Download Development of the Patient Safety Incident

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
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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
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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
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• 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
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• 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
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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