses benefits of more evolved local management systems available to trusts with LRMS This step effectively prevents any nongeneric feedback to individuals making reports Record of incident in NRLS The new Stage 1,2,3, Alerts allow for locally derived learning to be disseminated, but only on issues that make it to national Alert level. Benefit is lost when local learning remains local. Only Serious Harm or Death: <1% of reports National Clinical Review Nationally derived learning Fit for purpose? • The NRLS is 12 years old • Focuses on reporting from acute care; does not support reporting from: • Patients • Other sectors and healthcare settings • • • • Thus does not meet the needs of the Five Year Forward View Does not readily support the need for transparency No effective feedback links back to reporters Overlaps with other reporting systems in the NHS (e.g. STEIS, Yellow Card @ MHRA, CORESS for Surgery…) • Lack of real-time reporting capability and requires the manual uploading of incidents. Our aim We need a reporting and learning system that will help improve the ability: • of all healthcare-associated organisations to report more effectively (eg non-acute settings, Independent Sector, devolved nations) • to develop better learning that supports more improvement • to provide greater transparency of patient safety data • to reduce risks associated with: • duplication and omission • lack of standardisation • the gap between the capabilities of the NRLS and the needs of the NHS, patients, and other users Therefore, seeking to develop a successor to the NRLS, building on its success and making it fit for the future. How will the system work? Single Infrastructure PSIMS Encouraging Activity Enhancing Outputs Easy to report (staff and patients) Proactive engagement in analysis of transparent data (staff and patients) Useful, accessible resources (direct feedback + raw data + curated learning materials) Creating Impact Active learning and improvement of care Virtuous Cycle Supporting Inputs What might this mean in practice? Single Infrastructure Supporting Inputs Encouraging Activity Enhancing Outputs Creating Impact NRLS-like reporting & clinical review functions STEIS-like investigation/ management functions Maintaining LRMS upload stream Reporting, analysis & sharing tools Simple reporting apps (staff and patients) Data made transparent Optimised ‘questions’ for maximal learning Learning pulled from other places (eg complaints, investigations) In-built analysis tools Targeted feedback Curated learning materials Central platform for sharing and collaboration Users engaged in the reportinglearning cycle Knowledge shared across boundaries Effective interventions proliferate Where does “learning” come from? Encouraging Activity Transparent Data National Surveillance (eg NaPSAS) PSIMS Local and speciality interrogation of data Networks (eg Q Initiative, PS Collaboratives Sign Up To Safety) A.I. learning algorithmic trend-spotting Improvement projects: local and national Lessons from local investigations NRLS-like reporting & clinical review functions STEIS-like investigation/ management functions Reporting, analysis & sharing tools Optimised ‘questions’ for maximal learning Summary: the new direction PSIMS Re-Focus • Insight supported by transparency • Engagement with the reporting-learning cycle • Pro-active learning, sharing, and improvement Learning • Active learning processes prioritised • Better recognition of locally-generated learning • Easier to participate in analysis for learning Knowledge • Knowledge built together • Equitable structures to improve access to data and knowledge for all • Dedicated patient-facing reporting tools, linked to other Patient feedback channels Involvement • Enriched learning that incorporates the patient story Sharing • Better sharing of all learning materials • Easier access to examples of others’ improvement work • Supported by social media platform Workshop 1 • This session focussed on users who have Local Risk Management Systems (LRMS) • They use what is collected locally on LRMS to undertake batch-upload to the national system • The group comprised frontline staff, risk managers, patient safety leads, LRMSmanagers etc 12 Affinity map: clusters of activities/uses Outcomes, progress, change Investigations Business Intelligence Fulfilling statutory obligations to external/ national organisations Local Learning Internal assurance Benchmarking Assurance For learning Record and share incident to enable national learning CQC visits Sharing outcomes from incidents Intelligence monitoring Coordination across organisations Link to KPI data Deadline dates for SI reports Document Duty of Candour Transfer incidents between organisations for access /ownership SHOT RIDDOR Identifying changes as a result of learning/ improvement Monitor/track internal investigation process MHRA Learning for business intelligence (from more than one data source) Upload to NRLS Duty of Candour For assurance Theme reporting to benchmark against others For planning Inform improvement plans Link to governance data Screening Trend analysis SIRS Record level of investigation Commissioners Enable Patient Safety Alerts to be produced Risk analysis Capturing root causes and actions – have they helped? ICO Data for planning services / resources Commissioner role in SI tracking SABRE IHRMIR 13 Data to make the case for improvement work Trend analysis (type, specialty, area, staff?, patient? – and as a whole) Monitor efficiency of care within trust services User Stories A key part of the Discovery Phase process is to articulate the needs of users as a “User Story”. These are not necessarily direct quotes, but vignettes that summarise not only what is important to get right, but why. They typically take the form of “As a [role], I need [functionality]… so that [real-life impact of improvement]…” The next few slides contain the kinds of User Stories we have heard from people currently at the reporting end of the system. The Discovery Phase will also contain User Stories from other key user groups (eg National Users, Research and Stakeholder community) Local Users “As a trust risk “As a ward nurse, I need to be able to quickly and simply record safety incidents manager, I need to be able to upload data and share them with the right people, so from several different that I can get back to my patients ASAP, systems without knowing there will be a good response” getting loads of error “As commissioner I “As Nurse In Charge, messages or the need to be able to log I need clear guidance systems crashing, so into one place and on what constitutes that I can get on with see where all the each level of harm, so my main work” serious incident I can advise my team “As an independent investigations have how to report provider, I need to know got to and who is incidents accurately I’m meeting all CQC involved, so that the without wasting time safety reporting right people can take looking it up and requirements so I can the actions needed to agonising over continue to operate my get them closed” definitions” business” Local Users “As a service manager, I need to “As an ED registrar, I know how well my trust is need the system to fill performing compared to the one in basic details for me down the road in terms of safety automatically, such as incident reporting so I can make the the Trust name, my case for more resources” department, the “As a safety data patient’s DOB, etc, so I manager, I need to “As a patient safety can report the important be able to lead, I need to know things and get back to automatically if anyone else has my patients” cleanse data so I solved the problem “As an MDSO, I need the can upload it I’m stuck with, so I system to have a list of all quickly without can get a good our devices for me to breaching solution in place choose from, so I can Information without re-inventing complete reports quickly Governance rules” the wheel” and accurately” Local Users “As a Quality “As a trust safety lead, I need regular and Improvement timely feedback on our own incident data so I lead, I need to can answer queries and FOIs, and keep the know where the Board updated ” “As a patient safety biggest manager, I need the “As a trust risk problems are in system to send me and manager, I need to my Trust, so I all other relevant people be able to put all the can focus my notifications in a info in once, to one work on those consistent way, so that system, and know it issues” we can all keep on top of will alert all the the incident relevant management process” organisations like “As a small provider of NHS-funded care, I NHS Protect, CQC need to be able to report SIs without having and HSE” to call my commissioner to log it manually on my behalf” Local Users Next Steps We have a further mapping session in December for users who cannot map their local systems to the NRLS (including eForm users, patients, and organisations who cannot currently participate in national learning at all). This will generate further User Stories to add to the case. We’re also procuring a Data Modelling project, to decide what questions we need to the system to be asking to get maximum learning from minimum reporting burden. Once we’ve got all our User Stories, we’ll seek approval to get our Discovery Phase signed off, and to move to procuring an Alpha Phase, where we’ll start building a prototype and testing some of the functions… MVPs Workshop 2 • This session focussed on users who: – currently do not have LRMS, or – have a LRMS but cannot link it to the NRLS (eg independent providers) – and so either rely on eForms to report to the NRLS, or – are not able to report at all 21 Outputs: the reality (themes) What do you do now? • Significant Event Audit • Health Professional Feedback Pain! What processes do you follow? • Report to local systems • SI investigations • ISO standards for incident reporting and integrated quality systems • Some homecare products have their own guidelines and data sets to be collected • Report to head office • Review • Contact patients • Root cause analysis • Safety huddles • Share learning with board/head office, through bulletins, or with relevant networks (eg Medications Safety Officers) • Trend analysis • Change practice or SOPs • Plan-Do-Study-Act style cycles What systems do you use? • Datix • Ulysses • Excel • NRLS • STEIS • Q-Pulse • Bespoke local systems • We have no system! (dentistry) • Email • Ciris • SIRS • MHRA systems • RIDDOR (health and safety) What governance requirements do you have • CQC reporting • Commissioners • NHS England • STEIS • Insurers • PHIN • NHS Improvement Why do you do these things? • Patient Safety • Risk Management • Reputation • Learning – local and nationally, identify trends • Remaining competitive – responding to customers/commissioners • Required by regulators/because we have to/legal or 22 contractual requirement • To improve outcomes • To provide data to various bodies • Duty of candour • Professional standards • Insurance premiums • Promote positive attitude to reporting •Time consuming – reporting and investigating •Duplication •All in – nothing out: feedback? •Contributing nationally doesn’t help locally •Data quality issues – central resource capacity, staff knowledge, numbers don’t match •Mapping to NRLS •Coding of root causes •Applicability of codes to nonAcute settings •Inconsistent coding •What counts as serious harm? Subjectivity of definitions/categories •Sharing with local NHS is painful – no systems, duplication •Inconsistency of outputs •No defined input format •Hard to identify learning or contributory factors •Promote the need to report! •Hard to extract data Outputs: the dream (themes) Outcomes • Safer practice, visible change, making a difference: clear instructions, training, good challenges to providers • More resources for improvement • Learn from others including other industries • Open and transparent dialogue between all players – consistency, cooperation, building a common understanding • Business growth, be more competitive • Safer culture – move away from blame, fear of litigation etc Easy to use • One unified but configurable system, universal access point, enter data once – but not one-size-fits-all • Quick and simple to report (<2 mins for simple, <20 mins for serious: tiered levels of questions), only collects what is useful • Instant info • Multiple ways to report (iPad, apps, Siri, PC) • Intuitive and flexible • Secure, confidential, reliable, trusted, good information governance and clear rules for it • Plain English • Encouraging and supportive • Works for NHS and private providers; different care types and settings Data • How many similar incidents? against national standards • Who else is looking at the same problem? • Digital dashboards and data you can drill down into • All content should be measureable: against other content and • Local and national benchmarking Feedback • CPD points • Automatic feedback • Newsletters • Link to evidence bases • Acknowledgement/thanks/receipt! • 360 feedback – includes patients/families Functions • Prompts to next steps/review etc • Help functionality • Suggested actions • Case management, document upload • Promotion/PR – needs to add value • Open system • Local and regional early warnings • Anonymised dashboards for patients and research • Intelligent system 23 • Interoperability • Share with stakeholders including patients • Triage • Supports local governance Descriptors • • • • • • • • • • • • • • • • • • • • Cheaper Useful Sensible Vital for concerns Sensitive Advanced Safer More patientfocussed Believable Comprehensive More open More buy-in Accurate Worthwhile Assurance Confidence Rewarding Interactive Challenging Makes a difference Outputs: the nuts and bolts – affinity mapping results Improving Outcomes Reporting Learning • Make it demonstrably safer for patients • Offer solutions to identified problems • Allow staff to tell us how they think we solve the problem • Act: suggestions of what should be done • Share best practice • Make the financial argument for safety • Suggestions • Report solutions to problems • Identify root causes due to resource gaps – localised systems issues • Suggested practical changes and a timeline indication for when to review practice changes to assess whether they’ve had desired impact • Ensure everybody is listened to • System to guide you to make improvements using others’ experience • Tell me why I need to complete each field • Pre-populate fields to save time • Smart system • 360 input • Quick, easy, simple to report • Set standards for data • One-stop shop, patients don’t have to work out who to turn to • Collect info easily • Encourage different clinical groups to report • Integrated access • Commissioner reporting – standards across all commissioners • Submit data once and reuse across organisations (avoid duplicate submissions) • Easy access to key learning from other organisations/services to help us improve our own practice • Easy to share our own locallygenerated learning • Share learning • Analyse data/interrogate down into locality/GP/federation/area • Allow organisations to learn internally, locally and nationally, and externally • Continuous improvement • Review • Share learning with other organisations • Library of related incidents • Validated solutions to identify patient safety issues • Share learning outcomes • Focus on learning rather than reporting within fixed timeframes • Share learning to improve patient safety and quality of services • Appropriate standardised Root Cause Analysis • Best practice • Key word search for learning opportunities and recommendations nationally for internal cascade • Encourage reflection • Learning – organisation with a memory • Value all information and learn from basic mistakes Communications Categorisation Benchmarking and dashboards • “how are we doing” dashboards, KPIs, progress trackers • Standardised dashboards on important issues • Benchmarking • Meaningful data extraction – easyread graphs • Data analysis • Trends over time • RAG ratings • Comparison to relevant peers • Risk analysis – forward projection or cost impact/imperative • Possible causal analysis or info on how different indicators might be linked • Red flag issues relating to safety alerts • Information sharing • Electronic dashboard, drillable data • Confidential benchmarking • Dr Foster-esque reports • Rates per population, practice list 24 • Communicate changes/learning • Performance measurement • “buy-in” from regulators • Share details of incident/complaint with other agencies and provide single point to all where data/info can be held and shared • Clear categories and definitions for reporting • Clear common understanding of definitions and context • Comprehensive, common sense list of categories • Keep the patient at the centre – what happened? Why? How? Who? When? How is the patient affected? What is their/the family/carer’s perspective? • Clear, easy to understand definitions • Common across healthcare settings and sectors • Something on significance of categorisation – does not require subjective interpretation Trends • Themes that then highlight risks • Useable data • Identify where its going wrong • Hot-spot identification • Signal detection • Trend analysis • Identify patterns • National trending in real time, acknowledging differences in service provision type and activity level, to understand performance • Local reports on themes/trends by provider/categories Feedback • Highlight resources needed to solve issue • Highlight contributory factors • Feedback • Response • Good links to evidence bases for learning • Practical applications, not just words! • Instant feedback on numbers types, outcomes, actions from reports • Automatic feedback to reporters • Make feedback relevant to the work or area that I’m working in • Reports shared at all levels • Intelligence reporting • Incident reports geared to the size, complexity, level or risk of the care setting, in to improve reporting rates and engagement Accessibility Investigation • Find the right language to aid the translation of information • Inclusivity • Easy to use portal/app that is well-known and user-friendly • Time measured • Open to all • Configurable to sector (eg GP, independent, nursing home) • Configurable to population (eg CCG, STP, LA boundaries etc) • Great GUI (Graphical User Interface) • Integration across other systems – enable crosspopulation • Triage data to other organisations • Usable for an untrained user • Set standards for investigation and root cause analysis • Secondary investigation access to add/amend data – outside lead-investigator’s organisation Training • Prompt CPD cycle • Training on the theory of patient safety • CPD points for healthcare professionals • Sector-specific formal networks (eg MDO and MDSO) Other features/ functions • Assurance of actions • Support incident analysis and storage as well as reporting (eg document storage) • People-focus not processfocus • Link with quality – patient experience, safety, effectiveness • Interrogation of systems Outputs: your Minimum Viable Products (1/2) Trend analysis Communication and feedback 25 Detailed analysis for learning Outputs: your Minimum Viable Products (2/2) Reporting and Access 26 Outputs: one word to describe the situation - before and after One word on how you view reporting to the national system NOW Impossible Lost Unrecognised Confusing Frustrating Muddy Unknown Gappy No loop Difficult Detached Don’t do it Patchy Hard sell Exciting Irrelevant Fragmented Unclear Complex Inconsistent 27 One word on how you feel about reporting to the NEW SYSTEM Exciting Happy Intrigued Expensive Complex Illuminating Beneficial Challenging When? Stimulating Ambitious Courageous Amazing Encouraging Empowering Possible Opportunity Informed Hopeful Optimistic Responsive